Saturday, October 10, 2015

Head Forward Posture: Part 2 - Upper Cross Syndrome and the Sinew Channel

In the last post I discussed how a head-forward posture can, due to the additional load on the posterior cervical region, contribute to several injuries and orthopedic disorders. In this post, I will discuss a common relationship that a head-forward posture has with the shoulder girdle. The sinew channel relationship to this imbalance will also be discussed with the emphasis on the importance of assessing and treating this common pattern with acupuncture, tuina, and corrective exercises. In the next post, we will look at how this postural pattern relates to zangfu disharmony. Acupuncturists can greatly improve their results by recognizing and addressing this common postural imbalance when treating a wide range of conditions.

Upper cross syndrome describes a common postural pattern first discussed by Vladamir Janda, a Czech physician. Janda described this common upper body muscle imbalance as an X with one leg of the X consisting of a group of overactive (locked-short)* muscles and the other consisting of a group of inhibited (locked-long) muscles. This common pattern is seen with a head-forward posture and scapular protraction. 
*Note: locked-long and locked-short is terminology used by Thomas Myers and also employed by Sports Medicine Acupuncture. The tendency is for practitioners to think that inhibited muscles will feel soft and weak on palpation and that overactive muscles will feel ‘tight’. The reality is that there is often tension in both and they are both locked, one in a lengthened position, the other in a shortened. For practitioners of Chinese medicine, it might be helpful to consider the terms 'deficient' and 'excess.'

The muscles that contribute to this imbalance are listed below and grouped according to the overactive, locked-short leg of the X and the inhibited, locked-long leg of the X:

  • Overactive: Pectoral muscles, posterior cervical extensors, levator scapula, upper trapezius
  •  Inhibited: Lower and middle trapezius, anterior cervical flexors

Pectoralis minor, highlighted in red, pulls in and down in the front. Lower and middle trapezius (and rhomboids), highlighted in blue, pulls in and down in the back. When maintaining a balanced tone, this stabilizes and balances the shoulder girdle. The common muscle imbalance seen is for the pectoralis minor (red) to be overactive and the middle and lower traps (blue) to be inhibited.

The pectoralis minor is particularly important in its influence on scapular protraction as it has direct attachments to the scapula at the coracoid process. From the coracoid process, the pectoralis minor has an attachment to the 3rd, 4th, and 5th ribs. The fibers attaching to the 3rd rib have a relatively more horizontal fiber direction compared to the more vertical 5th rib attachment. This line of pull creates a medial rotation of the scapula, while the 5th rib attachment creates more of an anterior tilt. Scapular protraction often has components of both of these when the pectoralis minor is short.

The lower and middle trapezius, highlighted in blue, balancing
the pull of the pectoralis minor, highlighted in red. 
Balancing this line of pull is the lower and middle trapezius and the rhomboids. The lower trapezius balances the downward pull of the pectoralis minor while both the middle trapezius and rhomboids counter the movement of the scapula away from the midline. Both the lower and middle trapezius and the rhomboids have a tendency to become inhibited and fail to properly resist the pectoralis minor.








From A Manual of Acupuncture, by Peter Deadman. Notice
the connection of the LI sinew channel to the thoracic spine.
For acupuncturists, it can be very informative to review the pathway for the Large Intestine and Lung sinew channels. The Large Intestine sinew channel expands the influence of the primary channel as it attaches to the thoracic spine. I believe this to include a continuous sequence of muscles and fascial structures which start with the first dorsal interosseus muscle (accessible at LI-3 and LI-4) and continuing up the arm to connect, via the middle and lower trapezius, to the thoracic spine. The Lung sinew channel begins at the thenar muscles and continues up the arm to connect, via the pectoralis minor, to the ribs.

What this means is that the internally-externally related Lung and Large Intestine sinew channels work together to balance the shoulder girdle on the ribcage. When there is an imbalance between these two related channels, this is frequently seen with scapular protraction.

However, upper cross syndrome also describes cervical muscle imbalance. This includes the overactive cervical extensors on the posterior neck and the inhibited cervical flexors on the anterior neck. These can also be seen as an imbalance between internally-externally related sinew channels. The Urinary Bladder sinew channel includes the posterior cervical muscles, while the Kidney sinew channel includes the deep anterior cervical muscles such as the longus colli and longus capitis.

Even the pectoralis major can be seen to have a connection to the Urinary Bladder sinew channel. Through the thoracolumbar fascia, the Urinary Bladder sinew channel has a branch that I interpret as the latissimus dorsi. The latissimus dorsi attaches to the medial lip of the bicipital groove, in very close proximity to the attachment of the pectoralis major. However, classically the sinew channels are said to converge, and I believe the pectoralis major to be also part of the Heart sinew channel, so it is a region where the Urinary Bladder and Heart sinew channels converge.

BL-60 Kunlun, from A Manual of Acupuncture, by Peter Deadman
Also, there is a branch that attaches to the shoulder and connects with another area of convergence, the lower trapezius (this time converging with the LI sinew channel). In my view, both of these branches of the Urinary Bladder sinew channel (lats and lower traps) help explain how excessive pathological Yang can rise and contribute to tension manifesting in excess (overactivity) in the neck, shoulders and chest. It is helpful to review commentary about BL-60 Kunlun and understand that this point ‘Clears heat and lowers excess’. In addition it ‘pacifies wind and leads down excess’. This involves Liver disharmony with pathological Yang rising up the Urinary Bladder channel. This rising Yang often contributes to occipital headaches, neck pain, and shoulder pain. BL-10 Kunlun treats the manifestations of this rising Yang, often in combinations with SI-3 Houxi. Being a Jing-River point, it is an excellent point to relax the sinews, in this case associated with the Urinary Bladder sinew channel.

BL-60 Kunlun is a useful distal point to treat the rising Yang activity which contributes to the imbalance discussed with UCS, but in order to fully take patients out of this dysfunctional pattern, it is necessary to treat locally. Acupuncture to motor points of the affected muscles (both inhibited and overactive) is a great strategy to reset dysfunctional muscle spindles and balance the internally-externally related channels. In addition, tuina/myofascial release and corrective exercises help increase the therapeutic results.

UCS, therefore, offers fantastic insight into the coordinated balance between the sinew channels and common patterns of dysfunction that occur between internally-externally related channels. The Lung-Large Intestine sinew channels work together to balance the shoulder girdle, while the Urinary Bladder-Kidney sinew channels work together to balance the cervical spine.

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