Shoulders that roll forward and a head that juts out, often called rounded shoulders and forward head posture, may improve with exercise, according to a recent analysis. A systematic review and meta-analysis by Sepehri and colleagues, published in 2024 in the international journal BMC Musculoskeletal Disorders, pooled 22 exercise studies in people with "upper crossed syndrome." The forward head posture analysis alone included 903 people. The researchers reported that strengthening and stretching exercises, scapular stabilization exercises, and comprehensive corrective programs that work several muscle groups together all reduced forward head posture, rounded shoulders, and upper-back rounding. So where should you start? The answer to that question comes more from clinical principles than from research.

What the research showed, and what it hasn't yet

In the Sepehri analysis, rounded shoulders were pooled from 20 studies (774 people) and upper-back rounding from 18 studies (673 people). All three measures improved significantly after exercise. Heterogeneity, the degree of difference between studies, was high at 75–80%, and there were signs of possible publication bias. The researchers noted as limitations that few studies looked at long-term effects and that most measured only posture values.

On how to combine exercises, another review is more specific. A 2020 systematic review by Ranđelović and colleagues (15 studies) concluded that programs combining strengthening and stretching were the most beneficial for upper crossed syndrome. The minimum was 4 weeks, at least 3 times a week.

Some research looks specifically at people with neck pain. In a meta-analysis by Xing and colleagues in the Journal of Pain Research in 2026 (10 randomized controlled trials, 550 people), exercise improved the craniovertebral angle, a measure of how far forward the head sits, by an average of 3.38 degrees, along with pain and neck function. Combined exercise and programs of 8 weeks or more appeared to work better, but the researchers said the results should be interpreted cautiously due to low statistical power and rated the certainty of evidence as low to moderate.

The question in the title, though, that releasing first works better, has not been tested. None of the studies in the Sepehri analysis compared the order of stretching and strengthening.

Muscles crossing in an X: upper crossed syndrome

Upper crossed syndrome is a concept proposed by Vladimir Janda, a Czech neurologist and physical therapist. Viewed from the side, short, tight muscles and long, weakened muscles cross each other in an X pattern.

Page (2011) presents Janda's description as a pattern pairing tightness in the upper trapezius, chest muscles, and levator scapulae with weakness in the middle and lower trapezius, serratus anterior, and others. A textbook on the Janda approach adds weakness of the deep neck flexors, which support the head from deep in the front of the neck, along with tightness in the sternocleidomastoid and the muscles just below the back of the skull.

Before accepting this framework as fact, there's a point to note. In the same paper, Page wrote that researchers have not yet established whether muscle imbalance is a cause or a result of the problem. Upper crossed syndrome is one explanatory model for understanding the body.

Why release comes first

The Janda approach textbook by Page, Frank, and Lardner (2010) divides management into three stages: normalize the state of the surrounding tissues, restore muscle balance, and finish with sensorimotor training. In this column, I'll call them release, activate, and integrate.

The logic is simple. When the chest muscles are short and tight, they pull the shoulder blades forward. If you train your back in that state, the tight muscles keep pulling in the opposite direction. So you first create room to move, then wake up the muscles that have been idle.

The last stage takes the longest. Good posture for just the 10 minutes you exercise isn't enough. The new pattern needs to show up naturally in everyday movements like sitting, walking, and looking at a screen.

The goal isn't a military posture with the shoulders pulled back. Posture held by force doesn't last and creates tension elsewhere. The standard is a posture that stays comfortable even when you relax.

A basic routine to try at home

Do these movements slowly, within a pain-free range. If numbness or pain gets worse during or after, stop right away. Based on the reviews above, keep going at least 3 times a week for at least 4 weeks before judging whether anything has changed.

• [Release] Doorway chest stretch: Place your elbows on the door frame at shoulder height and step one foot forward until the front of your chest stretches gently. Hold for 20–30 seconds. 2–3 times.
• [Activate] Chin tucks: Sitting upright or lying down, gently draw your chin in as if pushing the back of your head backward, without nodding down. Hold for 5 seconds, 10 reps. This works the deep muscles at the front of the neck.
• [Activate] Shoulder blade squeeze: Without letting your shoulders rise toward your ears, gently draw your shoulder blades back and down. Hold for 5 seconds, 10 reps.
• [Activate] Wall slides: Stand with your back against a wall and your arms in a W shape, then slowly slide your arms up and down without letting your lower back lift off the wall. 8–10 reps.
• [Integrate] Screen setup: Set the top of your monitor at eye level, and use a stand and a separate keyboard for your laptop. Hold your phone up toward eye level, and stand up to change position every 30–60 minutes.

Author's note: posture is not the same as pain

A word on the link between posture and pain. In a 2019 meta-analysis by Mahmoud and colleagues (15 cross-sectional studies), adults with neck pain had more pronounced forward head posture than adults without pain. In adolescents, however, no meaningful difference appeared. All of these studies observed people at a single point in time, so we can't conclude that posture causes pain.

From a chiropractic perspective, even with the same rounded shoulders, where things are tight and where they're weak differs from person to person. So before choosing exercises, I look at front and side posture, muscle length, manual muscle testing (checking strength by applying resistance by hand), and movement patterns when raising the arms or turning the head. I treat changes in pain and daily function as more important markers than posture photos.

"Release first" is a reasonable clinical principle, not a law proven by research. Knowing that from the start helps you put more effort into consistency than into getting the order exactly right.

See a doctor first if…

• Numbness, reduced sensation, or weakness in the arm or hand
• Clumsiness with your hands or unsteady walking
• Neck pain that started after a fall or a blow
• Pain that continues even when lying down at night, or comes with fever or unexplained weight loss
• In older adults, especially those with osteoporosis, a noticeable increase in upper-back rounding over a short time (a check for a spinal compression fracture may be needed)
• Severe headache, dizziness, vision changes, or slurred speech occurring along with it

If you have any of these symptoms, see a doctor before doing posture exercises. It's safer to start exercising after other causes, such as nerve compression or a fracture, have been ruled out.

One thing is enough for today. Stand in a doorway and open up your chest for 30 seconds.

This article is for general health information. Everyone's condition is different, so an accurate assessment requires consulting a professional.