Upper-Crossed Syndrome

Introduction

Upper cross syndrome (UCS) is also known as proximal or shoulder girdle cross syndrome. In the UCS, the tightness of the upper dorsal trapezius and levator scapula crosses the tightness of the pectoralis major and minor. Weakness of the deep neck flexors crossed ventrally Weakness of the middle and lower trapezius muscles. This pattern of imbalance creates joint dysfunction, particularly the atlanto-occipital C4-C5 cervicothoracic glenohumeral and T4-T5 segments. Janda states that these pressure focal areas within the spine correspond to The transition zone where the morphology of adjacent vertebrae changes.

Specific postural changes are seen in UCS, including increased cervical lordosis and thoracic kyphosis with increased forward head posture and shoulder lengthening and rotation or abduction and winging of the scapula. These postural changes reduce the stability of the glenohumeral joint as the glenoid socket becomes tighter Abductor rotation and winging of the scapula due to serratus anterior weakness, resulting in verticality. This loss of stability requires increased activation of the levator scapulae and upper trapezius to maintain the glenohumeral joint center [1].

When the human body is exposed to gravity, for example when standing or walking, it is necessary to ensure proper activity of the skeletal muscles responsible for maintaining good body posture. When these muscles are not stimulated for extended periods of time against gravity, such as during prolonged sitting or Their stabilizing function is disturbed by the hypoactivity response, resulting in muscle weakness and atrophy. Deficits in the stability of the locomotor system trigger compensatory mechanisms—stabilizing functions are replaced by mobilized muscles. However, as a side effect Compensation leads to increased activity (hyperactivity) in the mobilizer, followed by decreased flexibility, which may eventually lead to a chain of pathological reactions within the musculoskeletal system [2][3][4][5][6][7].

Image: Trapezius muscle (highlighted in green) – posterior view [8]

Injury Mechanism/Pathological Process

According to Karel Lewit (1994), muscle imbalance usually precedes dysfunction [9]. V Janda (2013) also described this muscle imbalance as a condition in which some muscles become inhibited and weak, while others become short and stiff. This imbalance can lead to changes in the organization, which can Resulting in inappropriate movement patterns for individuals. This condition can eventually lead to side effects such as pain and inflammation. Janda largely attributes these predictive patterns to [10][11] due to fixed conditions and repetitive tasks. Muscle balance can be defined as The relative equality of muscle length or strength between agonist and antagonist muscles; this balance is necessary for normal movement and function [1].

This syndrome is mainly due to the shortness of the tonic upper neck muscles and anterior cervical muscles, and the inhibition and weakening of the staged deep anterior neck muscles and shoulder girdle muscles. This condition is caused by changes in altitude The increased head forward angle leads to forward extension and abduction of the shoulder joints, and hyperextension of the upper cervical spine, which is often associated with rounded head, scapular extension, and thoracic kyphosis [10][11]. These muscle imbalances and movement Dysfunction can have a direct impact on the joint surface, which can lead to joint degeneration. In some cases, joint degeneration may be the direct source of pain, but the actual cause of pain is often secondary to muscle imbalances [12].

Muscles may become unbalanced due to adaptation or dysfunction. This muscle imbalance can be functional or pathological:

1. Functional muscle imbalances occur as adaptations to complex movement patterns and include imbalances in strength or flexibility of antagonistic muscle groups [1]. The structural approach focuses on actual injuries to musculoskeletal structures, such as rotator cuff tendinitis or ligament Injuried. Functional approaches examine factors that contribute to structural damage. This approach is most useful in the physical therapy management of chronic “dysfunction” such as persistent arthralgia and tendonitis [13].
2. When a muscle imbalance impairs function, it is considered pathological. Pathological muscle imbalances are often associated with dysfunction and pain, although the cause may or may not be the original traumatic event. Pathological imbalances can also be insidious; many people have them Muscle imbalance without pain. Ultimately, however, pathological muscle imbalances lead to joint dysfunction and altered movement patterns, which in turn lead to pain. Be aware that this continuum of muscle imbalances can progress in either direction; muscle imbalances can lead to altered movement patterns vice versa. Some injuries result in muscle imbalances, while others may be the result of muscle imbalances. Sometimes the pathological imbalance is a functional compensation for the impairment [1]. For example, imbalances in biomechanical joint stress from muscle imbalances can lead to joint damage A vicious cycle of pain and inflammation forms. Structural inflammation then affects the neuromuscular system of the joint, causing further dysfunction. Eventually, the body adjusts the motor program to compensate for the dysfunction. The functional cause of the problem is muscle imbalance, while the symptoms are pain and inflammation from structural damage. Thus, both structural and functional lesions may be present, but for accurate diagnosis and treatment, the clinician must determine which lesion is the actual cause of the dysfunction [1].

Functional imbalance Pathological imbalance Non-traumatic With or without trauma Adaptations Adaptations Specific activities associated with dysfunction Painless With or without pain

Proprioception is the sense used to control the position and movement of the trunk and body parts in space [14]. Proprioception associated with head-space recognition requires not only information from the vestibular apparatus and visual information, but also proprioception Sensing information from the cervical spine [15]. Proprioception plays two important roles in the neck: they provide information to the central nervous system about cervical posture and movement, and they provide cervical reflexes to stabilize and protect the cervical spine [16]. Pathological damage Muscle fatigue and aging have been reported as causes of impaired position sense in the cervical spine, and recent studies have shown decreased position sense in patients with cervical spine damage or complaints of pain [17][18].

Clinical Presentation

Individuals with upper cross syndrome exhibit thoracic forward posture (FHP) kyphosis, as well as altered shoulder girdle function, scapular pterygium, and reduced thoracic spine mobility [19][1]. FHP rounded shoulders and Kyphosis is a postural deviation that includes excessive neck extension and thoracic spine flexion and downward scapular rotation with shoulder tilt and internal rotation [1]. FHP is associated with thoracic kyphosis [20]. In addition, FHP and Rounded shoulders have been reported as well as rounded and kyphotic deformities [20]. However, it is impossible to determine which is the cause and which is the effect. In UCS, the head is placed in the FHP [21].

Weak muscles:

1. Lower and middle trapezius.
2. Reduced SA activity by the serratus anterior will be accompanied by reduced control of the scapula in both static and dynamic states [22].
3. Infraspinatus
4. The deep neck flexors play a key role in maintaining neck posture. These muscles are weak and prolonged in FHP patients and fail to recruit normally [23].

Tight muscles:

1. Increased upper trapezius activity in UT increases anteversion of the scapula and elevates it, resulting in decreased subacromial space, thereby increasing the likelihood of shoulder pathology [22].
2. Pectoral muscle tightness of the pectoralis major exerts a forward force on the glenohumeral joint, reducing stability [24]. Tight pectoralis minor limits scapular supination, external rotation and retroversion, thereby reducing SAS [25].
3. Shortening of the levator scapula may affect muscle coordination and increase shear and compressive loads on the cervical spine [26].

Diagnostic Procedures

1. In clinical practice, it is recommended to start muscle assessment by analyzing upright posture and gait. Posture and gait analysis allows clinicians to gain a complete picture of a patient’s muscle function and is challenged to fully observe a patient’s entire movement Systematic rather than localized to the lesion level [27]. Muscle analysis in standing posture: posterior view anterior view lateral view [1].
2. Evaluation of balance[1].
3. Hipermobility[1].
4. However, assessment of muscle imbalances in patients with acute pain syndromes is unreliable and must be done with caution. Accurate assessment of tight muscles and movement patterns is only possible when the patient is pain-free or nearly pain-free. It is most useful Patients with relapse of pain after resolution of chronic phase or acute episode [27].

Upper-Quarter Muscles

The muscles of the upper body include those of the cervical spine, shoulders and arms. Muscles that are prone to tightness are the ones involved in the protective flexor response. Tightness in the upper trapezius pectoralis, especially the suboccipital muscle, is the hallmark of Janda UCS [1].

The upper trapezius is tested with the patient in the supine position with the head passively bent and laterally bent to the opposite side. Once the slack is tucked away, the shoulder girdle is pushed distally. Sequence obstruction is usually felt at the end of a push; however, when motion is restricted, obstruction There is a suddenly firm hard end reel[27].

The levator m. is examined in a similar manner, except that the head is also rotated to the contralateral side [27].

The deep back of the neck m. muscles can only be tested by thorough palpation. Assessment of the sternocleidomastoid is unreliable because it spans too many segments [27].

The pectoralis major m. is tested with the patient supine. The trunk must be stabilized prior to arm abduction because possible twisting of the trunk may mimic normal range of motion. Arms should be level. To estimate the clavicle section, allow the arm Hanging loosely, the examiner applies a backward slide to the shoulders. Usually only a slight soft barrier is felt [27]. V.Janda recommends testing the pectoralis major. Different parts of the pectoralis major muscle are tested separately. Clinicians can target specific by varying the amount of shoulder abduction.

• Lower sternal fibers. The clinician abducts the patient’s arm to 150° with slight external rotation. The normal length of these pectoral fibers allows the patient’s arm to be in a horizontal position; slight overpressure creates distal sensory resistance. Clinicians should also Palpate the sternal fibers in the medial axilla for tenderness. An inability to level the arm or palpable tenderness in the muscle indicates short or hypertonic muscles.

• Intermediate fibers of the sternum. The clinician abducts the patient’s arm to 90° and palpates the muscle fibers in the second intercostal space. The normal length of these fibers allows the patient’s arm to be lower than horizontal. There is a gradual end-to-end sensory resistance when applied by the clinician Slight overpressure. Palpation produces no tenderness.

• Clavicle fibers. The clinician places the patient’s arm in a stretched position close to the body and stops the arm. The normal length of these fibers allows the patient’s arm to be lower than horizontal. The clinician applies gentle front-to-back and tail Apply pressure through the glenohumeral joint and palpate the fibers below the clavicle. Resistance to this pressure should be gradual and the fibers should not be tender [1].

The pectoralis minor m. is tested with the patient supine. The clinician views the markings on the patient from above. The normal distance between the shoulder peak and the table is 1 inch. The levels of the front of the acromion can be compared with each other. two shoulder peaks Should be at the same level; a higher acromion suggests possible tightness of the pectoralis minor [1].

Latissimus dorsi m. Tested with the patient supine. The clinician stands next to the arm being tested. The clinician passively raises the patient’s arm over the head of the examination table. The normal length of the lats allows the arms to be placed at waist level on the table The spine of the book lays flat on the table. Tightness in this muscle is indicated by an arm above horizontal or extension of the lumbar spine [1].

[28]

Janda’s Basic Movement Patterns

Janda has identified six basic movement patterns that provide overall information about the quality and control of movement in a particular patient; these movements constitute the hip extension, hip abduction, curl, cervical flexion, push-up, and shoulder abduction movement pattern tests Foundation. Clinicians The left and right sides should be observed for comparison. Muscle or limb tremors during these tests are considered a positive finding indicating weakness or fatigue. Some patients do not require all six tests at once; clinicians should decide which tests to perform based on Posture Analysis and History [1].

Cervical Flexion Movement Pattern Test

[29]

Push-Up Movement Pattern Test

[30]

Shoulder Abduction Movement Pattern Test

[31]

Additional Movement Tests

Craniocervical Flexion Test

[32]

Breathing Patterns

The primary muscles responsible for breathing are the diaphragm, intercostal scalenes, transversus abdominis (TrA), pelvic floor muscles, and deep intrinsic spinal muscles. Each of these muscles plays a role in breathing and spinal stabilization. According to Kendall McCreary and Provance of Almost all of the 20 primary and accessory muscles involved in breathing have a postural function. Some patients may exhibit a relatively normal breathing pattern when relaxed in the supine position, but may shift to an accessory muscle or chest breathing pattern when functionally challenged Position, such as sitting at a computer or standing upright. Therefore, the patient’s breathing pattern should be assessed in different positions, especially any painful positions used in ADL. A simple test is to have a clinician gently place her hand on a patient’s shoulder during a quiet moment Breathe to notice any upward movement of the shoulders, which indicates assisted breathing. Here are a few things to keep in mind when assessing breathing:

• Start breathing – the starting breath should be in the abdomen, not the chest.
• Lateral excursion of the lower ribs during inspiration – movement of the thorax is best assessed with the patient in a sitting or standing position.
• End-Inspiratory Upper Chest Expansion – The most common fault pattern is upper or cranial excursion or elevation of the upper ribs by the scalenes and trapezius muscles in place of inefficient or inhibited diaphragmatic activity [1].

Therefore, for the assessment of UCS, alignment and its side effects, such as increased thoracic kyphosis or anteversion, are usually assessed, with less focus on key points, namely the scapula and associated altered muscle activation and movement patterns [33]. In this Considering that many researchers and therapists evaluate only one affected area alone, such as the head and shoulders or spine, and report some degree of postural deviation, regardless of other related misalignments and patterns of muscle activation and associated movement patterns, E.g scapulohumeral rhythm or neck flexion [34].

Outcome Measures

• Shoulder Pain and Disability Index (SPADI)[35]
• Neck Disability Index[36]
• Occiput to Wall Test
• SF-36 questionnaire[37]
• McGill-Melzack Pain Questionnaire[37]
• Visual analogue scale (VAS)[12]

Management / Interventions

In recent decades, therapists have sought to design appropriate exercises to correct musculoskeletal malalignments primarily through structural and functional approaches [38][39][40]. In traditional structural approaches, observed variations in misalignments such as UCS are attributed to biomechanics and is thought to result in adjustments in local muscle length and strength [38][39]. This may explain the stretching of the short muscles in the problem area and the strengthening of the weak muscles during the correction phase, while ignoring other related malalignments [41]. Interestingly, despite the popularity of this approach, few studies have been conducted based on this theory [42]. Furthermore, several review studies have questioned the effectiveness of strengthening and stretching exercises for improving postural disorders [43].

Bayattork M. Seidi F. Minoonejad H. et al. Effectiveness of a comprehensive corrective exercise program and subsequent detraining of aligned muscle activation and movement patterns in men with upper cross syndrome: protocol for a parallel group randomized controlled trial. Trial 21 255 （2020）。 https://doi.org/10.1186/s13063-020-4159-9

In contrast, a functional (neurological) approach to musculoskeletal problems is based on the interaction of the central and peripheral nervous systems and the involvement of muscular and skeletal structures in generating and controlling movement [44]. In this function method Musculoskeletal problems are attributed to the role of muscles in motor function; moreover, changes in alignment result not only from changes in muscle length and strength, but also from more important changes in muscular neuromuscular factors such as muscle recruitment [40]. In fact, the motor Due to the presence of dysfunction, the control unit may change the muscle activation strategy to achieve temporary stabilization. These changes in motor recruitment will alter the muscle balance movement pattern and ultimately the motor program [39]. Likewise, Hodges et al. Take note of the motor control Interventions need to be tailored to each individual’s postural muscle activation and movement patterns [45].

There have been some studies showing an effective exercise program for people with UCS, one of which is the Comprehensive Corrective Exercise Program (CCEP) [46] The following is a list of exercises used in CCEP:

Each workout begins with a 10-minute warm-up and ends with a 5-minute cool-down. The selected exercises are divided into three phases: initial improvement and maintenance.

The initial phase exercises (Fig. 3) [46] consisted of lying supine on a foam roller at three different arm abduction angles (Exercise 1A-C), lateral external rotation (Exercise 2), lateral forward flexion (Exercise 3), and standing diagonal flexion (Exercise 3). Exercise 4) and the Military Press (Exercise 5). Students with less ability can do exercises 4 and 5 in a sitting position. Once the participant has regained his muscular balance in the static condition, he will attempt to increase upper body movement in the exercise pose. During this phase, the frequency and intensity of the exercises will increase as long as Participants are able to demonstrate high-quality movement. The initial phase lasts 2 weeks and the exercise will consist of seven sets of 10-second holds to ten sets of 15-second holds.

The goal of the improvement phase is to create the necessary organizational fit among the participants. Therefore, Thera-Bands weights and training balls will be used during this phase. Improvement phase exercise (fig. 4) including side lying dumbbell external rotation (exercise 6) Forward bend with dumbbells (Exercise 7) Standing oblique flexion with dumbbells (Exercise 8) Standing external rotation with Thera-band (Exercise 9) Standing diagonal flexion with Thera-band (Exercise 10) 11) Prone V T and W Exercises (Exercise 12) and Abduction Standing on a Balance Board (Exercise 13). Advances the practice by considering the individual characteristics of each participant and observing the principles of overloading and the progression of the number of repetitions per set over 4 weeks improvement stage. Exercises will range from five sets of 10 repetitions to six sets of 15 repetitions.

Maintenance phase exercises: The exercises are the same as in the improvement phase, without any progression in intensity and frequency. The duration of the maintenance phase was 2 weeks [46].

V. Janda strongly believed that the CNS and motor system function as a unit of the sensorimotor system. He recommends dividing treatment into three phases:

Normalization of peripheral structures. All peripheral structures outside the CNS must be processed to improve the quality of incoming information received by the CNS.

• Central Indirect Technique: Vojta is close to Primal Reflex Release Technique (PRRT) and Feldenkrais.
• Local direct technique: soft tissue technique, nerve tension technique and neurodynamic joint movement technique, etc.
• Restores muscle balance. As a prerequisite to improving coordination, the balance between the phasic and tonic musculature must be improved.
• Promotes afferent system and sensorimotor training. This training improves motor coordination and thus promotes optimal mechanical loading of biological structures and efficient movement execution [1].

Other Science-Based Evidence Articles

1. Apoorva Phadke et al. In this study it was concluded that muscle energy techniques were superior to stretching techniques in improving pain and dysfunction in patients with mechanical neck pain [47].
2. Rasoul Arshadi et al. In this study, an eight-week course of corrective exercises balanced muscle activity for the management of developing upper quadrant musculoskeletal disorders in UCS patients [48].
3. Arshadi R. et al. In this study it was concluded that eight weeks of corrective exercise successfully decreased the activity of the SCM and UT muscles and the UT/SA and UT/LT ratios increased the activity of the SA and LT. With regard to the large effects observed, it can be said that corrective exercises (stretch strengthening and Stability exercises) are a safe and low-cost way to optimize the upper quadrant muscles. Corrective exercises can be suggested as an effective way to restore and maintain the balance of muscle activity in patients with UCS [49].

Differential Diagnosis

• Scheuermann’s Kyphosis
• Stress and anxiety
• Pseudoradicular syndrome
• Scalene syndrome