Student Work: Case study-Pain in neck, upper back and shoulders with forward head posture by Julieta Benavides

Michelle Burns
October 25, 2016

During the course of attending massage school at A New Beginning School of Massage, students are given a number of assignments that requiring research and writing. Some of these assignments result in very insightful and  well thought out information and  decision-making outcomes. I am happy to share some of their assignments for you to enjoy.


neck-painMy client suffers from pain in the neck, upper back and shoulders. He finds himself hunched over and has lost two inches in height over the last few years. He would like relief for the pain and help in improving postural distortion.

The case study is relevant in a wider context, because many clients come with identical complaints. In our society, a hunched over posture is very common due to standard daily activities - most clients spend lots of time on smartphones or computers, drive a car for at least an hour or two per day and sit at a desk for work. Even those who do not sit at a desk often do some type of work that involves rolling the shoulders inward to "do work" in front of them (landscapers, chefs, cleaning personnel, cashiers...the list is endless). Holding the body in this posture keeps the muscles of the neck, chest and back in constant contraction or elongation, a condition for which the body arguably was not designed. This can cause pain and spinal distortions and can lead to other conditions as a result of the dysfunctional posture.

Client Overview:

Initial Inspection

Lateral view

  • Head forward in relation to body, eyes facing forward (not down)
  • Thoracic kyphosis
  • Shoulders rotated anteriorly

Anterior view:

  • Shoulder rotated anteriorly
  • Head slightly rotated to the right
  • Arms slightly rotated medially (both from shoulder and below elbow)
  • Right hip rotated anteriorly in relation to left
  • Right leg abducted and laterally rotated at hip joint
  • Flattened right arch of foot
  • Left foot inverted

Posterior view

  • Right shoulder elevated in relation to left shoulder
  • Right iliac elevated in relation to left (anterior rotation visible from anterior view)
  • Left gluteal fold elevated in relation to right
  • Head forward syndrome
  • Lack of range of motion (anterior-posterior) and flexibility in head/neck area
  • Tightness in right shoulder/ neck area
  • Slightly shallow breathing
  • Tightness in right latissimus/quadratus lumborum area and/or weakness in right anterior internal obliques could possibly be causing right iliac anterior rotation. The abduction and lateral rotation of the same side leg might indicate tightness in gluteus medius or minimus, while the elevation of the opposite (left) side gluteal fold might indicate tightness in the gluteus maximus on the left side.

Client complaining of pain in neck, in sub-occipital region, in back of shoulders, upper back and rhomboid area, as well as headaches, jaw pain and periodic numbness or tingling in the arms and hands.

Injury History

During the client interview, I discover that the client has had multiple car accidents, shoulder and ankle injuries, all or some of which may be contributing to the postural distortion. He often feels as if "his head were on wrong". All of this may need to be addressed in a long-range plan.


1985 (age 4) - was involved in a car accident in a pickup truck with a front bench seat, during which the truck was hit head-on by a drunk driver driving 60mph. The seat belt broke so the client fell down toward the floorboard and hit his head on the dashboard. The client suffered a concussion, an injured pelvis (numbness in pelvis, hip imbalance later in life) and neck injuries. A chiropractic evaluation at the time determined that C1 and C2 were out of alignment. The client reported anxiety later in life, which he believes is related to the accident.

2016 (May, age 35) - the client was involved in a rear-end collision. His car was hit from behind, with the other car going approximately 20 mph. Immediately after the accident, the client reported a stiff neck. He was treated the same day by a chiropractor, who realigned C1 and C2. Over the next few days, his previous whiplash symptoms resurfaced: pain and swelling in the sub-occipitals, blurry vision, followed by depression and anxiety for 6 weeks, hands continually going numb and the inability to concentrate.

2016 (July, age 35) - the client was involved in another rear-end collision. His car was hit from behind, with the other car going approximately 30 mph. This time he did not seek medical treatment, but reported similar symptoms; swelling in sub-occipitals, headaches, blurry vision, TMJ and depression.

Shoulder Injury:

2010m - Crossfit, while performing overhead squat with 135 lb bar, his arms overhead with elbow locked, his right shoulder gave out. His elbow bent and the client felt pain around the superior lateral border of the scapula. He has been a basketball player for all of his life, but after the injury feels a stabbing pain when he releases the ball. The pain is not as he lifts the arm in shoulder flexion, but specifically when he extends the lower arm from the elbow to push the ball, on the right side.

The client recently used a very heavy garden tool to break up sod while gardening and felt pain with a similar movement. He felt the pain while driving the tool downward as opposed to up, specifically when extending lower arm to drive tool down into the soil.

My observations: There could be a problem with the supraspinatus tendon from the original injury or possibly a triceps tendon impingement. The client reports pain when I press in both of the tendon areas.

Additional Injuries:

1995-1999: Various muscle sprains playing basketball, torn cartilage in right knee

1999: Grade 3 sprain and fracture to right ankle, subsequent grade 2 sprain and fracture to same ankle; later grade 2 sprain to left ankle

2000: Grade 2 sprain and fracture on both right and left ankles

2001: Grade 2 sprain and fracture on right ankle

While all of these injuries and accidents have clearly contributed to the postural distortion, I will begin by addressing the basic structural dysfunction that is generally believed to cause head forward syndrome. This will address his original complaint of pain in the shoulders and neck, his hunched over posture and some of the other symptoms I observed, like the limited range of motion in his head and the shallow breathing.

Intervention Overview

Head forward posture is widely credited to have been discovered by Dr. Vladimir Janda in 1979. He defined what is now known as "Upper Crossed Syndrome." It is a muscle imbalance pattern denoted by tightness in the chest and back of the neck and weakness in the front of the neck and lower back. Clinically, there is a crossing pattern through the shoulder that looks like this: tightness in the upper trapezius, levator scapula and suboccipitals on the dorsal side, crossed with tightness in the sternocleidomastoid, pectoralis major and pectoralis minor on the ventral side.

Since the tight muscles are continually contracting, the weakened muscles are in a perpetual state of stretch. As they are trying to hold the body up against the force of the tighter muscles, they are in a constant state of eccentric contraction. A widely accepted theory states that trigger points develop in muscles such as these which are continually contracting, which causes the client to feel pain in these areas and areas of referred pain.

My client reports pain in many of the areas designated as trigger points and referred pain areas for Upper Crossed Syndrome, including the side of the face, jaw, sub-occipital region, upper back and rhomboids. He also displays several symptoms indicative of Upper Crossed Syndrome, including shortness of breath, decreased range of motion of the head and hand numbness.

Treatment Plan:

The plan is to stretch the muscles which are locked short, combined with releasing some of the trigger points and later activating the muscles that are locked long. Exercise at home will be critical to activating those muscles.

Over the last few massages, I have been warming and massaging the pectoralis muscles first to release them, including skin rolling, deep effleurage, compression and passive stretches. In addition, I have been working on releasing the sub-occipital muscles through positional release, deep friction and compression. I have also incorporated some passive stretching of the neck, focusing slightly more on the right side, as that side appears to be more contracted. The upper trapezius has also been a focal point for deep effleurage and compression.

I have also made sure to massage the trigger points in the muscles that are lengthened, specifically the rhomboids and lower trapezius. After addressing the trigger points, I massage these muscles with effleurage strokes in the direction of their origins in order to avoid further elongating them. Finally, I have given my client some exercise suggestions in order to strengthen and reactivate these muscles.

The goal is for my client to get some relief from his pain and to slowly begin to release the tightened muscles. As he is able to do this, the overstretched muscles should be able to slowly return to their original length; doing the exercises at home should help him strengthen them, which will help the healing process.


Literature Review:

According to research, manual manipulation of the tissues is not as effective as manual manipulation combined with exercise. In randomized trials, it has been found that the use of these multiple modalities has resulted in a decrease in pain and increase in client satisfaction.


After multiple massages, the client has slightly increased range of motion in his neck and his shoulders. He reports a decrease in his pain symptoms, and his chest appears slightly more elevated with the shoulder slightly less protracted. The change is subtle, but noticeable both to me and my client.

We will continue to address his Upper Crossed Syndrome, while slowly adding in therapies to address the related issues of whiplash and the shoulder injury.


Burns, Michelle, BSRN, BSAltMEd, LMT, Regaining Healthy Posture: Tools for Relieving Upper Crossed Syndrome, 2014

Gross, A., Kay, T., Hondras, M., Goldsmith, C., Haines, T., Peloso, P., Hoving, J. Manual Therapy for Mechanical Neck Disorders: A Systematic Reviw., Manual Therapy, 2002.


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