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88 m a s s a g e & b o d y w o r k n o v e m b e r / d e c e m b e r 2 0 2 0 theoretical concepts regarding posture and upper back pain is the upper-crossed syndrome model popularized by Vladimir Janda. You can find references to this model in physical therapy, orthopedics, chiropractic, massage therapy, and almost any other manual therapy practice. In this model, there is proposed tightness and subsequent strength in the neck extensors and anterior upper thoracic muscles. Their opposing muscles, the neck flexors and posterior upper thoracic muscles, are then thought to be weakened through reciprocal inhibition. The "cross" comes from a hypothetical line being drawn between the tight/short muscles and between the overlengthened/ weak muscles. When the two lines are superimposed on each other it produces a cross pattern, which is where this postural distortion gets its name (Image 5). The idea is relatively simple and mechanically seems to make sense. However, in the years since this original idea was proposed, it has come under greater scrutiny. For example, there isn't any strong research to support the idea that shortened muscles are strong while their opposing muscles that may be held in a more lengthened position are weak. If that were true, you wouldn't see the incredible strength in dancers, gymnasts, and other athletes where muscular strength is combined with extensive flexibility. In her excellent book on stretching, Jules Mitchell reminds us that "muscles don't get stronger by being held in a shortened position. They get stronger from progressive loading." In addition ". . . muscles don't necessarily become weak from stretching. They become weak when loads are insufficient." 3 In the upper-crossed syndrome model, the idea is that anterior neck flexors and upper thoracic back muscles are functionally weak from reciprocal inhibition. Supposedly this weakness, along with continual postural stress, causes upper back pain. There may be something to the idea of reciprocal inhibition generally, but we have drastically oversimplified movement mechanics with this idea. Movement and muscle control are not limited to just one plane with exactly opposing muscles. Muscles have multiple actions, which makes the idea of reciprocal inhibition much more complicated. There is another misapplication of the concepts of upper-crossed syndrome commonly proposed. Supposedly working on the rhomboids of a person with the postural pattern of upper- crossed syndrome exacerbates the condition as these muscles are already overstretched. Treating these muscles is thought to increase this lengthening. First of all, there is no significant evidence that massage can manually lengthen muscle tissue in this way, especially in any kind of permanent way. So, we don't "pathologically lengthen" muscle tissue with our manual work. There is a benefit to working on muscles that seem hypertonic and maintained in a shortened position, like the anterior chest muscles and cervical extensors. But we will not exacerbate a postural disorder from treating the upper back muscles. We must also remember that upper back pain may be caused by factors other than mechanical overload and postural strain. TSP may result from bony disorders and degenerative conditions of the vertebral column, rib articulation problems, as well as various systemic disorders that may affect the gastrointestinal, cardiopulmonary, and renal systems. In one of ABMP's recent podcast episodes, pathology instructor Ruth Werner highlighted a case in which a client reported upper back and shoulder pain that at first seemed like a common musculoskeletal disorder. However, further investigation indicated that the problem was originating from gall bladder disease (Episode 18 – Shoulder Injury—Or Is It?—"I Have a Client Who …" with Ruth Werner, www. abmp.com/podcasts/ep-18-shoulder-injury- or-it-i-have-client-who-ruth-werner). We should remember that not all seemingly musculoskeletal-related problems are in fact that, and may be related to other issues. TREATMENT STRATEGIES While there are several potential conditions involving structural dysfunction in the thoracic spine, the vast majority of upper back pain complaints involve the soft tissues. As a result, massage is an excellent strategy for these complaints. There are some key considerations for this region that will make your treatments more effective. The upper back has numerous tissue layers Your knowledge of anatomy comes in handy as you address your client's soft-tissue pain. Generally, like in other treatments, start the session using a broad contact surface, like the palm or backside of the fist. Then, get more specific by using a small contact surface, like a fingertip, thumb, or pressure tool. This is what produces the best results for chronic tightness and The upper-crossed syndrome. Image from 3D4Medical's Complete Anatomy application. 5