upper crossed syndrom explained

Upper crossed syndrome and how sitting will ruin your shoulders

Upper crossed syndrome is a postural condition that develops over time in the region of the shoulders and upper back, and the muscular imbalance creates potential risk to other structures throughout this region.

What is upper crossed syndrome?

Upper crossed syndrome is a postural imbalance that occurs in the muscles of the upper back, scapular, and shoulder joints. This condition is a result of prolonged sitting and will be exacerbated by poor posture.

While sitting, some muscles are stuck in a shortened position—a position which begins to take hold. At the same time, other muscles are stuck in a lengthened position, and these muscles become weak or inhibited.

Pertinent anatomy

It’s important to know some basic anatomy of the upper back and shoulders to understand upper crossed syndrome. First, you need to understand some of the bony anatomy (which includes the joints). Then, you can learn the muscles involved and how they are affected.

Bony anatomy

To begin, the bones of the middle and upper back are called the thoracic spine, which is comprised of 12 bones. The bones of the neck, called the cervical spine, are also involved. The cervical spine has 7 bones.

The scapulae are your shoulder blades. The attachment of your arms to the shoulder blades are your shoulder joints, and the shoulder blades are held onto your body by groups of muscles (read below).

Lastly, your ribs, clavicles (collar bones), and sternum (breast bone) are attachment sites for a few muscles involved.

anatomy of the cervical & thoracic spines, scapulae, and arms
Bony anatomy of the cervical & thoracic spines, scapulae, and arms

Muscles involved in upper crossed syndrome

Muscles that are affected in upper crossed syndrome include back muscles, neck muscles, and shoulder muscles.

  • Back muscles
    • Upper trapezius: muscles that attach from your shoulder blades to your neck and skull; these are the muscles at the top of your shoulders most commonly involved in shrugging
    • Lower trapezius: the antagonist to the upper trapezius, these muscles pull your shoulder blades downward
    • Serratus anterior: these muscles stabilize your shoulder blade; they separate (protract) your shoulder blades and hold them flush against your ribs
  • Neck muscles
    • Levator scapula: muscles that attach from your shoulder blades to your neck; these are smaller muscles that are also involved in shrugging
    • Sternocleidomastoid: a two-part muscle that attaches from your skull to your collar bones and sternum; these muscles can turn your head or flex your head/neck (i.e. looking down)
    • Deep neck flexors: these muscles stabilize your cervical spine and are primarily involved in a chin-tuck action (pulling your head back over your shoulders)
  • Shoulder muscles
    • Pectoralis major: your chest muscles; these muscles pull your arms in front of you and towards the middle
The pectoralis major, sternocleidomastoid, and serratus anterior muscles
The pectoralis major, sternocleidomastoid, and serratus anterior muscles


Upper crossed syndrome occurs when prolonged poor posture (most often sitting) creates tightness in some muscles and inhibition of others.

Tight or hypertonic muscles

Many people have a tendency to sit or stand with their shoulders rounded forward and their head and neck looking downward.

In this position, the pectoralis major and sternocleidomastoid muscles described above are shortened from the forward rounding position.

At the same time, the shoulder blades tend to be shrugged, creating shortness in the upper trapezius and levator scapula muscles. Over time, the muscles begin to hold in this shortened position.

This response to shortening is described as chronic hypertonicity. A hypertonic muscle is one that has an unconscious, partial contraction. A hypertonic muscle will also have resistance to stretching due to this low-grade contraction.

The tight or hypertonic muscles in upper crossed syndrome include:

  • Pectoralis major
  • Sternocleidomastoid
  • Upper trapezius
  • Levator scapula

These tight muscles will pull on the bones to which they attach, even when you’re not sitting or standing with poor posture.

Weak or inhibited muscles

While in this rounded position, the lower trapezius, deep neck flexors, and serratus anterior muscles described above are inactive.

Over time, this prolonged inactivity combined with the antagonist muscle tightness (hip flexors and lumbar erector spinae) creates weakness or inhibition of these muscle groups:

  • Lower trapezius
  • Deep neck flexors
  • Serratus anterior
Tightness occurs in the upper trapezius and weakness occurs in the lower trapezius
Tightness occurs in the upper trapezius and weakness occurs in the lower trapezius

Muscle imbalance

Tightness of the pectoralis major, sternocleidomastoid, upper trapezius, and levator scapula along with weakness/inhibition of the lower trapezius, deep neck flexors, and serratus anterior creates a postural imbalance in the upper back, neck, and shoulders.

The postural imbalance noted in upper crossed syndrome is a forward rotation and shrugging of the shoulders with an forward leaning position of the head and neck.

This imbalance may lead to mechanical or postural neck pain.

Signs & symptoms

As a postural imbalance, upper crossed syndrome does not necessarily present with pain or other symptoms. The signs of upper crossed syndrome are the same details as described in Pathophysiology.

  • Muscular imbalance
    • Tight or hypertonic: pectoralis major, sternocleidomastoid, upper trapezius, levator scapula
    • Weak or inhibited: lower trapezius, deep neck flexors, serratus anterior
  • Postural imbalance
    • Forward rounded shoulders: the shoulder joints will be pulled forward and inward
    • Shrugged shoulders: the shoulder blades will be elevated
    • Anterior head carriage: the mid-back, head and neck will be flexed forward, and the head will not be flush over the shoulder joints

Other symptoms may include:

  • Neck pain
  • Shoulder pain
  • Decreased range of motion of the shoulders, mid-back, and neck
  • Feeling tightness or discomfort with shoulder or neck movements

Common mechanism of injury

The mechanism for the onset of upper crossed syndrome is simple and straight forward. Prolonged poor posture, most often from sitting, will lead to the muscular imbalance.

poor posture is a common mechanism for upper crossed syndrome
Prolonged poor posture while sitting is a common mechanism for upper crossed syndrome

Prevention & rehabilitation: how do you fix upper crossed syndrome?

Likewise to the mechanism, prevention is simple and straight forward. Check your posture, and avoid prolonged sitting by taking breaks.

However, there are other preventative measures to reduce your risk of developing upper crossed syndrome if you are stuck in a seated position for many hours per day.

Sometimes, a simple reminder can help to keep your body in a better position. However, prolonged sitting—especially in a poor position—will create the muscular imbalances described earlier.

When this happens, simply thinking about sitting more appropriately may still be ineffective. So, we developed Power-Up Posture with 21 exercise and stretches to help improve your posture!

Power-Up Posture

Power-Up Posture: gamer guide to a healthy career

Power-Up Posture is an exercise and stretch program designed to counter the ill-effects of prolonged sitting. The program is effective for both prevention and rehabilitation of upper crossed syndrome.

Power-Up Posture is a comprehensive program to stretch and relax the hypertonic muscles and to stimulate activation and strengthening of the inhibited muscles affected in upper crossed syndrome.

Through participation of this program, you can effectively prevent these muscular imbalances and reduce pain associated with prolonged sitting and poor posture.


  1. Bae WS, Lee HO, Shin JW, Lee KC. The effect of middle and lower trapezius strength exercises and levator scapulae and upper trapezius stretching exercises in upper crossed syndrome. Journal of Physical Therapy Science. 2016;28(5):1636-1639.
  2. Arshadia R, Ghasemia GA, Samadib H. Effects of an 8-week selective corrective exercises program on electromyography activity of scapular and neck muscles in persons with upper crossed syndrome: Randomized controlled trial. Physical Therapy in Sport. 2019;37:113-119.
  3. 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. BioMed Central Open Access. 2020;21(255).
  4. Abdolahzad M, Daneshmandi H. The Effect of an 8-week NASM Corrective Exercise Program on Upper Crossed Syndrome. Journal of Sport Biomechanics. 2019,5(3):156-167.

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This information is for educational purposes only and is not intended to replace the advice of your doctor. Esports Healthcare disclaims any liability for the decisions you make based on this information.

The information contained on this website does not establish, nor does it imply, doctor-patient relationship. Esports Healthcare does not offer this information for diagnostic purposes. A diagnosis must not be assumed based on the information provided.

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