Posture Evaluations, Part 2: Forward Head and Forward Shoulder

By Jeffrey Tucker, DC, DACRB

According to Dr. Al Sears, muscle is the first physical sign of aging, in the sense that people who age well are often well-muscled, which protects them from age-related ailments including pain and disease.

I think this is correct, but I would add that I think one of the first physical signs of aging is also poor posture. Forward head carriage is observed when the chin goes forward. From my experience, when the head starts to go forward (anterior shift), people start to look older. Prolonged sitting can cause muscle imbalances in the neck and shoulder that lead to the "poked chin" posture. Once forward head posture starts, the shoulders may start to round, thoracic kyphosis becomes accentuated, the sacral base may shift, and/or the pelvis distorts. The end result: occipital misalignment.

Evaluating Posture Distortions

I know that evaluating forward head posture leads to one of those "chicken and egg" questions. Is it ascending or descending; from top to bottom or bottom to top? Sometimes I know the answer and sometimes I have to guess. I just look for patterns and sequences of how all this stuff works together in my patient's big picture. For example, have them sit on a chair or a stool; observe from the side as they sit down and stand up. Watch the head and neck area only. The normal pattern is for them to lead with the posterosuperior aspect of the head. If the SCMs and suboccipitals are dominating, they will lead with the chin. This is a faulty pattern.

Follow the logic of forward head posture and forward shoulder posture. It may be associated with underactive, lengthened, inhibited deep cervical flexors, lower trapezius and serratus anterior; or overactive, facilitated suboccipitals (longus coli, capitus), upper trapezius, levator scapulae, SCM and pectoralis muscles. Janda described this muscle imbalance pattern as theupper crossed syndrome.

You can correlate this information with standing and sitting palpation. If you observe a forward head in the standing posture, palpate and assess the patient's suboccipital muscle tension. Then have them sit down. If tension in the suboccipital area subsides, the forward head may be secondary to forward-drawn posture from the pelvis. Sitting down takes the pelvis out of the equation.

Sometimes there is a temporomandibular component causing a forward head posture. This is called a descending process and goes something like this: When airway space is compromised, the body moves the head into a forward position, opening up the airway space. This can cause a hyperlordotic upper cervical region and a straightened or reversed lower cervical curve. This may ultimately cause the whole suboccipital musculature to contract. The visual righting mechanism compensates for this by bringing the head forward, which also opens the airway along with the suboccipital contraction.

Forward head posture is multifactorial and may sometimes necessitate dental cooperation. Sacro-occipital technique (SOT) integrates cranial adjustments with dental interventions to help make proper corrections. In addition, sleep issues are pandemic and airway issues are also present. And when patients have overactive suboccipital muscles and the upper cervicals are fixed or out of alignment, there is an association with cervicogenic headaches and other related complaints.

Corrective Rehab Strategies

Corrective exercise/rehab strategies try to improve the muscle imbalances and joint motion. In doing so, the forward head posture can be corrected if the compensatory patterns are not too severe. Instructions to patients include postural awareness so they stop the faulty repetitive action during sitting, standing, sleeping and talking. Get them aware of how they are sticking their chin forward, which changes the relationship of the head to the torso.

Another suggestion is to teach them proper alignment of the feet while standing. Proper alignment of the feet includes "grounding" or "rooting" though the four corners of the feet (the big toe mound, the baby toe mound, the inner heel and the outer heel). Equal weight distribution on these areas lifts the arches and equally distributes weight between each foot. Tell patients to keep constant and equal weighted contact through these points to get "grounded" and to think of the roots of a tree. Notice if lifting the toes toward the nose while standing helps to activate the foot muscles and lift the arches. Also, telling your patients to maintain a "tall spine'"while they are standing and walking is easily understood and helps improve forward head posture.

Have you ever noticed that when you ask one of your older patients to get up from the table or a chair, they are often walking before they fully straighten up? Most of us do that to some degree. Just observe others or yourself when you are in a rush.

Also think about how many children are in school working with their heads down, and how many people have their computer monitor or keyboard tray at the wrong level. Our computer lifestyle promotes overactivity of the pectoralis minor, while the mid-lower trapezius muscles become lengthened. The rhomboids and serratus become inhibited as well. This imbalance causes a gradual rounding of the shoulders, resulting in a change in thoracic 4 segment. T4 dysfunction often occurs with head forward / round shouldered posture. It arises most often from muscle length-tension relationship imbalance and force-couple relationships.

Corrective exercise strategies taught by the National Academy of Sports Medicine for forward shoulder posture and forward head posture include balancing upper-body muscle length-tension relationships and developing good strength. Specific corrections for forward head posture include inhibiting and lengthening the levator scapula, upper trapezius, SCM and suboccipital muscles. Activate the deep neck flexors with chin tucks, and teach the patient whole-body exercises like the prone ball cobra.

The whole-body approach to abnormal forward shoulder posture is to check for a thoracolumbar hypertrophy and swayback alignment. A swayback decreases the demands of the hip extensors. The gluteals may appear underdeveloped and usually test weak manually. People who stand in a forward-leaning posture have greater demand on the gastrocsoleus muscle and less demand on the anterior tibialis. A person with a supinated rigid foot (a high instep) may have a line of gravity that is more toward the rear of the foot and tend to use the anterior tibialis muscle to bring the body forward. This person has a tendency to develop anterior shin splints.

Specific correction includes inhibiting and lengthening the levator scapulae, upper trapezius, pectoralis muscles, and latissimus dorsi. Some simple post-isometric relaxation exercises or self-stretching of these muscles, alternating with rhomboid muscle "squeezes" to effectively strengthen the rhomboid and improve the T4 dysfunction, will help restore shoulder and head posture. Also, activate the mid/lower trapezius with prone abduction and scaption exercises. Activate the teres minor and infraspinatus muscles with side-lying external rotation exercises. Use squat-to-row maneuvers and "push-ups with a plus" as a whole-body exercise.

Keep in mind that for all postural corrections, you cannot omit the inhibition component (foam roll) and only perform stretches, and you cannot omit stretching and just perform soft-tissue techniques. A combination exercise/rehab approach is best to correct forward head or forward shoulder posture.