Korean J Sports Med.  2025 Mar;43(1):13-22. 10.5763/kjsm.2025.43.1.13.

Comparative Study on Scapular Alignment and Neck and Shoulder Muscle Strength in Subjects with Forward Head Posture and Round Shoulder Posture

• Jeong KY
• Kim TG
• Yu IY
• Kim SY

• KMID: 2565711
• DOI: http://doi.org/10.5763/kjsm.2025.43.1.13

Abstract

Purpose
The purpose of this study is to compare scapular alignment, muscle strength around the scapula and neck according to the classification of forward head posture (FHP), round shoulder posture (RSP) and forward head with round shoulder posture (FHRSP).
Methods
Scapular alignment, muscle strength around the scapula, and neck strength were measured according to the FHP and RSP alignment classification for male college students. Scapular alignment was confirmed by measuring acromial depression, scapular lateral displacement, and scapular acromion distance. Muscle strength was measured during isometric contraction of upper trapezius (UT), middle trapezius (MT), lower trapezius (LT), and neck muscles.
Results
Acromial depression was significantly greater in the FHP (7.20±1.02 cm) than in the RSP group (5.60±1.26 cm) and FHRSP (5.26±1.75 cm) (p＜0.05). The strength of the UT was significantly greater in the FHRSP (1.12±0.12 N/BW) than in the FHP (0.87±0.19 N/BW), and the strength of the LT was significantly greater in the control group (0.20±0.04 N/BW) than in the FHP (0.15±0.03 N/BW) and RSP (0.15±0.04 N/BW) (p＜0.05). The LT:UT ratio was significantly greater in the control group (0.20±0.05) than in the FHRSP (0.15±0.02) (p＜0.05).
Conclusion
UT strength was higher in RSP subjects with scapular elevation accompanied by FHP than in those with FHP alone. And LT strength and the LT:UT ratio were higher in subjects withno abnormalities in postural alignment. We suggest that these results can serve as a reference for evaluation and intervention according to postural alignment in clinical practice.

Keyword

Posture; Bone malalignment; Scapula; Muscle strength; Superficial back muscles

Figure

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  Fig. 1 Cranio-vertebral angle (A) and forward shoulder angle (B).

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  Fig. 2 Shoulder alignment: acromial depression (A), scapular lateral displacement (B) and acromial distance (C).

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  Fig. 3 Shoulder muscle strength: upper trapezius muscle (A), middle trapezius muscle (B), and lower trapezius muscle (C).

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  Fig. 4 Neck muscle strength: neck flexor (A) and neck extensor (B).

Reference

1. Silva AG, Johnson MI. 2013; Does forward head posture affect postural control in human healthy volunteers? Gait Posture. 38:352–3. DOI: 10.1016/j.gaitpost.2012.11.014. PMID: 23219786.

2. Kwon JW, Son SM, Lee NK. 2015; Changes in upper-extremity muscle activities due to head position in subjects with a forward head posture and rounded shoulders. J Phys Ther Sci. 27:1739–42. DOI: 10.1589/jpts.27.1739. PMID: 26180310. PMCID: PMC4499973.

3. Lee JH. 2016; Effects of forward head posture on static and dynamic balance control. J Phys Ther Sci. 28:274–7. DOI: 10.1589/jpts.28.274. PMID: 26957773. PMCID: PMC4756019.

4. Singla D, Veqar Z. 2017; Association between forward head, rounded shoulders, and increased thoracic kyphosis: a review of the literature. J Chiropr Med. 16:220–9. DOI: 10.1016/j.jcm.2017.03.004. PMID: 29097952. PMCID: PMC5659804.

5. Ruivo RM, Pezarat-Correia P, Carita AI. 2014; Cervical and shoulder postural assessment of adolescents between 15 and 17 years old and association with upper quadrant pain. Braz J Phys Ther. 18:364–71. DOI: 10.1590/bjpt-rbf.2014.0027. PMID: 25054381. PMCID: PMC4183261.

6. Kendall FP, McCreary EK, Provance PG, Rodgers , et al. Muscles: testing and function with posture and pain. 5th ed. Lippincott Williams & Wilkins;2005.

7. Jung SH, Hwang UJ, Kim JH, Gwak GT, Kwon OY. 2022; Effect of improved thoracic kyphosis on forward shoulder posture after mobilization in individuals with thoracic hyperkyphosis. Clin Biomech (Bristol). 97:105707. DOI: 10.1016/j.clinbiomech.2022.105707. PMID: 35763888.

8. Chang MC, Choo YJ, Hong K, Boudier-Revéret M, Yang S. 2023; Treatment of upper crossed syndrome: a narrative systematic review. Healthcare (Basel). 11:2328. DOI: 10.3390/healthcare11162328. PMID: 37628525. PMCID: PMC10454745.

9. Cools AM, Struyf F, De Mey K, Maenhout A, Castelein B, Cagnie B. 2014; Rehabilitation of scapular dyskinesis: from the office worker to the elite overhead athlete. Br J Sports Med. 48:692–7. DOI: 10.1136/bjsports-2013-092148. PMID: 23687006.

10. Neumann DA. Kinesiology of the musculoskeletal system: foundations for rehabilitation. 3rd ed. Mosby;2016.

11. Cools AM, Witvrouw EE, Mahieu NN, Danneels LA. 2005; Isokinetic scapular muscle performance in overhead athletes with and without impingement symptoms. J Athl Train. 40:104–10.

12. Hannah DC, Scibek JS, Carcia CR. 2017; Strength profiles in healthy individuals with and without scapular dyskinesis. Int J Sports Phys Ther. 12:305–13.

13. da Costa BR, Armijo-Olivo S, Gadotti I, Warren S, Reid DC, Magee DJ. 2010; Reliability of scapular positioning measurement procedure using the palpation meter (PALM). Physiotherapy. 96:59–67. DOI: 10.1016/j.physio.2009.06.007. PMID: 20113764.

14. Çobanoğlu G, Demirkan MY, Ecemiş ZB, Güzel NA. 2024; Forward head posture and its effect on muscle activation. Gazi Sağlık Bilimleri Dergisi. 9:85–93. DOI: 10.52881/gsbdergi.1376080.

15. Horton SJ, Johnson GM, Skinner MA. 2010; Changes in head and neck posture using an office chair with and without lumbar roll support. Spine (Phila Pa 1976). 35:E542–8. DOI: 10.1097/BRS.0b013e3181cb8f82. PMID: 20445477.

16. Yip CH, Chiu TT, Poon AT. 2008; The relationship between head posture and severity and disability of patients with neck pain. Man Ther. 13:148–54. DOI: 10.1016/j.math.2006.11.002. PMID: 17368075.

17. Struyf F, Nijs J, Mottram S, Roussel NA, Cools AM, Meeusen R. 2014; Clinical assessment of the scapula: a review of the literature. Br J Sports Med. 48:883–90. DOI: 10.1136/bjsports-2012-091059. PMID: 22821720.

18. Nijs J, Roussel N, Vermeulen K, Souvereyns G. 2005; Scapular positioning in patients with shoulder pain: a study examining the reliability and clinical importance of 3 clinical tests. Arch Phys Med Rehabil. 86:1349–55. DOI: 10.1016/j.apmr.2005.03.021. PMID: 16003663.

19. Gallego-Izquierdo T, Arroba-Díaz E, García-Ascoz G, Val-Cano MD, Pecos-Martin D, Cano-de-la-Cuerda R. 2020; Psychometric proprieties of a mobile application to measure the craniovertebral angle a validation and reliability study. Int J Environ Res Public Health. 17:6521. DOI: 10.3390/ijerph17186521. PMID: 32911612. PMCID: PMC7559098.

20. Cools AM, Johansson FR, Cambier DC, Velde AV, Palmans T, Witvrouw EE. 2010; Descriptive profile of scapulothoracic position, strength and flexibility variables in adolescent elite tennis players. Br J Sports Med. 44:678–84. DOI: 10.1136/bjsm.2009.070128. PMID: 20587640.

21. Hislop HJ, Montgomery J. Daniels and Worthingham's muscle testing: techniques of manual examination. 6th ed. WB Saunders;1995.

22. Donatelli R, Ellenbecker TS, Ekedahl SR, Wilkes JS, Kocher K, Adam J. 2000; Assessment of shoulder strength in professional baseball pitchers. J Orthop Sports Phys Ther. 30:544–51. DOI: 10.2519/jospt.2000.30.9.544. PMID: 10994864.

23. Phillips BA, Lo SK, Mastaglia FL. 2000; Muscle force measured using "break" testing with a hand-held myometer in normal subjects aged 20 to 69 years. Arch Phys Med Rehabil. 81:653–61. DOI: 10.1016/S0003-9993(00)90050-9. PMID: 10807107.

24. Lee ST, Moon J, Lee SH, et al. 2016; Changes in activation of serratus anterior, trapezius and latissimus dorsi with slouched posture. Ann Rehabil Med. 40:318–25. DOI: 10.5535/arm.2016.40.2.318. PMID: 27152283. PMCID: PMC4855127.

25. Viriyatharakij N, Chinkulprasert C, Rakthim N, Patumrat J, Ketruang B. 2017; Change of pectoralis minor length, and acromial distance, during scapular retraction at 60° shoulder elevation. J Bodyw Mov Ther. 21:53–7. DOI: 10.1016/j.jbmt.2016.04.015. PMID: 28167190.

26. Hürer C, Angın E, Tüzün EH. 2021; Effectiveness of clinical Pilates and home exercises in sagittal cervical disorientation: randomized controlled study. J Comp Eff Res. 10:365–80. DOI: 10.2217/cer-2020-0186. PMID: 33706543.

27. Dewan N, Raja K, Balthillaya Miyaru G, MacDermid JC. 2014; Effect of box taping as an adjunct to stretching-strengthening exercise program in correction of scapular alignment in people with forward shoulder posture: a randomised trial. Int Sch Res Not. 2014:510137. DOI: 10.1155/2014/510137.

28. Gaffney BM, Maluf KS, Curran-Everett D, Davidson BS. 2014; Associations between cervical and scapular posture and the spatial distribution of trapezius muscle activity. J Electromyogr Kinesiol. 24:542–9. DOI: 10.1016/j.jelekin.2014.04.008. PMID: 24875461. PMCID: PMC9717492.

29. Harms-Ringdahl K, Schüldt K. 1989; Maximum neck extension strength and relative neck muscular load in different cervical spine positions. Clin Biomech (Bristol). 4:17–24. DOI: 10.1016/0268-0033(89)90063-6.

30. Abdollahzade Z, Shadmehr A, Malmir K, Ghotbi N. 2017; Research paper: effects of 4 week postural corrective exercise on correcting forward head posture. J Mod Rehabil. 11:85–92.

31. Valizadeh A, Rajab R, Rezazadeh F, Mahmoudpour A, Aali S. 2014; Comparison of the forward head posture on scapular muscle contributions during shoulder flexion of predominant arm in women with forward head posture. Zahedan J Res Med Sci. 16:68–72.

32. Ludewig PM, Cook TM. 2000; Alterations in shoulder kinematics and associated muscle activity in people with symptoms of shoulder impingement. Phys Ther. 80:276–91. DOI: 10.1093/ptj/80.3.276.

33. Lukasiewicz AC, McClure P, Michener L, Pratt N, Sennett B. 1999; Comparison of 3-dimensional scapular position and orientation between subjects with and without shoulder impingement. J Orthop Sports Phys Ther. 29:574–86. DOI: 10.2519/jospt.1999.29.10.574. PMID: 10560066.