Upper Crossed Syndrome

What is Upper Crossed Syndrome?

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Is posture that important?

Upper Crossed Syndrome bodytonic clinic SE16 London

Upper cross syndrome is a postural condition and before I define what it is, I have to talk about the importance (or unimportance!) of posture.
Posture. A buzzword in the work office setting and is probably going to be a hot topic for many years to come. In the physical therapy world, the word “posture” is almost a taboo word, believe it or not. Whether we’re talking about osteopathy or physiotherapy, posture is a seriously debated topic. Why? Well, historically, the thought process was that “poor posture” can cause pain. Is this the case? No. Over the past decade or so, many studies (Swain et al., 2020) have shown that having a posture that is not ideal does not cause pain. The scientific evidence is simply not there and the relationship between “poor posture” and pain is very poorly correlated (Slater et al., 2019).
So why is everyone still almost semi-obsessed with having the “perfect” posture? It’s likely due to false beliefs from being brought up, about how we have been raised in a culture where lifting or sitting in a poor position will induce pain, but according to the latest research, it doesn’t! Another reason could be how people who have sat on a chair for 8 hours during work and suddenly get up and then experience back pain. The primary factor they will link with their back pain is the posture they have been in for 8 hours, and not the fact they haven’t been moving, which is the more likely factor for their back pain. I believe it depends on a combination of both the osteopath or physiotherapist and the patient themselves on how much emphasis they should address the posture as a potential factor for their discomfort.

What is Upper Crossed Syndrome?

So bearing in mind that posture is not the cause of neck or back pain, but more as a factor for pain, we can now define what upper crossed syndrome is. Do you ever recall the classical “poor-looking” posture typically seen in desk-based workers and the older population? That is essentially the upper crossed syndrome presentation. Upper crossed syndrome refers to the changes in muscle activation in the upper quarter of the body, which could result in shoulder and neck discomfort (Bayattork et al., 2020). The muscles that are considered overworking, will be the pectorals (chest region) and the upper trapezius region (the upper shoulder muscles), which is an area that plenty of desk-based workers experience aches and pains. In contrast, muscles that are underworking will be the deep neck flexors (ones that tuck in your chin) and the lower trapezius region (ones that put your shoulder blades into your back pockets). It is described as a “cross” because if you look from the side, the line that crosses the upper shoulders and the chest is considered the “tight” or “overworked” muscles, whereas the line that crosses it from the chin to the mid-back is considered to be “weak”.
Muscles will always have other muscles working in the opposite direction relative to them. For example, the biceps versus the triceps, or the quadriceps versus the hamstrings. Moreover, muscles can also be (roughly) divided into two categories based on their fibre type, which are tonic and phasic muscle groups. Tonic refers to muscles that have long endurance and are often called the postural muscles, whereas the phasic muscles are the dynamic muscles which are involved with movement (Mujawar and Sagar, 2019). You need a degree of balance between these types of muscle groups for optimal function, aesthetic, and possibly for pain reduction.

What are the symptoms of Upper Crossed Syndrome?

We have to view upper crossed syndrome as mainly a dysfunction disorder, rather than a disorder of pain. As mentioned before, upper cross syndrome is rarely the primary cause of neck and back pain, but it can in fact, limit optimal function of the neck and shoulder joints (Bayattork et al., 2020). An example of limiting function would be a reduction in the range of motion of the neck and shoulder, so you won’t be able to fully flex your shoulders (reach upwards towards the sky with your arms straight). If upper crossed syndrome does relate to pain, then it acts more like a catalyst for pain rather than the cause, meaning it can exacerbate existing pain (Page et al., 2010).

The main signs and symptoms are:

  • A forward head posture
  • Hunching of the upper-mid back (thoracic) region
  • Elevated shoulders
  • Protracted (rounding) of the shoulders
  • Reduction in thoracic mobility

These signs are a result of muscles groups not working in balance. The tonic muscle groups tend to be the ones that get “tight” and overworked which are:

  • Upper fibres of the trapezius – the big meaty upper shoulder neck muscles
  • Pectorals – these are your main chest muscles
  • Levator scapulae – this is a muscle that raises (or “elevates”) the shoulder blade (or “scapula”)

On the other hand, the phasic muscles are the ones that can be “weak” as they are not being activated and not being used which are:

  • Lower and middle fibres of the trapezius – the trapezius muscle is actually very large and extends all the way to your lower back
  • Deep neck flexors – these are the ones that tuck in your chin and helps maintain good looking posture
  • Serratus anterior – also known as the “punching” muscle. It lives between your shoulder blade and the ribcage and can often be seen as a fan-like muscle

What are the common causes of Upper Crossed Syndrome?

As a principle in musculoskeletal anatomy, structure governs function and vice versa. This means the shape and characteristics of bone, ligaments, muscles, tendons, etc, dictate what it does, and it goes both ways as the function can also influence the shape. This is important as we have to look at the onset of injury, as upper crossed syndrome can result from either a traumatic or non-traumatic cause. More commonly, causes of upper crossed syndrome are normally non-traumatic and develop slowly. This is where the function changes the structures of your body. For example, these could include:

  • Long hours of sitting at the desk
  • Long term use of smartphones
  • Favouring to strengthen the tonic muscle groups e.g. at the gym
  • Neglecting the use of the phasic muscles

Essentially, if you expose your body to functions that promote the use of these tonic muscle groups, the more you are going to predispose yourself to upper cross syndrome.In rarer cases, recovery from a traumatic injury can cause upper cross syndrome. Examples include:

  • A shoulder injury from a rugby tackle – this could result in the muscles surrounding the affected area to spasm due to the body’s protective mechanism.
  • Wry neck – sometimes referred to as acute torticollis, where the muscles on one side of your neck goes under spasm, likely when you get up first thing in the morning. Muscles around the area will compensate and fall into this upper cross position which is temporarily more comfortable.

Pre-existing injuries/disorders can also lead to altered movement patterns and disrupt the tonic and phasic muscle groups balance. An example is osteoarthritis (normal age-related changes) of either the neck and shoulder, which can affect its full range of motion. If this happens, because of the lack of exposure to the full ranges of these joints, the body will start to mould into a position of least resistance and pain, which is usually the upper crossed syndrome posture.

How is Upper Crossed Syndrome diagnosed?

There is no real gold standard in diagnosing upper crossed syndrome mainly because it can be assessed by a clinician by eye. There are a few tools a clinician can use such as screening tests to assess the mobility and function of the shoulder, neck, and thoracic joints. You can try this basic test out now. Try reaching up towards the ceiling with your arms above you as straight as you can. Do this while opening out your chest and standing tall. You should (hopefully!) be able to reach upwards with your hands 180 degrees from its starting position. To illustrate the impact of upper cross syndrome in overall mobility, try raising your arms again, but this time deliberately slouch and curve your mid-back by locking it in place. You should notice that your arms are unable to reach as high due to the relationship between the mid-back, neck, and shoulder joints.

What are the treatment options for Upper Crossed Syndrome?

Going back to what upper crossed syndrome is, it is the imbalance between the tonic (“tight”) and phasic (“weakened”) muscle groups. So it makes sense that the best treatment option is to reduce the tightness in the tonic area and strengthen the weakened areas! On top of this, it’s also important to strengthen the entire body with compound exercises, mainly to override the motor program adapted by your brain if you have been experiencing upper crossed syndrome for a long time (Page et al., 2010). Also being mindful of what you are trying to achieve with these exercises has also been shown to reduce any perceived discomfort (Cramer et al., 2018).

So which are the best exercises to achieve this?

The three main areas that I like to focus on first that show the quickest change are the tight pectorals, the tight upper fibres of the trapezius, and the hypomobile thoracic spine (mid-spine that is not moving well). My favourite exercises are:

  • Chest stretch using a door frame
  • Active child’s pose (modified) – focus on “sinking down” through your mid-back
  • Neck stretch – focus on relieving the tension in your upper neck

These are more focused on relaxing and relieving the tonic or “tight” areas, so the next steps are to strengthen the “weakened” areas. The following exercises are aimed to be more habitual, meaning these need to be done daily and consistently to see visible changes over time:

  • Chin tucks
  • Setting your shoulder blades – envision placing your shoulder blades into your back pockets
  • Pelvic tilts (posterior) – imagine tucking in your tailbone while lying on your back with your knees bent and feet flat on the ground.

But before you go on and try out these exercises, ask yourself, “what are your goals”? If you are experiencing pain in the upper shoulder and neck regions, it is very important to understand that having “perfect posture” is likely not going to completely fix the issue, and that pain is always going to be multifactorial. Remember, everyone is different and their position to get comfortable is always going to be unique to the individual (Slater et al., 2019). Don’t forget that posture is only a factor for any neck or upper shoulder discomfort, and not the cause. However, if your goals are to have better posture for aesthetic reasons and better shoulder and neck function, then correcting upper crossed syndrome is a more achievable goal.

Whatever your goals may be, whether it is pain relief, aesthetics, or to optimise your body’s function, an osteopath or physiotherapist is able to formulate a plan to help you on your way to achieving them.


Bayattork M, Seidi F, Minoonejad H, Andersen LL, Page P. The effectiveness of a comprehensive corrective exercises program and subsequent detraining on alignment, muscle activation, and movement pattern in men with upper crossed syndrome: protocol for a parallel-group randomized controlled trial. Trials. 2020;21(1):255. Published 2020 Mar 12. doi:10.1186/s13063-020-4159-9

Cramer H, Mehling WE, Saha FJ, Dobos G, Lauche R. Postural awareness and its relation to pain: validation of an innovative instrument measuring awareness of body posture in patients with chronic pain. BMC Musculoskelet Disord. 2018;19(1):109. Published 2018 Apr 6. doi:10.1186/s12891-018-2031-9

Kim EK, Kim JS. Correlation between rounded shoulder posture, neck disability indices, and degree of forward head posture. J Phys Ther Sci. 2016;28(10):2929-2932. doi:10.1589/jpts.28.2929

Mujawar, Junaid & Sagar, Javid. (2019). Prevalence of Upper Cross Syndrome in Laundry Workers. Indian Journal of Occupational and Environmental Medicine. 23. 54-56. 10.4103/ijoem.IJOEM_169_18.

Page P, Frank CC, Lardner R. Assessment and treatment of muscle imbalance: The Janda Approach 2010, Champaign, IL: Human Kinetics.

Slater, Diane & Korakakis, Vasileios & O’Sullivan, Peter & Nolan, David & O’Sullivan, Kieran. (2019). “Sit Up Straight”: Time to Re-evaluate. Journal of Orthopaedic & Sports Physical Therapy. 49. 562-564. 10.2519/jospt.2019.0610.

Swain CTV, Pan F, Owen PJ, Schmidt H, Belavy DL. No consensus on causality of spine postures or physical exposure and low back pain: A systematic review of systematic reviews. J Biomech. 2020 Mar 26;102:109312. doi: 10.1016/j.jbiomech.2019.08.006. Epub 2019 Aug 13. PMID: 31451200.

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