Text Neck Syndrome

Ross Hauser, MD

If you are reading this article, you are likely someone who has been diagnosed with “text neck” or “text neck syndrome. The term Text Neck Syndrome was created to describe this condition that can develop from frequent texting.  This sometimes controversial diagnosis was probably given following a physical examination where headaches and neck pain were present and your doctor asked you about your cell phone and computer use. But beyond headache and neck pain, you may have come to this article because you may have “mysterious” and unexplainable symptoms. We will discuss these symptoms below.

An epidemic of text neck syndrome.

In an August 2022 review study from doctors at the Department of Anatomy, School of Medicine, Faculty of Health Sciences, National and Kapodistrian University of Athens, Greece (1), the warnings and concerns of neck pain and other symptoms becoming epidemic because of technology were given.  “New technologies and the potentially harmful addiction to cell phones and computers while reading or texting are inducing an epidemic of text neck syndrome. By focusing on postural correction, both pain alleviation and a better quality of life can be achieved for the patient.”

Text Neck

Text Neck

Prolonged periods of looking down at our phones will weaken and overstretch the ligaments along the neck, leading to “text neck.” The head is heavy, and the longer it is kept in a head-forward/flexed position, the greater the pressure on these ligaments. The frequent and prolonged flexion of the neck causes degenerative changes to the curve of the cervical spine and all the structures that support the neck. As the ligament weakness ensues, the forward head position worsens, and the ligaments can no longer keep the vertebrae in their proper alignment. To protect and stabilize the vital structures running through the neck, including the spinal cord, neck muscles will tighten and spasm. What we may feel is neck pain, tension headaches, and tingling sensations, among many other symptoms.

Massage, chiropractic care, or physical therapy can often provide symptomatic relief from text neck. When these first-line methods only provide temporary relief and do not cure the problem, the ligaments may be permanently overstretched, and the normal curve of the spine could be compromised. The treatment to strengthen ligaments is known as prolotherapy or regenerative injection therapy. As the ligaments strengthen, the treatment focus may advance to restoring a more normal cervical spine curve. Once the issue has been medically resolved, having better posture while using the phone, performing regular upper body exercise, and utilizing accessories like headsets or features like voice-to-text can help prevent recurrences.

ligament creep

Text Neck and Ligament Creep

When spinal tissues are exposed to continued compression or stress, they deform and go through a transformation that can become permanent. This process is also called “creep.” Creep is a medical condition that results from the elongation of the ligaments that hold our bones together due to long-term tension on them. This can be caused by various types of bad posture, including the forward head posture involved in text neck. As we have seen, if this goes on for too long, the ligaments will stretch to the point of no return. In our neck, we have seven vertebrae that are held together by ligaments. Text neck causes these ligaments to get too loose, to the point where they can no longer hold these seven vertebrae together. The bones shift and can pinch other nearby structures causing some of the symptoms of text neck. Since the ligaments aren’t able to hold the bones together, the muscles will try to do this job. Since it’s a job they are not meant to do, muscle spasms will occur along with more of the symptoms of text neck.

Ligamentous cervical instability (LCI) is a common condition that can be overlooked or missed by current static supine diagnostic testing methods. Its incidence is increasing with the current ever-prevalent forward head-face-down lifestyle. This is especially damaging for children who have a heavier head-to-neck strength ratio than adults and are looking at computers and down at cell phones and tablets. While these humble acts of looking at electronic devices can appear innocuous, they aren’t

What are the symptoms of text neck syndrome?

  • Muscle tension and pain especially in the upper back and neck by the occiput or base of the skull.
  • Tightness across the shoulders, headaches, and neck soreness.
  • Pain in the back, arms, fingers, hands, wrists, and elbows. Some sufferers may also notice numbness and tingling in their upper extremities.

Severe symptoms of text neck syndrome

As we will discuss further below, the cervical neck ligaments, the supporting structures that hold the neck bones in place, become stretched and damaged. When the ligaments cannot hold the bones of the neck in place, the bones wander. When the neck bones wander they can compress the nerves, the carotid sheath, and/or spinal cord.

  • The two most common mechanisms by which severe symptoms arise are:
    • venolymphatic drainage compression (fluid gets backed up in the brain, this is explained further below) leading to intracranial hypertension and alterations of brain function and,
    • cervicovagopathy (cervical-induced vagus nerve injury or signal interference) causing dysautonomia and systemic inflammation.

Anatomical, Neurological, and Psychiatric Symptoms

Now let’s listen to doctors at Kore University of Enna in Italy. In their paper, the doctors sought to better understand the mysterious psychological side of Text Next Syndrome. After reviewing previously published studies they wrote in October 2022 in the journal Clinical Neuropsychiatry (2): “The overall results (outcomes) showed a strong association between (non-specific/chronic musculoskeletal disorder in neck, head or low back (that are called Upper Disorders)  and mood disturbance, anxiety, depression, stress, alexithymia (the inability to express emotions), and low social support. Thus, high levels of Upper Disorders were associated with high levels of psychological disease.”

Text Neck and cervical spine degeneration

Text neck can eventually lead to arthritic degeneration of the cervical spine. Forward head posture stretches the ligaments that hold the vertebrae together. When the ligaments get overstretched from this posture and for prolonged periods, they become weakened. With weakened, stretched, and loose ligaments, the vertebrae move more than normal, putting more pressure on the discs between the vertebrae. Sometimes they move out of their normal position. This is called subluxation. Chiropractors can manipulate the vertebrae back into place, but because the ligaments remain weak and stretched out, the fix is only temporary. This process leads to degeneration of the discs as well as degeneration where the different vertebrae meet, called the facet joint. Text neck with this forward head posture accelerates the aging and degeneration of the intervertebral joints, resulting in degenerative joint disease of the cervical spine.

It is important to realize that unchecked cervical instability could damage the cervical spinal cord, and with the faced-down posture of looking at a cell phone, the vertebrae move forward, narrowing the spinal canal. If it were not for muscle tension and spasms and other compensatory mechanisms that stop excessive cervical motions from injuring vital neurovascular structures, spinal cord damage could occur. If the ligament injury does not heal and the excess motions and forces continue in the neck, degenerative breakdown of the adjacent vertebral segments occurs in the disc, facet, and uncovertebral joints, as well as the vertebral endplates. This can be manifested as a clicking, grinding, or popping sensation as the person moves or manipulates their own neck. The motion eventually will be limited as bridging osteophytes occur on the facet joints along with disc degeneration, ultimately fusing the joint.

Controversy: Does text neck syndrome cause weakness in the arms and hands?

In a March 2024 paper in the European Spine Journal (3), the researchers wrote of their study: “The objective of (our) study was to correlate neck and upper-limb disabilities with neck flexion (looking down) in university students who are smartphone users. (In other words, does looking down at a smartphone cause weakness in the hands and arms? Is this a symptom of text neck syndrome?). While handling smartphones, a posture with sustained neck flexion known as “Text Neck” is usually adopted, and some authors related musculoskeletal symptoms on the neck and the upper limb. However, recent studies state that such an association is questionable.”

Text neck and Fibromyalgia

In October 2022, doctors at the Kochi Medical School in Japan published the case of a 50-year-old man in the journal Rheumatology (4). This man had pain around the head, neck, and shoulder blades and paraesthesia in both upper limbs. He had been treated with analgesics for 7 years for suspected fibromyalgia, but the symptoms did not improve. Laboratory examination revealed that C-reactive protein and matrix metalloproteinase-3 levels (elevated inflammatory levels seen typically in fibromyalgia patients) were within the normal ranges. Other tests that may reveal a fibromyalgia diagnosis were also negative.  Radiography and magnetic resonance imaging revealed linearization and straightening of the cervical spine. . . Thus, the patient was diagnosed with text neck syndrome. The patient was educated to take frequent rests and raise his smartphone to eye level while texting. His neck pain was reduced, and neurological symptoms resolved.

An epidemic of text neck among medical and nursing students

More than a quarter of medical students had text neck syndrome, and most of them had a mild neck disability.

In June 2024, doctors published a paper on the impact of text neck on medical students. (5) In this study, medical students with at least 3 of the 6 text neck syndrome symptoms and a history of more than four hours a day spent on a smartphone were diagnosed with text-neck syndrome. Of these students, the doctors found that the worse symptoms were found in females, those being overweight, those who were right-handed, and those using four digital (computers, tablets, phones, etc.) devices or more, having low levels of physical activity, and spending more than three hours a day sitting down.

Female nursing students with text neck syndrome suffer from more significant musculoskeletal discomfort than male students

A March 2024 paper in the journal Cureus (6) also found female nursing students suffer from more significant musculoskeletal discomfort than male students. Also, prolonged use of mobile phones, especially at bedtime, makes them more prone to musculoskeletal discomfort. Further: “The findings conclude that prolonged and repetitive use of mobile devices, such as smartphones and tablets, can cause musculoskeletal pain and discomfort, especially in the neck, shoulders, and upper back areas. . . Based on the findings, it is recommended that students take a break every 30 minutes to stretch or change their position. Recommendations for reducing discomfort caused by extended mobile phone use include incorporating exercises that target the muscles used while using a phone, such as neck stretches, shoulder rolls, and upper back exercises. These exercises aim to enhance muscular strength and reduce the likelihood of developing musculoskeletal discomfort.”

Texting while walking is the worst

An August 2021 ergonomic study (7) found that two-handed texting while walking is the most physically demanding texting scenario on the neck muscles, and this physically demanding aspect of neck muscle strain may be attributable to the dynamics of the (forward) head while walking with the head facing downwards.

Of course, it isn’t just when we are texting that we take that forward head posture. We spend hours and hours hunched in front of our computers, looking at our tablets, our readers, our media players, and our games. Even sleeping with high pillows contributes to the problem. The forward head posture that occurs with Text Neck is actually a health condition that occurs due to the position of the head as it moves forward from the center of the shoulders. As the head moves forward the center of gravity changes. This causes an increase in pressure on the musculature over the head and shoulders because of the downward angle and weight of the head while texting. The more the head shifts forward, the greater the pressure around the neck area. This pressure also increases when in this head-forward posture for prolonged periods of time. The frequent and prolonged flexion of the neck causes changes in the cervical spine, the curve of the neck, and the structures that support the neck. These structures include the muscles, the ligaments, and the tendons.

What type of strain was placed on the neck during smartphone use when the user was walking fast, walking slow, or standing still?

A November 2023 paper in the journal Healthcare (8) “conducted a preliminary exploration into the disparities in head/neck posture and viewing behaviors of smartphone users across three postures: standing and two walking speeds (slow and normal).” The goal was to see what type of strain was placed on the neck during smartphone use when the user was walking fast, walking slow, or standing still. In this study, 60 young participants (30 men and 30 women) were followed.

What the researchers found was “that, irrespective of walking speed, using a smartphone while walking led to a more pronounced disparity between the cervical and head positions, resulting in increased strain on the neck compared to smartphone use while standing. The heightened neck load can be attributed to the concurrent dynamic nature of both walking and smartphone usage.”

Furthermore, the sustained arm posture required to hold smartphones might directly impact neck flexion and viewing distance (which may lead to higher eyestrain.” The researchers suggest: “it is advisable to limit smartphone usage when walking, and particularly when employing two-handed operation (both thumbs on the phone as in texting and web browsing).

The problem in children, mysterious pediatric disorders

The larger head-to-body ratio, innate ligament laxity, lower neck strength in relationship to head weight, and increasing access to tablets and cell phones make ligament cervical spine instability a more prevalent and recognized problem in children. The strain on the cervical ligaments is greater in children.  C1-C2 instability is the most common instability seen in kids.

An April 2023 case history in the journal Cureus (9) writes: “Text neck syndrome is a growing concern in the pediatric population due to the increased use of mobile devices and screens, potentially leading to long-lasting musculoskeletal issues. ” The doctors then go on to describe a case of a six-year-old boy with a one-month history of cephalgia (head and face pain) and cervicalgia (neck pain), who initially received insufficient care. After nine months of chiropractic intervention, the patient reported significant improvements in pain relief, neck mobility, and neurological symptoms, supported by radiographic findings.” In summary, the doctors write: “This report emphasizes the importance of early recognition and intervention in pediatric patients, as well as the role of ergonomics, exercise, and proper smartphone usage habits in preventing text neck and maintaining spinal health.”

A problem that starts in childhood, worsens in adolescence, and becomes a life-long chronic problem in adulthood

A February 2021 paper in the International Journal of Environmental Research and Public Health (10) describes the path poor posture can take from childhood to adulthood. This paper from pediatricians at the University of Chieti in Italy suggests that the symptoms of chronic pain in the neck and shoulders can sometimes also be referred to the head, causing headache and muscle tension, frequently encountered in adolescents. In fact, the trigger points of the nociceptive (pain sensation) signal in the head, neck, and shoulders share the same pathways as chronic tension headaches in children, so this may justify why neck and shoulder pain can begin in childhood and early adolescence and persist into adulthood with chronic musculoskeletal problems. (the pain in children travels that same pathway later in adulthood). “Thus, maintaining incorrect sitting postures for a long time could cause the appearance and persistence of musculoskeletal disorders related to the head, neck, shoulders, and dorsal-lumbo-sacral spine.”

A March 2023 paper in the journal Healthcare (11) warned that the “pandemic of cell phone use among children and young adolescents has led to the emergence of a set of musculoskeletal symptoms that have not been seen before in this age group. These symptoms can range from neck and shoulder discomfort to pain, peripheral neurological symptoms of the upper extremity, and long-term complications such as disk prolapse and degenerative disk disease of the cervical spine.” The authors also suggest text neck syndrome could also include eye and ear symptoms, psychological problems, peripheral neurological symptoms, and poor academic performance.” The suggested treatments are: “a combination of spinal adjustment techniques, cervical extension-traction therapy (to restore the natural curvature of the cervical spine), and instrument-assisted soft tissue manipulation (Graston Technique), with the primary objectives of rectifying shoulder asymmetry, spinal misalignment, and muscle tension.”

What can I do for Text Neck?

Of course, prevention is ideal, by keeping your spine and posture maximized and healthy. However, once text neck has advanced, and the ligaments are stretched out, treatment to strengthen the ligaments is what is needed. Prolotherapy is the treatment that strengthens and repairs weakened and damaged ligaments.

Exercises and text neck syndrome

A May 2023 study published in the journal Pain Management Nursing (12) examined the benefits that self-management corrective exercises on text neck syndrome may offer. Who did the researchers study? University students using smartphones.

The 60 students were divided into two groups, the experimental group which performed “corrective exercises” to strengthen and correct the neck structure for 5 days a week for 8 weeks, and a control group. Standard survey scoring was performed in regard to the patient’s pain, function, and disability. The results suggested, “Significant differences between the (pre-treatment scores) before and after the intervention in the experimental group showed that the head tilt angle, gaze angle, and forward head posture were reduced, and the neck tilt angle  increased and improved after the intervention in various measurement positions.”

A September 2023 paper in the journal European Review for Medical and Pharmacological Sciences (13) investigated the efficacy of neck stabilization training vs. Contrology or Pilates training in individuals with Text Neck Syndrome.

There were 75 patients in this study with a history of recurrent neck pain in the previous four months, having moderate pain (at least 4/10 on the numeric pain rating scale), and constantly using mobile phones (more than 4 hours a day) were randomly divided into one of three groups: a control group (neck isometric training) and two intervention groups (neck stabilization training and Contrology or Pilates training).

They were assessed for craniovertebral angle (CVA), numeric pain rating scale, and neck disability index (NDI questionnaire) at baseline and at four weeks post-intervention.

There was a significant difference in the craniovertebral angle (cervical spine curvature problems), numeric pain rating scale (more pain), and neck disability index (pain and function) among individuals with Text Neck Syndrome following intervention as compared to the control groups.

Both the neck stabilization and Contrology (Pilates) training increased craniovertebral angle (head moving into correct alignment) and reduced neck pain and neck disability in individuals with Text Neck Syndrome. The two intervention groups showed similar effects in all the clinical outcome measures, suggesting almost equivalent effectiveness in the individuals with Text Neck Syndrome.

Prolotherapy is an ideal Text Neck treatment?

Massage, chiropractic care, or physical therapy can often provide symptomatic relief from text neck. When these first-line methods only provide temporary relief and do not cure the problem, the ligaments may be permanently overstretched, and the normal curve of the spine could be compromised. The treatment to strengthen ligaments is known as prolotherapy or regenerative injection therapy. As the ligaments strengthen, the treatment focus may advance to restoring a more normal cervical spine curve. Once the issue has been medically resolved, having better posture while using the phone, performing regular upper body exercise, and utilizing accessories like headsets or features like voice-to-text can help prevent recurrences.

By injecting a dextrose solution at the location of the stretched-out ligaments and loose vertebral structures, Prolotherapy causes a mild inflammatory response in that area. This localized reaction directed at the source of the problem ligaments, stimulates a healing cascade. Blood flow is increased to the damaged area, as are cells the body needs for regeneration and repair. Ligaments are made of collagen, and part of this wound-healing cascade includes deposits of collagen. When this new collagen matures the ligaments get tighter and stronger. Once strengthened, the ligaments are once again able to do their job of holding the vertebrae in place. The muscles will be able to relax, the spasms will stop, and the vertebrae will no longer move excessively. The symptoms of Text Neck will resolve because the ligaments are tightened.

Symptoms and conditions of Craniocervical and Cervical Instability


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