Upper Crossed Syndrome [CASE STUDY]

Before After Charlotte.jpg

Upper Crossed Syndrome

Upper Crossed Syndrome (or UCS) is a muscle imbalance usually as a result of poor posture, which is common in a sedentary lifestyle. Typically the chest and suboccipital muscles are shortened and the muscles in the front of the neck (deep cervical flexors) and the back are lengthened.

How Can It Develop

Our bodies are always working to be efficient, which means it will adapt to different environments and situations and meet the demand. If you repeat a movement (or lack of movement) over a sustained period of time, your body will adapt to it. This happens at a cellular level. If a muscle cell is not stressed enough, it will shrink and get weaker, because there is no demand to be anything more.

In sedentary life, the structures involved in UCS adapt to become energy efficient for that type of lifestyle and poor posture develops as a result.

Who is the case study

Charlotte W., aged 22 is currently studying public policy and HR in her third year. Her daily routine currently involves sitting for much of her day and minimal physical activity. She had been an active participant of group fitness at a commercial gym in the past, although she has struggled to find effective ways to improve her posture directly.

She came in with upper crossed syndrome and wanted to work on getting her posture corrected, as well as feeling more confident in her daily life. Charlotte did not have access to any equipment outside of what she had in her own home.

Assessment and Analysis

Original assessment consisted of standing posture analysis, muscle strength, and function tests.

Charlotte Posture Initial.JPG

Initial posture analysis:

  • Rounding in thoracic spine

  • Forward head

  • Protraction of both scapula

  • Anterior tilting of both scapula, although more pronounced on right

  • Slightly Elevated left scapula

  • Slightly Internally rotated at the shoulders

  • Slight anterior pelvic tilt

Once cued, Charlotte could pull her shoulders back, bring her head in to neutral and stand upright with near ‘optimal’ posture. However, she reported that it was very uncomfortable for her to do so.


Core strength and function:

The overall core (primary and secondary in combination) was tested for functionality and strength using the deadbug and plank exercises, because a strong core is responsible for large amounts of stability in all movements. The muscles would need to be functioning together efficiently to ensure no compensatory movements take place through training or daily life.

This was tested initially through the Deadbug exercise, where Charlotte lay in a supine position with her legs and arms held out in front. She then lowered one arm and one leg on alternate sides slowly towards the ground while maintaining a flat back or lumbar flexion against the floor to cue in lower abdominal activation.

  • It was found that the Deadbug position was very difficult to maintain and no abdominal activation could be felt by Charlotte.

  • A plank was then tested, where Charlotte could instantly feel her core muscles engage. After spending time in a plank, Charlotte could then activate her core muscles in a Deadbug.

  • The cue ‘squish your back into the ground’ worked well to keep lower abdominal activation throughout the Deadbug.

  • The abdominals fatigued after a few sets of Deadbug, indicating that strength needed development.


Serratus anterior muscle strength and function:

Serratus anterior was tested to check functionality and strength. This is because the serratus anterior muscle is responsible for a lot of stabilisation of the scapula and if it is inactive, a ‘winging scapula’ is often seen.

An inactive serratus anterior would make control of the scapula much more difficult, and would need addressing to help improve the symptoms of UCS.

The serratus anterior was tested first in a supine position by getting Charlotte to reach with one arm while externally rotating. She then slowly flexed from the shoulder into an overhead position. Throughout this, the serratus was tested for activation through palpitations and verbal questioning.

  • The serratus anterior was tested for strength and function. Activation was not felt by Charlotte initially, until touch feedback was given through palpation. Once the sensation of an activated serratus was established, Charlotte could activate it at will, although it took a great amount of concentration.

  • Once comfortable activating both sides in a supine position, Charlotte moved into more exercise based activation that integrated multiple movements. The starting point was a basic Arm-bar, where Charlotte had to lay on one side and hold a weight out above her with her arm externally rotated, using her serratus anterior to help stabilise. We used this exercise to measure overall progression with the serratus anterior.

The Treatment Plan

The treatment plan we established was to move with optimal posture through various movement patterns. Over the 6 weeks we used various stabilisation exercises specific to UCS as well as more general movement patterns to develop overall strength for functional daily life. This progressive approach allowed for observable changes in movement patterns, towards the end goal of Charlotte moving without having to think about it.

Weekly breakdown of sessions:

Week 1

Initial assessments as described above. The following exercises were coached during the session and given as homework:

  • Plank for 30 seconds

  • Deadbug 2 sets of 10

  • Wall slide 2 sets of 10

Week 2

Deadbug progress: Charlotte can now get legs closer to full extension without losing tension in abdominals. The wall slide has also shown improvement. The arms are getting further up the wall without having any of the form breaking down.

New Exercises: The ‘T-Bar’, ‘Arm-Bar’, and a modified Sphinx exercise was introduced to look at shoulder and neck stability in more complex movements. Demand for activation of the shoulder stabilising muscles is much higher in these position than in any prior movements completed.

T-Bar: this exercise focuses on teaching scapula retraction, strengthening the rhomboids, middle trapezius, and lower trapezius. It is described below:

  • For the T-Bar exercise you start lying on your back with your scapula pinching the floor to keep you stable. With your legs raised and bent at 90°, slowly move your legs from left to right while holding your contact to the ground with your scapula.

Charlotte responded well when cued to ‘grab the floor with your shoulders’, holding tension through her back. This became much more difficult when she began tilting her legs from side to side, and continually verbal cueing was needed to maintain a hold on the floor.

Arm-Bar: this exercise demands the shoulder stabilising muscles such as serratus anterior and lower trapezius to work to balance a weight using optimal position. It was taught as described below:

  • Start in a side lying position with the arm which is not in contact with the ground balancing a weight above you. This provides a proprioceptive cue for the body, as it’s optimal to hold it vertical. Using stability demand in this way with proper coaching of the shoulder mechanics develops the muscles to be able to engage in context to function.

The serratus anterior was both visually more active, and could be felt to be activating much more through touch feedback (palpations) during the Arm-Bar, than it had been during initial assessment.

Modified Sphinx: this exercise was introduced to help reduce tension in the neck by encouraging proper alignment of the cervical spine. It was also used to increase cervical rotation (moving your head from side to side) in a better position, as opposed to the relatively fixed range associated with UCS.

  • For the Sphinx exercise begin by lying on your stomach with your elbows directly underneath your shoulders, and your palms flat on the floor. From here prop your chest up by pushing through your forearms, and keep your back arched. Next, pull your neck back and tuck the chin, then slowly rotate the head from side to side over a count of 5 seconds.

During this exercise, it was noted that rotation of the cervical spine needed improvement as end range of motion could not quite be reached.

In session:

  • Deadbug 2 x 10

  • Wall slide 2 x 10

  • Arm-Bar 3 x 10 second holds each side.

  • T-Bar 2 x 10

  • Sphinx 2 x 10

At home exercises:

  • Deadbug 2 x 10

  • T-Bar 2 x 10

  • Wall slide 2 x 10

  • Sphinx 2 x 10

Week 3

We continued with week 2 in session exercises. The Arm-Bar was progressed to involve a slow roll of the hips towards the ground to increase the stability demand of the serratus anterior, lower trapezius and rhomboid muscles. The T-Bar was removed from homework this week as it was beginning to be painful to perform on a hard surface at home.

In session:

  • Arm-Bar 3 x 8 (with hip roll)

  • Push up stance with a pull through 3 x 14 (wide legs for support)

  • T-Bar 2 x 10

  • Sphinx 2 x 10

  • Deadbug 2 x 10

At home exercises:

  • To sit in optimal active posture for 10 minutes out of each extended sitting session.

  • Deadbug 3 x 10

  • Wall slide 2 x 10

  • Sphinx 2 x 10

  • Push up stance pull through 3 x 14

  • Lateral neck stretch 2 x 40 second holds

Week 4

We continued with the progression of in-session exercises. Stability of the shoulder had developed enough that we looked at more complex overhead movements.

In session:

  • Deadbug 2 x 10

  • Arm-Bar 3 x 8 (heavier weight)

  • Wall slide 2 x 10

  • Walking lunges with dumbbell held overhead 2 x 12

  • Cat Camel (with a foam roller on lower back) 3 x 10

At home exercises:

  • Wall slide 2 x 10

  • Cat Camel 2 x 6

  • Deadbug 2 x 10

Week 5

Progression exercises had developed significantly. Deadbug was now being achieved with full ROM. Wall slide ROM was also much higher without compensation. Arm-Bar progressed to being done with eyes closed. We began learning the Turkish Get-up to further challenge stability in a complex movement.

In session:

  • Deadbug with a Swiss ball 2 x 20

  • Arm-Bar 3 x 8 (eyes closed)

  • Wall slide 2 x 10

  • Push up stance with a pull through 3 x 14 (wide legs for support)

  • Turkish Getup (step 1)

At home exercise:

  • Cat camel for 2 x 6

  • Bird dog 2 x 10

  • Wall slide 2 x 10

  • Deadbug 2 x 20

  • Lateral neck stretch 2 x 40 second holds

Week 6

Progression exercises now looking and feeling easy to complete. Developed the Turkish Getup through the session, and finished with a circuit to see how stability held up as fatigue set in.

In session:

  • Deadbug with Swiss ball 2 x 20

  • Wall slide 2 x 10

  • Turkish Getup (steps 1 - 4, 2 steps off entire movement)

  • Overhead farmer carries, Swiss ball plank and Turkish Getup done in a circuit.

At home exercise:

  • Cat camel 2 x 6

  • Wall slides 2 x 10

  • Deadbug 2 x 20

  • Turkish get ups (steps 1 - 3)


Before After Charlotte.jpg

The strategy implemented did show improvement in the posture presented. Her shoulders could be seen to be less rounded after the 6 weeks of treatment as well as being more upright overall. Charlotte also felt significantly stronger in her core and was able to move her shoulders through full range of motion without lumbar or forward head compensations. She is also able to perform many different movement patterns while maintaining neutral spine now.

However, as the original treatment plan was for Charlotte to move through the movement patterns without her having to think about it, we cannot say that it was entirely effective.

While Charlotte’s active posture was far more optimal now, her passive posture would revert back to nearly what it was if she relaxed for a few moments. Overall the strategy proved mildly effective as Charlotte had a lot more control of her muscles and was stronger, but would need alteration to increase its effectiveness for her patterns to happen more subconsciously.


If this case study were to take place again some changes would be made to increase the effectiveness of treatment.

  • To enhance the results of the treatment, total duration of the plan would likely need to increase.

  • Good communication between client and trainer is a major factor in determining the effectiveness of treatment. If this case study were to take place again I would ensure that the client knew the purpose of each exercise prescribed throughout treatment. This is important as people are much more reluctant to attempt an exercise they’re not comfortable doing if they don't know the importance of why they’re doing it.

  • Greater emphasis on the Cervical spine positioning would also be needed. Charlotte’s Thoracic and Scapula mobility improved dramatically, however her Cervical spine positioning did not. Chin tucks would likely help as they help strengthen the deep neck flexors. Activating the Longus Capitis and Longus Colli in combination with chin tucks would strengthen a more neutral cervical spine position. Chin tucks also stretch the suboccipitals which are responsible for extension of the upper most part of the neck. This would likely improve the forward head, by strengthening it in a more optimal position.

  • As well as chin tuck, some manual therapy techniques on the neck could be introduced to improve proprioception (awareness) to the area and reduce tension there before exercise. Exercises that could help would be massage of the suboccipitals and the upper trapezius.

A combination of; manual therapy, chin tucks, and improved communication between trainer and client, would likely result in an overall more effective result.