Upper Cross Syndrome: Assessment & Management in Family PracticeHKDU Symposium Dec 2014

Dr. Ngai Ho Yin AllenFamily Medicine SpecialistPGDipMusculoskeletal Medicine MBBS(HK), DCH(London), DFM(CUHK), DipClinDerm(London), FRACGP, FHKCFP, FHKAM(Family Medicine)

Muscle imbalances can spread through the muscular system in a predictable manner

Janda (1987, 1988) has classified these patterns as:1. Upper crossed syndrome

2. Lower Crossed syndrome &

3. Layer syndrome

The crossed syndromes are characterized by alternating sides of inhibition and facilitation in the upper quarter and lower quarter

Janda’s Crossed Syndromes

The Upper Crossed Syndrome

Facilitation of: Suboccipital muscles

Upper trapezius,

Levator scapulae,

Sternocleidomastoid, and

Pectoralis muscles

Inhibition of: Deep cervical flexors

Lower trapezius,

Serratus anterior, and

Rhomboid muscles

The Upper Crossed Syndrome

Weak deep cervical flexors

Weak lower trapezius,

rhomboids, serratusanterior

Tight suboccipitals, upper trapezius, levator scapulae

Tight sternocleidomastoid, pectoralis muscles

Muscles Inhibited in UCS

Deep neck flexorsLower trapezius

Serratus

anterior

Rhomboid muscles

Forward head posture increases stress on upper cervical segments

Cervicogenic headache occured more often in people with anterior head positioning (J Manipulative Physiol Ther. 2004)

According to Travell & Simons trigger point theories, anterior head positioning has significant contributions to the perpetuation of myofascial TrPs in the head, neck and shoulder muscles, as well as TMJ disorders

Anterior Head Positioning

Suboccipital, posterior cervical, upper trapezius and splenius capitis muscles contract and shorten to bring the head into extension to allow the eyes to gaze forward

Consequences of UCS (1)

Loss of cervical

lordosis & flattening

of cervical curve

TrPs development

causing headache and

neck pain

TrP Referred Pain Pattern of Suboccipital Muscles

TrP Referred Pain Pattern of Posterior Cervical Muscles

TrP Referred Pain Pattern of Upper Trapezius

TrP Referred Pain Pattern of Splenius Capitis

Sternocleidomastoid and splenius cervicis placed in a mechanical disadvantaged position as a result of reduced cervical lordosis

Consequences of UCS (2)

Muscle overloading & TrP

development causing headache and

neck pain

TrP Referred Pain Pattern of Sternocleidomastoid

Sternal division Clavicular division

TrP Referred Pain Pattern of Splenius Cervicis

Suprahyoid and infrahyoid muscles placed in stretched position

Consequences of UCS (3)

Counteracting force of

mandibular elevating

muscles

Increased intra-articular

pressure of TMJ

Muscle TrP

development

causing ear pain,

facial pain and

jaw pain

TMJ Dysfunction

TrP Referred Pain Pattern of Digastric Muscle

Posterior belly TrP Anterior belly TrP

TrP Referred Pain Pattern of Temporalis Muscle

TrP Referred Pain Pattern of Medial Pterygoid

TrP Referred Pain Pattern of Lateral Pterygoid

TrP Referred Pain Pattern of Masseter Muscle

Increased cervical extension compression of C0/1, zygapophyseal joints and nerve roots

Consequences of UCS (4)

Compression of C0/1, zygapophyseal joints

and nerve roots

Degenerative changes of zygapophyseal

joints and cervical nerve root impingement

Tightness of pectoralis and upper trapezius creates an anterior force on glenohumeral joint and limits scapular upward rotation, external rotation and posterior tilt

Consequences of UCS (5)

Reduction in subacromial space

Subacromial impingement syndrome,

rotator cuff tendinosis and tear

Assessment of Upper Crossed Syndrome

Patient is observed from:

1) In front

2) Behind

3) From the side

Concentrate on head position and any asymmetry

Inspection

Inspection From Front

Observe:

1) Eye levels

2) Chin position

3) Shoulder elevation

Inspection From Side

Observe:

1) Ear lobe position

2) Exaggerated or reduced lordosis

Ideal position from side: straight line passing through earlobe and AC joint of shoulder

Clinically, assessment of anterior head position is probably the single most useful postural parameter in a patient with head and neck pain complaints

A simple test: 1. Looking at the patient from the side and

place a real or imaginary plumb line on a tangent to the crest of the thoracic spine kyphotic curve

2. Then measure the distance from this line to the depth of the cervical curve

3. This distance should be ~6cm

Measurements > 6cm indicate anterior head positioning

Anterior Head Positioning

Inspection From Behind

Observe:

1) Head position

2) Shoulder elevation

3) Scoliosis of thoracic spine

Other examination directed by patient’s symptoms. These may include:

1. Cervical spine palpation and range of motion examination

2. Neurological examination of upper limb

3. Shoulder palpation and range of motion examination

4.Shoulder impingement tests

5. Temporomandibular joint examination

6.Head and neck, shoulder trigger point palpation

Other Examinations

Management

Depends on clinical expertise. These may include:

1. Office and daily activities ergonomic assessment

2. Medications: simple analgesics and second-line analgesics as temporary pain control

3. Trigger point injections or dry-needling

4. Manual therapies

5. Home exercise prescription and postural correction (most important for long-term management)

Management in Family Practice

Different approaches:

Local anesthetic without corticosteroid and adrenaline, e.g.

0.5% procaine (less myotoxic), 1% lidocaine

Dry needling (more post-injection soreness)

One MUST know the anatomical danger zones before injection.

E.g. rhomboid injection can cause pneumothorax

Trigger Point Injection

Sternomastoid trigger point injection

Manual Therapy

Randomized controlled studies showed that spinal manipulative therapy (SMT) is effective for cervicogenic headaches, particularly those focused on treatment of the upper cervical segments (Spine 2002)

Systematic reviews of randomized control trials using manual therapy in cervicogenic headache patients suggest better outcomes compared to no treatment (Man Ther. 2010 )

Direct and indirect techniques. Generally post-isometric relaxation is much safer than high-velocity low amplitude (HVLA) techniques

Muscle energy technique for releasing

the left levator scapuae

HVLA thrust technique for treating a

C5 FRS Left dysfunction

Sternocleidomastoid and Upper Trapezius stretching exercises

Exercise Prescription (1)

Pectoralis stretching exercises

Home Exercise Prescription (2)

Levator scapulae stretching exercises

Home Exercise Prescription (3)

Deep neck flexor strengthening exercises

Home Exercise Prescription (4)

Eccentric deep neck

flexor exercises

Lower trapezius strengthening exercises

Home Exercise Prescription (5)

Rhomboid strengthening exercises

Home Exercise Prescription (6)

Serratus anterior strengthening exercises

Home Exercise Prescription (7)

Simple Shoulder Postural Exercise

Stand with feet ~4 inches apart, arms at the sides and thumbs pointing outward

Tighten the buttocks to stabilize the lower back Rotate the thumbs, arms and shoulders out and back while inhaling,

squeezing the shoulder blades together in back Maintain this position while pulling the shoulders down and exhaling Hold this position while breathing normally and correct the head

posture (see following slide)

Simple Head Postural Exercise

Perform the shoulder postural exercise first

Once the shoulder posture has been corrected, gently move the head backward to bring the ears in line with the shoulders

This must be accomplished without moving the nose up or down and without opening the mouth

Postural Avoidance (1)

Positioning of the pillow to produce relief of the sternocleidomastoid:

1. Patient supine with the corners of the pillow tucked between the chin and shoulders. NOT to place pillow under the shoulders

2. Patient side-lying with the pillow between the head and shoulder. NOT to place pillow under the shoulder so that the chin lies in the hollow of the shoulder placing the SCM and scalenes in shortened positions

Postural Avoidance (2)

Support for short upper arms: when the patient’s upper arms are short in relation to torso height, they do not reach the armrests of most chairs. This imposes sustained gravity stress on the trapezius

Select chairs with armrests of the correct height to provide elbow support

Hands-in-pockets posture can also help to relieve strain on upper trapezius

Postural Avoidance (3)

Avoid working at a desk with the head turned to one side and projected forward to see documents or a display screen

Avoid the so-called “bird-watching” posture for prolonged period

The above postures place the splenius cervicis in sustained contraction

THE END