Conditions & Treatments - Upper Crossed Syndrome


Upper Crossed Syndrome (UCS) is described as a muscle imbalance pattern located at the head and shoulder regions. It is most often found in individuals who work at a desk or who sit for a majority of the day and continuously exhibit poor posture. Vladimir Janda, MD, an expert in the research of muscle imbalances, characterized Upper Crossed Syndrome by over activity of the upper trapezius, levator scapulae, sternocleidomastoid and pectoralis muscles, and reciprocal weakness of the deep cervical flexors, lower trapezius & serratus anterior (1, 2, 3). The image above illustrates Upper Crossed Syndrome where tightness of the upper trapezius and levator scapulae crosses with tightness of the pectoralis major & minor and weakness of the deep cervical flexors crosses with weakness of the lower trapezius and serratus anterior (3). Table 1 lists the actions of muscles involved in Upper Crossed Syndrome.

Table 1 - Actions of Muscles Involved in Upper Crossed Syndrome (4)

Upper TrapeziusAction: Elevates scapula. Upward rotation of scapula. When acting with the other sections of the trapezius it retracts the scapula.

Reversed Origin-Insertion Action: Laterally flexes head & neck to side of contraction. Rotates head & neck away from side of contraction. Acting bilaterally, extends the head and neck.

Levator ScapulaeAction: Elevates scapula & downward rotation of scapula. Working with upper trapezius, elevates & retracts scapula.

Reversed Origin-Insertion Action: When scapula is fixed, laterally flexes & slightly rotates cervical spine to the same side

Deep Cervical Flexors

Longus ColliAction: Acting bilaterally, flexes cervical vertebrae. Acting unilaterally, assists in rotation to opposite side and lateral flexion.

Longus CapitisAction – Acting bilaterally, flexes cervical vertebrae and head. Acting unilaterally, rotates and laterally flexes cervical vertebrae and head to the same side.

Rectus Capitis AnteriorAction: Aids in flexion of the head and neck.

Lower TrapeziusAction: Depresses the scapula. Retracts the scapula. Upward rotation of scapula. Gives inferior stabilization of scapula. Aids to maintain spine in extension.

Serratus AnteriorAction: Protracts scapula and upward rotation of scapula. Stabilizes vertebral border of scapula to thoracic cage, along with rhomboids and middle trapezius. 

Sternocleidomastoid Action: Acting unilaterally, draws head to ipsilateral shoulder & rotates head to opposite side. Acting bilaterally, flexes head.

Pectoralis Major (sternal division) – Action: Flexion, adduction, medial rotation & horizontal flexion of the humerus at shoulder. Also extends flexed humerus. Through its action on the humerus it depresses, protracts & rotates scapula downwards.

Pectoralis MinorAction: Depresses scapula & rotates scapula downward.

Reversed Origin-Insertion action: When scapula is fixed, aids in rib elevation in forced inspiration.  

This imbalance of the muscles at the head and shoulder regions will result in postural changes and movement dysfunction for individuals who present with UCS. Individuals who present with UCS will display a forward head, haunching of the thoracic spine, elevated & protracted shoulders, and scapular winging (1, 2, 3, 5). They may complain of symptoms such as neck pain, jaw pain, upper thoracic pain & headaches given the compomised posture which results in added stresses to the various surrounding structures & tissues. Research presented at the 2009 Annual International Conference of the IEEE EMBS stated: “Over time poor posture results in pain, muscle aches, tension and headache and can lead to long term complications such as osteoarthritis. Forward head carriage may promote accelerated aging of intervertebral joints resulting in degenerative joint disease (5).”

PT Findings in Patients with Upper Crossed Syndrome
Besides the imbalances and postural deviations mentioned above, physical therapists may also find joint dysfunction particularly at the atlanto-occipital joint, C4-5 segment, cervicothoracic joint, glenohumeral joint, and T4-5 segment (3).

Upper Crossed Syndrome Treatment Options for a PT
• Postural Training / Functional Training
• Sensorimotor training
• ROM exercises
• Stretching (see videos 45, 47 & Z20 for cervical spine/neck)
• Strengthening/Stabilization (see video 43 for cervical spine/neck)
• Manual Therapy / Joint Mobilization / STM / Myofascial Release
• Modalities


When treating patients with UCS the shortened muscles must be restored before embarking on training of the weakened muscles. This is based on Sherrington's Law of reciprocal inhibition which states that when one muscle is shortened or tightened its opposite muscle relaxes (1, 2).


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Last revised: April 15, 2011
by Chai Rasavong, MPT, MBA



1) Hertling D & Kessler R. Management of Common Musculoskeletal Disorders: Physical Therapy Principles and Methods. Fourth Edition. Lippincot Williams & Wilkins. 2006;150.
2) Page P & Frank C. The Janda Approach to Chronic Musculoskeletal Pain. Accessed 4/15/11
3) Muscle Imbalance Syndromes - Upper Crossed Syndrome Accessed 4/15/11
4) Flash Anatomy - The Muscles: Origins, Insertions, Action, Innervation, Synergist. Bryan Edwards Publications. 2000
5) 31st Annual International Conference of the IEEE EMBS Minneapolis, MN. USA, Sept 2009 in article by Kapandji. 42 Pound Head. Physiology of Joints. 3;82-87.

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