Comparison of pain and scapulohumeral rhythm in female students with and without upper crossed syndrome

Khosravi, Zahra; Mohammad Ali Nasab Firouzjah, Ebrahim; Homayounnia Firouzjah, Morteza

doi:10.22034/27.1.91

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Volume 27, Issue 1 (3-2025)

EBNESINA 2025, 27(1): 91-104

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Comparison of pain and scapulohumeral rhythm in female students with and without upper crossed syndrome

Zahra Khosravi

, Ebrahim Mohammad Ali Nasab Firouzjah ^*

, Morteza Homayounnia Firouzjah

Department of Exercise Physiology and Corrective Exercise, Faculty of Sport Sciences, Urmia University, Urmia, Iran , e.mohammadalinasab@urmia.ac.ir

Keywords: pain, shoulder joint, postural balance, kyphosis, children, musculoskeletal abnormalities

Full-Text [PDF 1807 kb] (129 Downloads) | Abstract (HTML) (501 Views)

Type of Study: Original |
Received: 2024/11/2 | Revised: 2024/12/25 | Accepted: 2025/01/6 | Published: 2025/04/5

Extended Abstract: (167 Views)

Introduction

Upper Crossed Syndrome (UCS) is a common musculoskeletal condition characterized by a distinctive pattern of muscle imbalances around the neck and upper back region. Specifically, UCS involves tightness in the upper trapezius and scapular muscles on the back (dorsal side) intersecting with tight pectoralis major and minor muscles on the front (ventral side). Concurrently, this tightness is accompanied by weakness of the deep neck flexors in the front of the neck and weakness of the middle and lower trapezius muscles in the upper back [6]. This combination of muscle tightness and weakness leads to maladaptive postural changes and abnormal joint mechanics. Clinically, UCS manifests as a forward head posture, an exaggerated cervical (neck) curve, increased thoracic kyphosis, scapular protraction (where the shoulder blades move forward), and winging of the scapula [7].
UCS is notably prevalent among children and adolescents, particularly students, due to their prolonged periods of poor posture often associated with studying, screen use, or inadequate ergonomic settings. Despite its frequent occurrence, there remains a significant gap in comprehensive studies examining the full spectrum of complications stemming from UCS. These complications may include chronic neck and shoulder pain, altered scapular positioning, changes in the kinematics of shoulder movement, and disruptions to the scapulohumeral rhythm—the coordinated movement between the scapula (shoulder blade) and the humerus (upper arm bone).
Given the importance of shoulder function in daily activities and sports, understanding the impact of UCS on pain and scapular mechanics is critical. The present study aimed to address this gap by comparing neck and shoulder pain levels, as well as scapulohumeral rhythm, between female students diagnosed with UCS and those without postural abnormalities.

Methods

This study employed a causal-comparative design to investigate differences between two groups of female students: those with UCS and healthy controls. Conducted during the 2022-2023 academic year in Khalkhal city, 60 female students aged between 10 and 12 years were recruited as participants.
Initial screening involved a postural assessment using a posture assessment grid [18] to identify abnormalities consistent with UCS. Based on physical examination and objective measurements, participants were divided equally into two groups: 30 students exhibiting signs of UCS and 30 healthy controls without postural deficits.
Postural assessment involved detailed photographic analysis to measure forward head posture and shoulder angles [20]. Specific angle thresholds were used to define UCS: forward head angles greater than 46 degrees and round shoulder angles greater than 52 degrees were considered indicative of abnormal posture [16]. The photographic analysis software used for this task had been previously validated with confirmed reliability and accuracy [21], ensuring dependable measurement of anatomical angles.
Additionally, the degree of thoracic kyphosis was measured using a professional goniometer program [22]. Kyphosis was defined as a thoracic curvature angle exceeding 42 degrees [16]. Prior reliability studies of the measurement tool reported excellent intra-rater (ICC=0.88) and inter-rater reliability (ICC=0.91), supporting its use in clinical research settings [22].
To evaluate neck and shoulder pain intensity, a Visual Analog Scale (VAS) was administered where participants rated their pain on a continuum from 0 (no pain) to 10 (worst imaginable pain) separately for the neck and shoulder regions. The VAS has shown adequate validity (0.70) and high reliability (0.97) for pain assessment in similar populations [23, 24].
Assessment of scapulohumeral rhythm was performed using the Lateral Scapular Slide Test (LSST). This involved measuring the distance from the vertebral column to the inferior angle of both the dominant and non-dominant scapulae at three arm positions: neutral (0 degrees), 45 degrees, and 90 degrees of shoulder abduction. Measurements were taken using a tape measure, providing a quantifiable method for comparing scapular positioning and movement between participants [28]. The LSST test has demonstrated good reliability, with intragroup correlation coefficients ranging from 0.91 to 0.92, and is widely accepted for clinical evaluation of scapular dyskinesis [28].
Statistical analysis was conducted using SPSS software, version 26. Independent t-tests compared the differences in pain scores and scapular distances between the UCS and control groups at a significance level of 0.05.

Results

Analysis of the collected data revealed significant differences between the UCS group and healthy controls in several key outcome measures. Students with UCS reported notably higher levels of pain in both the neck and shoulder regions while at rest compared to their healthy peers (p = 0.001).
Furthermore, the scapular position as assessed by the LSST demonstrated significant abnormalities in the UCS group across all measured arm positions. At neutral (0 degrees), 45 degrees, and 90 degrees of shoulder abduction, the distances between the scapulae and the vertebral column on both the dominant and non-dominant sides were consistently greater in students with UCS compared to the healthy group (p-values ranging from 0.001 to 0.013).

Discussion and Conclusion

The findings of this study clearly demonstrate that female students with UCS experience significantly more neck and shoulder pain than those without postural abnormalities. This reinforces the hypothesis that muscle imbalances intrinsic to UCS contribute to musculoskeletal pain even at rest, supporting the observations reported in similar studies by Amiri et al., Ghaffar et al., and Jaideep et al. [29, 31, 32].
Additionally, the impaired scapulohumeral rhythm observed in UCS-affected students indicates altered scapular movement patterns during arm elevation, a finding consistent with prior research by Das et al., Ghafouri et al., and Khosravi et al. [15, 16, 33]. Proper scapulohumeral rhythm is essential for efficient shoulder biomechanics, preventing injuries, and maintaining functional upper limb mobility. Disruption in this rhythm may therefore predispose students to further musculoskeletal dysfunctions.
Mechanistically, UCS creates a vicious cycle: muscle imbalances increase tension and fatigue in affected muscles, resulting in pain, reduced range of motion, and abnormal movement patterns. Over time, these changes may instigate degenerative joint changes and chronic disability if left unaddressed.
Given these insights, early identification and intervention for UCS in school-aged children is vital. This study suggests that trainers, physical education teachers, healthcare providers, and parents should collaborate to implement corrective exercise programs aimed at strengthening weak muscles, stretching tight muscles, and improving postural alignment. Such programs could help prevent the development or progression of UCS and its associated complications, ultimately promoting better musculoskeletal health and quality of life in young populations.

Ethical Considerations

Informed consent was obtained from the parents or guardians of all participants prior to enrollment in the study. The research objectives were clearly explained, and parents were assured that the evaluation methods posed no risk to their children. Confidentiality of participants’ personal information was maintained throughout the study.

Funding

There is no funding support.

Authors’ Contributions

All authors contributed equally to the conceptualization, design, implementation, data analysis, and manuscript preparation of this study. They also take full responsibility for the accuracy, integrity, and final approval of the published article.

Conflict of Interest

Authors declared no conflict of interest.

Acknowledgments

This study is based on the first author’s master’s thesis (code IR.SSRC.REC.1401.105) and was approved by the Sports Sciences Research Institute. The authors extend their sincere gratitude to all the students and their parents for their kind participation and cooperation, which was invaluable to the successful completion of this research.

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Khosravi Z, Mohammad Ali Nasab Firouzjah E, Homayounnia Firouzjah M. Comparison of pain and scapulohumeral rhythm in female students with and without upper crossed syndrome. EBNESINA 2025; 27 (1) :91-104
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