Physical therapists commonly evaluate sitting and standing posture as part of the management strategy for neck and shoulder pain.1,2 Upper quarter posture is considered ‘normal’ when the scapulae are partially retracted and the ears are vertically in-line with the shoulders;3 however, patients with neck and shoulder pain often demonstrate a “forward head” posture,4,5 which may be a precipitating and maintaining factor in pain syndromes.
Forward head posture creates an imbalance between the posterior neck extensors and the anterior neck flexors and shoulder muscles,6,7 increases the load on posterior cervical structures (i.e. bones, ligaments, muscles, facet joint capsules),8 and changes the osteokinematics of the scapulothoracic articulation.6,9 Traditional treatment strategies have attempted to reverse “poor” posture via “scapular stabilization” and neuromuscular re-education. Classic “motor control” exercises attempt to quiet the activity of the upper and middle trapezius muscle while facilitating the serratus anterior muscle so as to reverse forward head posture and perhaps reduce neck9-12 and shoulder pain.12,13
Notably, the most common treatment for neck pain among physical therapists in Sweden (82% to 94%) was reported to be “improving posture”;14 furthermore, greater than 75% of physical therapists in India believe that “abnormal motion and improper posture” are significant contributing factors to subacromial impingemnt.15 Nevertheless, a causal relationship between “poor posture” and neck and shoulder pain has not yet been clearly established.16-19 Moreover, for the reduction of pain and disability in the short and long-term, “posture correction” has not yet been shown to be an effective treatment strategy for neck and/or shoulder pain.19-22
NECK PAIN & FORWARD HEAD POSTURE
After studying the relationship between “forward head posture” and “rounded shoulders” in subjects with and without neck pain, a significant correlation between neck pain and “poor work posture” was found; however, the presence or absence of a neutral, forward-looking posture was not related to the incidence of neck pain.23,24 Moreover, the authors concluded that forward shoulder posture was not related to neck pain.23,24 In addition, after review of 109 studies on neck pain in the work place, the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and its Associated Disorders concluded that, “interventions aimed at modifying workstations and worker posture are not effective in reducing incidence of neck pain in workers.”20
While forward head or “turtle neck”25 posture appears increasingly more common due to increased use of smart phones, tablets, and laptop computers, no significant correlations have been found between decreased craniovertebral angle and neck pain.11 In a 2013 study, thirty dentists with chronic neck pain and forward head posture were randomly assigned to receive either deep neck flexor strengthening exercises along with posture correction or conventional isometric strengthening exercises.26 While forward head posture improved more in the deep neck flexor exercise and postural correction group, both groups experienced similar within-group reductions in pain and disability.26
In a 2017 study where 130 adolescents with forward head posture and protracted shoulders were randomly assigned to receive 16-weeks of either physical education combined with postural corrective exercises or physical education alone,27 the group that received postural corrective exercises demonstrated “better posture”; however, there was no significant difference in neck pain between the two groups27—which is the bottom line in truth. Likewise, in a 2018 study where 90 asymptomatic college students were compared with 50 college students with subclinical neck pain,28 pressure pain thresholds were found to be lower in the students with subclinical neck pain, however, there was no difference in forward head posture between the two groups. As such, the authors conceded, “these findings are in contrast with the current assumptions on the association between neck pain and forward head posture.”28
SHOULDER PAIN & SCAPULAR STABILIZATION
Forward head posture theoretically leads to static positional changes and dynamic motion control changes to the neck and shoulder girdle—i.e. changes in motor timing/feed-forward activation delay, thoracic kyphosis, protracted, elevated, anterior tilted, and downwardly rotated scapulae—that may give way to decreased subacromial space, increased through range irritation, increased inflammation and resultant shoulder impingement and pain.29-31
In a 2017 study that compared 51 patients with subacromial impingement to 50 asymptomatic individuals, Land et al. found that patients with impingement had significantly greater increases in thoracic flexion and forward head posture, and this seemed to correspond with decreased upper thoracic motion, passive internal rotation and posterior shoulder range.32 In contrast, Bullock et al. found no difference in levels of shoulder pain in individuals with a slouched sitting posture compared to individuals with an erect body posture.33 Importantly, and in another 2017 study, no relationship was found between the presence of thoracic kyphosis and the incidence of subacromial impingent31, a finding that is consistent with previous studies.16
A more erect posture may facilitate greater ROM but it appears to have no effect on shoulder pain.16 Moreover, in a 2014 review of 10 randomized controlled trials, it was concluded that there is no difference between scapular positioning in patients with subacromial impingement compared with asymptomatic individuals.18 Furthermore, the findings raise “the possibility that deviation from a ‘normal’ scapular position may not be contributory to subacromial impingement syndrome, but part of normal variations.”18 Notably, neither asymptomatic subjects nor patients with subacromial impingement identified as having a forward head posture “follow a set pattern referred to extensively in medical, physiotherapy, and osteopathy textbooks and articles.”19 That is, “postural assessment has a very limited role in the clinical decision-making process in subjects with subacromial impingement.”19
Although a relationship between poor posture and subacromial impingement has yet to be established,31,34 the assessment of static and dynamic posture continues to be common place in entry-level DPT programs and in clinical practice.35,36 Moreover, an effort to “correct posture” in patients with shoulder impingement using muscle strengthening, stretching and mobilization techniques remains a common strategy in physical therapy practice.37,38,39
Although active postural correction and taping may improve shoulder elevation in the scapular plane in both asymptomatic individuals and in patients with subacromial impingement, these improvements in shoulder movement do not amount to significant reductions in actual shoulder pain.30 Furthermore, “scapular stabilization” exercises may improve static posture and shoulder mobility, but they do not improve pain.21 Notably, in a recent meta-analysis of 6 randomized controlled trials, although scapular focused interventions were found to improve shoulder pain and function in patients with impingement, these changes did not persist beyond four weeks.22 Moreover, there was no change in forward shoulder posture following the intervention.22
While posture may be a contributing factor in neck pain and/or shoulder impingement syndrome, neither “posture correction” exercises nor “scapular stabilization” exercises have been found to reduce neck or shoulder pain in the long-term. Therefore, postural assessment by physical therapists has a limited role in the clinical decision-making process of patients with neck or shoulder pain.
Courtney Proen, DPT, Dip. Osteopractic, Cert. SMT, Cert. DN
Fellow-in-training, AAMT Fellowship in Orthopaedic Manual Physical Therapy
Senior Physical Therapist, First Choice Physical Therapy, Fresno, CA
Raymond Butts, DPT, PhD, MSc (NeuroSci), Dip. Osteopractic
Senior Faculty, AAMT Fellowship in Orthopaedic Manual Physical Therapy
James Dunning, DPT, MSc (Manip Ther), Dip. Osteopractic, FAAOMPT
Director, AAMT Fellowship in Orthopaedic Manual Physical Therapy
- Blanpied PR, Gross AR, Elliott JM, et al. Neck Pain: Revision 2017. J Orthop Sports Phys Ther. 2017;47(7):A1-A83.
- Diercks R, Bron C, Dorrestijn O, et al. Guideline for diagnosis and treatment of subacromial pain syndrome: a multidisciplinary review by the Dutch Orthopaedic Association. Acta Orthop. 2014;85(3):314-322.
- Hansraj KK. Assessment of stresses in the cervical spine caused by posture and position of the head. Surg Technol Int. 2014;25:277-279.
- Haughie L, Fiebert I, Roach K. Relationship of forward head posture and cervical backward bending to neck pain. Journal of Manual & Manipulative Therapy. 1995;3(3):91-97.
- Lau KT, Cheung KY, Chan KB, Chan MH, Lo KY, Chiu TT. Relationships between sagittal postures of thoracic and cervical spine, presence of neck pain, neck pain severity and disability. Man Ther. 2010;15(5):457-462.
- Lindstrom R, Schomacher J, Farina D, Rechter L, Falla D. Association between neck muscle coactivation, pain, and strength in women with neck pain. Man Ther. 2011;16(1):80-86.
- Thigpen CA, Padua DA, Michener LA, et al. Head and shoulder posture affect scapular mechanics and muscle activity in overhead tasks. J Electromyogr Kinesiol. 2010;20(4):701-709.
- Yoo WG. Effect of the Neck Retraction Taping (NRT) on Forward Head Posture and the Upper Trapezius Muscle during Computer Work. J Phys Ther Sci. 2013;25(5):581-582.
- Im B, Kim Y, Chung Y, Hwang S. Effects of scapular stabilization exercise on neck posture and muscle activation in individuals with neck pain and forward head posture. J Phys Ther Sci. 2016;28(3):951-955.
- Holtermann A, Mork PJ, Andersen LL, Olsen HB, Sogaard K. The use of EMG biofeedback for learning of selective activation of intra-muscular parts within the serratus anterior muscle: a novel approach for rehabilitation of scapular muscle imbalance. J Electromyogr Kinesiol. 2010;20(2):359-365.
- Wegner S, Jull G, O’Leary S, Johnston V. The effect of a scapular postural correction strategy on trapezius activity in patients with neck pain. Man Ther. 2010;15(6):562-566.
- Sun A, Yeo HG, Kim TU, Hyun JK, Kim JY. Radiologic assessment of forward head posture and its relation to myofascial pain syndrome. Ann Rehabil Med. 2014;38(6):821-826.
- Weon JH, Oh JS, Cynn HS, Kim YW, Kwon OY, Yi CH. Influence of forward head posture on scapular upward rotators during isometric shoulder flexion. J Bodyw Mov Ther. 2010;14(4):367-374.
- Bernhardsson S, Oberg B, Johansson K, Nilsen P, Larsson ME. Clinical practice in line with evidence? A survey among primary care physiotherapists in western Sweden. J Eval Clin Pract. 2015;21(6):1169-1177.
- Phadke V, Makhija M, Singh H. The use of evidence-based practices for the management of shoulder impingement syndrome among Indian physical therapists: a cross-sectional survey. Braz J Phys Ther. 2015;19(6):473-481.
- Barrett E, O’Keeffe M, O’Sullivan K, Lewis J, McCreesh K. Is thoracic spine posture associated with shoulder pain, range of motion and function? A systematic review. Man Ther. 2016;26:38-46.
- Raine S, Twomey LT. Head and shoulder posture variations in 160 asymptomatic women and men. Arch Phys Med Rehabil. 1997;78(11):1215-1223.
- Ratcliffe E, Pickering S, McLean S, Lewis J. Is there a relationship between subacromial impingement syndrome and scapular orientation? A systematic review. Br J Sports Med. 2014;48(16):1251-1256.
- Lewis JS, Green A, Wright C. Subacromial impingement syndrome: the role of posture and muscle imbalance. J Shoulder Elbow Surg. 2005;14(4):385-392.
- Cote P, van der Velde G, Cassidy JD, et al. The burden and determinants of neck pain in workers: results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. Spine (Phila Pa 1976). 2008;33(4 Suppl):S60-74.
- Moezy A, Sepehrifar S, Solaymani Dodaran M. The effects of scapular stabilization based exercise therapy on pain, posture, flexibility and shoulder mobility in patients with shoulder impingement syndrome: a controlled randomized clinical trial. Med J Islam Repub Iran. 2014;28:87.
- Saito H, Harrold ME, Cavalheri V, McKenna L. Scapular focused interventions to improve shoulder pain and function in adults with subacromial pain: A systematic review and meta-analysis. Physiother Theory Pract. 2018;34(9):653-670.
- Nejati P, Lotfian S, Moezy A, Moezy A, Nejati M. The relationship of forward head posture and rounded shoulders with neck pain in Iranian office workers. Med J Islam Repub Iran. 2014;28:26.
- Nejati P, Lotfian S, Moezy A, Nejati M. The study of correlation between forward head posture and neck pain in Iranian office workers. Int J Occup Med Environ Health. 2015;28(2):295-303.
- Kang JH, Park RY, Lee SJ, Kim JY, Yoon SR, Jung KI. The effect of the forward head posture on postural balance in long time computer based worker. Ann Rehabil Med. 2012;36(1):98-104.
- Gupta BD, Aggarwal S, Gupta B, Gupta M, Gupta N. Effect of Deep Cervical Flexor Training vs. Conventional Isometric Training on Forward Head Posture, Pain, Neck Disability Index In Dentists Suffering from Chronic Neck Pain. J Clin Diagn Res. 2013;7(10):2261-2264.
- Ruivo RM, Pezarat-Correia P, Carita AI. Effects of a Resistance and Stretching Training Program on Forward Head and Protracted Shoulder Posture in Adolescents. J Manipulative Physiol Ther. 2017;40(1):1-10.
- Pacheco J, Raimundo J, Santos F, et al. Forward head posture is associated with pressure pain threshold and neck pain duration in university students with subclinical neck pain. Somatosens Mot Res. 2018:1-6.
- Sahrmann S. Diagnosis and Treatment of Movement Impairment Syndrome. London: Mosby; 2002.
- Lewis JS, Wright C, Green A. Subacromial impingement syndrome: the effect of changing posture on shoulder range of movement. J Orthop Sports Phys Ther. 2005;35(2):72-87.
- Alizadehkhaiyat O, Roebuck MM, Makki AT, Frostick SP. Postural Alterations in Patients with Subacromial Impingement Syndrome. Int J Sports Phys Ther. 2017;12(7):1111-1120.
- Land H, Gordon S, Watt K. Clinical assessment of subacromial shoulder impingement – Which factors differ from the asymptomatic population? Musculoskelet Sci Pract. 2017;27:49-56.
- Bullock MP, Foster NE, Wright CC. Shoulder impingement: the effect of sitting posture on shoulder pain and range of motion. Man Ther. 2005;10(1):28-37.
- Raine S, Twomey L. Posture of the head, shoulders and thoracic spine in comfortable erect standing. Aust J Physiother. 1994;40(1):25-32.
- Kendall F, McCreary E, Provance P. Muscles, Testing and Function With Posture and Pain 5th edition. Baltimore: Williams & Wilkins; 2005.
- Ellenbecker TS, Cools A. Rehabilitation of shoulder impingement syndrome and rotator cuff injuries: an evidence-based review. Br J Sports Med. 2010;44(5):319-327.
- Grimsby O, Gray JC. Interrelationship of the spine to the shoulder girdle. In: Donatelli RA, ed. Clinics in Physical Therapy: Physical Therapy of the Shoulder. New York, NY: Churchill Livingstone; 997:95-129.
- Neer CS, 2nd. Impingement lesions. Clin Orthop Relat Res. 1983(173):70-77.
- Griegel-Morris P, Larson K, Mueller-Klaus K, Oatis CA. Incidence of common postural abnormalities in the cervical, shoulder, and thoracic regions and their association with pain in two age groups of healthy subjects. Phys Ther. 1992;72(6):425-431.