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Crossed Patterns

A common postural imbalance involves a forward position of the head, along with protracted shoulders. Janda[1] called this the ‘upper crossed syndrome’ and showed how it led to a variety of pains and problems, ranging from temperomandibular stress, to neck pain, shoulder dysfunction, thoracic outlet symptoms, inability to use the thorax normally in breathing – and many other consequences.
This pattern is associated with shortness and tightness in the cervical spine extensors, the pectoral muscles, as well as the upper fixators of the shoulder, the inhibition and weakness in the lower fixators and as well as the deep neck flexors.

The upper-crossed syndrome is also usually associated with a lower crossed pattern, in which the lower back muscles, as well as the hip flexors (psoas for example), are over-tight and short, and the abdominals and gluteal muscles are weak and not infrequently lengthened.

The stresses and strains these patterns create – affecting soft tissues as well as joints – account for much of the pain and dysfunction that make up the bulk of the work of osteopaths, physiotherapists, chiropractors and massage therapists.[2]

Evolution and Effects of Trigger Points

Distressed tissues tend to involve a major degree of ischemia – inadequate blood and oxygen supply.[3] Such tissues are a natural breeding ground for myofascial trigger point which are a major feature in all chronic, and much acute, musculoskeletal pain.[4] While it is well-known that trigger points can produce pain, it is a less appreciated fact that trigger points also alter the function of the tissues to which they refer[5] – illustrated by the case described below.

Case

A healthy woman in her mid-30s presented for treatment for severe discomfort, and at times quite severe pain, as well as some restriction in range of movement affecting her left shoulder,  ongoing for several months. She was unable to lie on that side at night.

There had been minor surgery in the region, several years earlier, following an episode of shoulder pain, involving removal of calcified tissue in the deltoid region of the upper arm.

She was tall and habitually held her head forward of its centre of gravity, with rounded (protracted) shoulders. Her lower back was very tense and arched, while the abdominal muscles were weak and lacking in tone (‘sway back’).

Examination

Both pectoralis major and minor were short (more on the left than the right), drawing the glenoid fossa, anteriorly, so that, in order to control the humerus, the rotator cuff group were at a considerable disadvantage resulting in extreme shortness of infraspinatus and subscapularis.

The scapula was unstable, poorly controlled by the lower fixators of the shoulder, and demonstrably winging whenever the arm was raised sideways or anteriorly.

A number of active trigger points were present in both upper trapezii, and an extremely sensitive active trigger point was discovered on the anterior surface of the left scapula, near its lateral border, that fired precisely into the region of the upper deltoid where she had previously been treated surgically.

Her abdominal core stabilizers muscles were all weak and inhibited.

Therapeutic Interventions

A combination of Muscle Energy Technique (MET), Neuromuscular Technique (NMT)[6] and Pilates type exercises were used to:

•    Deactivate trigger points;
•    Stretch and release over-shortened upper shoulder fixators, rotator cuff, posterior cervical, low back and hip flexor muscles;
•    Facilitate tone in the weakened lower fixator and core stabilizing muscles.

Outcome

After six weekly treatments the shoulder pain was no longer apparent, and postural improvement had been.

This suggests that treatment of the area of pain in the shoulder, without this broader postural and rebalancing focus, would almost certainly lead to failure.

Integrative Features

Whole-body, postural (crossed syndromes) patterns, impact the mechanics of the shoulder, and rehabilitation demands attention to these features as well as local muscle changes.

Trigger points influence not only pain, but secretions and other functions in target areas.

Manual treatment, combined with postural re-education, home stretching and exercise, as well as core (and scapular) stabilization (Pilates), offer an integrated bodywork approach.

References

1.    Janda V. Evaluation of Muscular Imbalance. In: Liebenson C (ed). Rehabilitation of the spine. Williams and Wilkins. Baltimore. 1996.
2.    Lewit K. Manipulation in Rehabilitation of the motor system. Butterworth Heinemann. London. 1999.
3.    Baldry P. Acupuncture, Trigger Points and Musculoskeletal Pain. Churchill Livingstone. Edinburgh. 1993.
4.    Wall PD and Melzack R (eds). Textbook of Pain. 2nd edition. Churchill Livingstone. Edinburgh. 1990.
5.    Simons D, Travell J and Simons L. Myofascial Pain and Dysfunction: The Trigger Point Manual. Vol 1. Upper half of body. 2nd edition. Williams and Wilkins, Baltimore 1999
6.    Chaitow L and Delany J. Clinical Applications of Neuromuscular Techniques. Volume 1. Upper Body. Churchill Livingstone. Edinburgh. 2000.