Upper Crossed Syndrome [Case Study - Alec]

Posture Before After Image.jpg


At ONI we periodically go out to the public and ask for people to work with our specialists as case studies. The case studies have two main aims:

  • to help people live powerfully, without pain or injury.

  • provide a learning experience for the ONI team to apply the latest skills and strategies to real cases and real people.

November 2018 intake - Angelika O.

Angelika is one of our November 2018 case studies. Alec Morrison who has just recently joined the ONI team is working with Angelika to help with some of her upper body posture issues. The case study ran between 21 November to 11 December 2018.

A little bit about Angelika

  • is 21 years old

  • is a student studying fashion and design

  • works part time in retail but prior to that has had five years working in the hospitality industry

  • walks a lot but is otherwise relatively sedentary and does not actively go to the gym but has, in the past, done bodyweight/callisthenics at home.

Upper Crossed Syndrome.jpg

What is UCS?

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 always seek efficiency in functions like energy use and movement. The body adapts to different environments and situations to meet any demand on it. If you repeat a movement (or lack of movement) over a sustained period of time, your body will adapt to it and it will become your baseline position during that movement.

This happens at a cellular level. If a muscle cell is not stressed enough, it will shrink and get weaker (atrophy), because there is no demand or stimulus placed upon it. The cell itself and the muscles which are made up of these cells will then adapt and position themselves where they are strongest, with UCS generally in a position of poor posture.

This can limit range of motion and strength in certain movements. Depending on the severity of the UCS it can even stop people from doing a movement or activity altogether.

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 (see diagram above). When a person lives a sedentary lifestyle they do little or no physical activity.   

According to the World Health Organization (WHO), globally, 1 in 4 adults are not active enough. The body adapts to this lack of stimulus (the environment) and places the body in the most energy efficient position.


Angelika’s symptoms

Angelika displays UCS. Due to having UCS she suffers from neck and chest tightness, and shoulder and upper back pain. She notes that her lower back is quite tight but strong from being in a hunched position. Generally she feels quite stiff, particularly in the upper back and shoulders. She also suffers from tension headaches and tends to click her joints in her upper body and neck regularly to relieve tension.

Why would she show these symptoms?

There are a number of factors that could lead an individual to display UCS. In Angelika’s case it is likely to be related to her sedentary lifestyle and the body positions she holds when she works and studies. In hospitality she notes that her general body position is to be hunched over or carrying heavy objects in front of her which over time may have caused her to hunch over. When she studies she is seated on tables that are slightly too low for her, she notes that the tables can’t be adjusted and that her seat has no back support. These two aspects together, would also likely accentuate her UCS symptoms.

Other things of note

Angelika has a condition in which she does not have any subcutaneous tissue on her right bicep and front of her shoulder. The area is red in colour and is hyper-sensitive to touch. This condition does not affect her mobility in her arm or shoulder, and is therefore not likely to affect our prescribed method to help her UCS symptoms. However, it is something to be aware of especially if we look to do anything that has the risk of causing impact with her right bicep and shoulder

Angelika’s goals

Over the six-week case study period Angelika wants to be able to hold and maintain a good posture. When asked what ‘good’ means to her she talked about having her shoulders down, her chest up, her neck straight, her core being stronger and generally less soreness and tension.

She also associates a good posture with being confident, something she wants to display when working in retail and in general life. We agreed that working to be more dynamic in the way she moves as well as being able to achieve a ‘good’ posture for a longer period of time were goals we will strive to.



Assessment and analysis
- starting broadly and then narrowing in

Angelika is very aware of her body and is able to move herself into strong positions. The issue is maintaining those positions.

Broad test

Thoracic extension

For my first test I asked her to go into thoracic extension (one of the positions associated with ‘good’ posture). With minimal cueing Angelika was able to get into and hold that position. However, after about 20 seconds she started to feel some discomfort in her neck, shoulders and back. She also felt some strain in her core and lower back. The pain in the lower back was likely due to a compensation she made to get into thoracic extension.


Positioning arms overhead

Individuals with UCS can struggle with moving their arms into an overhead position. The overhead position requires thoracic extension and scapular movement which are commonly dysfunctional with those who display UCS.

We tested Angelika’s overhead position. She was able to position her arms overhead but again like the early test of thoracic extension she could only maintain the position for a short period of time before she felt tightness in her shoulders and upper traps. A few movement compensations were required for Angelika to get her arms into an overhead position.


These were the use of her upper trap to elevate the scapula instead of demonstrating functional serratus anterior and lower trap engagement to produce the necessary movement for overhead position. A slight forward head was also observed, perhaps indicating a shortness or lack of ability to functionally lengthen the levator scapulae. She also had a slight arching of the lower back.

Narrow test

Serratus anterior


After we went through the two assessments noted above we also wanted to test the serratus anterior. This muscle is responsible for a lot of stabilisation of the scapula. Like in the previous UCS case study we tested the functionality of Angelika’s serratus anterior. To do this we got Angelika to lay on her back (supine position) and got her to first, lift one of her arms to 90 degrees, cued her to try and let her fingertips reach the ceiling by trying to protract her scapula and externally rotate her arm while maintaining body contact with the ground. She then slowly move into flexion of the shoulder and brought her arm into an overhead position, this was then repeated for the other arm. Throughout the exercise, the serratus anterior was tested for activation through feel and questioning.

Initially, Angelika was able to feel her serratus working on the left hand side but not on the right. Through cueing and some haptic feedback from the muscle she was able to get some activation on her right side.



Our approach to achieving Angelika’s goals over the six week period

Angelika’s main goal was to be able to hold and maintain her description of a ‘good posture’. Our approach included strengthening and stability exercises, both bodyweight and with added resistance, to target weaker postural muscles as well as re-train movement patterns so that Angelika is able to hold her description of a ‘good posture’. This main goal of hers will not only help her physically but also help with her confidence, something she noted she wanted to display when working in retail and in general life. We worked hard together to achieve this as described below.

Pathway to better posture
- Sessional notes

Week 1

Week one included the consult and various assessments noted earlier. We also worked through two other exercises which she also did at home.


Description and cues

  1. Thoracic extension into a 15 second isometric hold

    Either standing or sitting, retract and depress your shoulder while extending your thoracic spine. Do not bend in the lower back or crane the neck. Hold this position for 15 seconds.

  2. T-bar

    Lie flat on your back with legs up, bent at the knees and raise them toward your chest. Lift your arms and spread them like a cross. Now try and grip the floor with your middle back and back of the shoulders. Make sure your back is flat on the ground and move your hips from side to side (as far as they can go) while maintaining this grip on the floor.

Rationale for the exercises prescribed

As Angelika was able to hold a ‘good’ posture but struggled to maintain it, the focus of week one’s exercises was to try and strengthen her thoracic extension and teaching scapula retraction while limiting any pain. The resistance in the exercises were gravity and her bodyweight which was considered to be the most effective approach to start with.

We worked on the following exercises during the session and they were also prescribed for her to do at home:

1-2 times a day:

  1. Thoracic extension and isometric hold - 3 to 4 sets of 6 reps (hold for 15 seconds)

  2. T-bar - 3 to 4 sets of 8 reps (1 rep is moving from left to right)

Week 2

During the week two session we had a recap on the previous session and talked about how she went with the exercises at home. Angelika noted that she was feeling muscles that she had not felt before in her upper back and shoulders. She noted that her tension headaches had reduced and she did not and could not click the joints in her upper back as much as she normally could.

She said that in the T-bar exercise she experienced some tightness in the hips and felt that this restricted some of her movement. To mitigate this tightness she said she incorporated some stretches, I approved of this approach and told her to continue to stretch where possible.

In the thoracic extension exercise she felt like she could maintain the position longer as the week progressed and it was not as sore when she moved into this position. She also said that she integrated this position when she walked and during other activities.


Description and cues

  1. Hip hinge

    While maintaining thoracic extension and making sure she was in strong position I got her to hinge at the hips. I cued this by getting her to imagine someone had a rope attached to her waist/hips and slowly pulled her backwards while having a slight bend in the knees. She would then slowly go back to her starting position while engaging her glutes at the top of the movement.

  2. Deadbug

    I told her to lie flat on her back with legs up, bent at the knees. Lift your arms straight up so they are at 90 degrees with her body. While her back was flat on the ground I got her to slowly alternate moving her left arm (then right) back overhead while extending her right leg (then her left) flat toward the ground. To engage her serratus anterior, I got her to try to engage it by pushing her shoulders away from the ground when in the start position and maintaining this position through the movement.

Rationale for the exercises prescribed

Angelika now had more muscle awareness in her upper back and shoulders. She was able to hold her thoracic spine in a good position without too much soreness or difficulty. This week, I wanted to add some resistance and a fundamental movement pattern to her previous exercises. I felt moving through a hip hinge while maintaining thoracic extension was a good progression. This trained her to be fluid when holding a strong position and also added more resistance to the movement as she was not just stationary.

Angelika also wanted to strengthen her core as she felt like this would help her maintain a ‘good posture’. I decided to add dead bugs while trying to activate the serratus anterior into her exercises for the week. This would not only strengthen her core like she desired but also act as another exercise to activate and strengthen the serratus.

We worked on the following exercises during the session and they were also prescribed for her to do at home:

1-2 times a day

  1. Hip hinge - 3 sets 10 reps

  2. Dead bug - 3 sets 8-10 reps

Week 3

We made it halfway through the case study and Angelika continued to make progress with both the movements prescribed and being able to hold a ‘good’ posture. Unfortunately, due to her schedule she was not able to do as much exercise as she would of liked at home. However, she was still able to do one session a day. She feels like she is getting stronger and has more control over her body. She found the dead bug exercise difficult but persisted with doing it as she feels that strengthening her core will aid in helping her maintain ‘good’ posture.

When asked how she felt the sessions were going she said that she is seeing results and that the treatment plan is really helping her and her posture issues.


Description and cues

  1. Hip hinge with arms raised to the side (like a cross)

    As last week but added resistance by getting her to extend her arms laterally and hold them in a fixed position like a cross.

  2. Lying down serratus activation

    Lie flat on the floor, keep back flat on the ground. While arm is raised at 90 degrees reach the ceiling by extending your shoulder blade. Now with a weight move arm above your head while maintaining the fixed shoulder position. Make sure the weight doesn't touch the ground and that you do the movement in a controlled manner.

  3. Deadbug

    As the previous week but without focus on serratus activation.

Rationale for the exercises prescribed

To add more resistance to Angelika’s movements I decided to get her to have her arms spread like a cross when doing the hip hinge. This position makes it a little harder for Angelika to maintain good form and enables progression with little impact to the body. Once she has mastered this movement we will look to incorporate more weight and possibly a row to the movement.

During week two when I got her to do dead bugs I tried to also get her to really focus on consciously activating her serratus anterior at the same time. However, this was too hard for her as focusing on her core and working that was difficult enough. This week we pared it back and worked on the dead bug and serratus anterior individually. I wanted to work on her serratus as getting it stronger will help stabilise her scapula and continue to strengthen her posture.

We worked on the following exercises during the session and they were also prescribed for her to do at home:

1-2 times a day

  1. Hip hinge with arms raised by the side - 3 sets 10 reps

  2. Serratus activation - 3 sets 8 reps

  3. Dead bug - 3 sets 8-10 reps

Week 4

After working with Angelika to develop her stabiliser muscles in her back and shoulders I decided to ramp up the training and begin to change the focus to building muscle in these areas. Angelika is now able to hold ‘good’ posture for longer than she ever has. We have integrated this posture into movements like a hip hinge. We are now going to add exercises like bent over rows to strengthen and further develop the muscles that assist with ‘good’ posture.


Description and cues

  1. Dumbbell bent over row

    Get into a hip hinge position with a dumbbell, extend arms and drive your elbows up in line with your back, make sure you keep you back straight (in thoracic extension) and that you row the weight in a controlled fashion (at the top of the movement your arms should be at 45 degrees). Hold the weight at the top of the movement for a second before bringing it back to the starting position.

  2. Overhead squat

    With a bar, raise your arms above your head (have a wide grip), keep this position locked and keep your body upright, make sure you try and tuck your pelvis before squatting. Try and activate the serratus and maintain it throughout the movement. When squatting imagine you are sitting down, make sure your feet are shoulder width apart and your feet are pointing outwards. Try and get your knees to track toward your smallest toe when you are squatting up and down. Also try and keep your core engaged and tight.

  3. Deadbug with resistance from band

    Do a normal deadbug and either get someone (in this case her boyfriend) to use a band/belt while you are holding it to add resistance from different angles on each side when you are doing the exercise. Alternatively you can get him to provide some resistance by trying to move you while you do the movement.

Rationale for the exercises prescribed

The bent over row keeps her in thoracic extension while the rowing movement builds and strengthens her back. In previous weeks we got Angelika to feel and activate her serratus. This was in a lying down (supine) position which gave her support from the ground. A progression for the serratus is to do overhead movements. I decided that an overhead squat would provide more stress to the stabiliser muscles in her back and shoulders and also push her a bit more than in previous weeks. The deadbug with added resistance not only makes the movement harder but also trains her body to cope with stress from different angles and planes which is transferable to movements in daily life like reaching or twisting to pick up an object.

We worked on the following exercises during the session and they were also prescribed for her to do at home:

Once a day or five times a week

  1. Bent-over rows - 3 sets 10 reps

  2. Overhead squat - 3 sets 8 reps

  3. Deadbug with band/belt resistance or with your boyfriend nudging you - 3 sets 6 reps

Week 5

This was the penultimate week of the case study. Angelika said she is feeling stronger and did her best to do the prescribed exercises at home with limited gym equipment. This week I wanted to keep on challenging Angelika and help her develop strength and muscle so that she can maintain a ‘good’ posture for longer. Ultimately we wanted this to become her new baseline.


Description and cues

  1. Overhead squat

    As last week however, we spent more time working on the movement and in particular stabilising the scapula while maintaining good form throughout the movement.

  2. Dumbbell bent over row

    As last week

  3. Face pull

    With the cable machine or with a resistance band, from a standing position, hold onto the cable with your fists in the air, step away until you get tension in the cable, have a slight lean backwards and squeeze your glutes together. Pull the cable towards your face, make sure your elbows are higher than your shoulders, hold for one second and then repeat.

  4. Bird dog

    Effectively the same movement as the dead bug but without the floor supporting your torso. Get on all fours, extend left arm while extending right leg then repeat for the other arm and leg. Make sure the back remains flat and that you limit rotation in the hips.

Rationale for the exercises prescribed

I added a face pull to her routine to give her a different exercise to help with scapula retraction. Being able to do a face pull in itself showed Angelika that she has made a lot of progress from week one. She said to me that ‘if this was the first week of the case study I would be not able to do this movement properly’. The next new exercise I prescribed this week was the bird dog. This movement is a natural progression for the dead bug and also tests her balance.

We worked on the following exercises during the session and they were also prescribed for her to do at home:

Once a day or five times a week

  1. Overhead squat - 4 sets 8 reps

  2. Bent-over rows - 4 sets 10 reps

  3. Face pulls - 3 sets 8 reps

  4. Bird dog - 4 sets 8 reps

The final week - week 6

For the final week of the case study we recapped on the progress Angelika has made and also progressed her exercises from the previous week. This week we added a unilateral bent over row and a push up to her treatment plan.


Description and cues

  1. Overhead squat

    As last week however, we increased the rep range and set number to continue to challenge Angelika.

  2. Dumbbell bent over row - unilaterally

    As last week, but we focused on getting her to stabilise her scapula and upper body by challenging her to row one arm at a time.

  3. Push up

    We got Angelika to initially do push ups against a wall. She found it too easy so we progressed to doing push ups against a bench. This was an incline push up which she did on her knees. I made sure her back was flat and in a strong position while her arms and head formed an arrow shape as she pressed herself up. One other cue was to keep her core tight, this maintained a strong position throughout the movement. I could tell her serratus was activated as there was no winging in the scapula.

  4. Bird dog

    As last week but with more repetitions and a slower movement tempo to increase resistance through the movement

Rationale for the exercises prescribed

I progressed the bent over row to a unilateral row to challenge her hinge position and to try and work both sides of her body equally. I also prescribed a push up to her regime to provide further balance and stability to her scapula and upper back. Previous exercises have focussed on scapula retraction. However, to be able to maintain a ‘good’ posture and to be able to move in and out of different positions different exercises that cover different movements/actions are a necessity.

We worked on the following exercises during the session and they were also prescribed for her to do at home:

  1. Overhead squat - 4 sets 10 reps

  2. Unilateral bent-over rows - 4 sets 10 reps

  3. Incline push up - 3 sets 8 reps

  4. Bird dog - 4 sets 10 reps

Angelika beginning her overhead squat

Angelika displaying overhead position at end of case study.jpg


In six weeks Angelika made some visible changes in her standing posture. However, what I was most proud of was the changes she felt physically and the tools she now has to maintain a ‘good’ posture. In particular, Angelika is not as sore as she used to be, she has less tension headaches and is much more mobile.

When Angelika and I reflected on her goals at the start of the six week training period, she agreed that she had made significant progress in achieving them. She is now more conscious of her static posture and is actively incorporating a ‘good’ posture in daily activities like walking etc.

Angelika, through this case study has the tools to maintain and even strengthen her posture. Going forward, it will be up to her to continue her exercises and put the tools she has at her disposal to good use.


On reflection, if this case study was to be repeated, the aspects I would have considered altering are:

  • Increasing the frequency of sessions between the trainer and the case study client to take the treatment plan to the next level

  • Incorporating pushing exercises like a push up earlier in the treatment plan instead (e.g. week 5) of extra scapula retraction and stabilisation exercises like the face pull

  • Adding a targeted mobility routine, perhaps including both stretching and soft tissue work, to the treatment plan may have also aided in improving posture through relieving tension and complementing the strength based exercises prescribed

  • Spending more time at the beginning of the case study to learn more about the client and how they tick may also further help buy-in into the treatment plan.