Text Neck

Original Editor - Vidhu Sindwani

Top Contributors - Shoko Otsuka, Kim Jackson, Lucinda hampton, Vidhu Sindwani, Lauren Lopez, Rucha Gadgil and Kalyani Yajnanarayan  

What is Text Neck?[edit | edit source]

Text neck.jpeg

The term “text neck” was introduced by a chiropractor in US.[1]

The definition of text neck is overuse syndrome, usually resulting from excessive strain on the neck from looking down at any handheld mobile device, which can lead to headaches, neck pain, shoulder and arm pain, breathing compromise.[2]

The text neck posture during using hand-held mobile device is similar to the forward head posture, while the upper neck is held in flexion rather than extension.[3]

There are many literatures on the association between using a mobile device and neck pain or symptoms which suggested the negative effects of text neck, whilst a majority of them have been concluded that existing evidence is limited.[1][3][4][5][6][7][8][9]

The following studies have found no correlation between text neck and its symptoms assumed to occur:

Forward neck and neck pain/headache

  • A study of over 1100 Australian teenagers found that despite higher rates of depression, forward head posture had no connection with neck pain or headaches.[10]
  • A study investigated the association between text neck and neck pain in adults and reported that the cervical flexion angle of the standing and sitting participant using a smartphone did not associate with the prevalence of neck pain, neck pain frequency, and maximum neck pain intensity.[11]
  • A systematic review found that forward head posture was significantly correlated with neck pain measures in adults, whilst no association was found between FHP and most of neck pain measures in adolescents.[12]

Text neck and musculoskeletal symptoms

  • A study investigated the associations of mobile touch screen device (MTSD) use with musculoskeletal symptoms and exposures, however there was limited evidence showing their associations.[13]

Mobile devices use is causing young people to sprout horns

  • Shahar and Sayers (2018)[4] reported that the use of mobile devices is causing the development of prominent exostosis emanating from this enthesis in young adults.
  • This research[4] gained widespread attention and was subject to significant criticism due to significant limitations and flaws, such as the source, size of the sample, and the ability to conclude about smartphone use from X-ray evidence.[14][15]

Epidemiology[edit | edit source]

In 2023, reports estimate the total number of global smartphone users to reach 6.8 billion. Given the global population to reach just over 8 billion, 8 in 10 people will be equipped with a smartphone (85%)[16].

Recent figures have shown that around 87% of teenagers (14-18 years) in USA and 79% teenagers (12-15 years) in UK own and use smartphones.[13]

Among adults aged 18-34 years, 92% and 95% reported owing a smartphone in USA and Australia, respectively.[17]

Looking at the literature on the association between texting and neck pain, the answer is really muddled, because the studies that have been done on the topic are flawed.[18][17]. Scientific studies don’t appear in a vacuum; they are part of a growing body of evidence. To simply report on a single study is misleading.

Further trials and longitudinal research is needed to establish association between texting and neck pain and guidelines for use[17].

Clinically Relevant Anatomy[edit | edit source]

Cervical spine

The cervical spine is the most superior portion of the vertebral column, lying between the cranium and the thoracic vertebrae.[19]

The main role of the cervical spine is to support and promote the movement of the head and neck.[20]

It consists of seven distinct vertebrae (C1-C7) and six intervertebral discs (IVD).[19]

Osteology[edit | edit source]

Atlas[edit | edit source]

  • The first cervical vertebra.
  • Has no vertebral body.
  • Two occipital facets of the neural arch articulate with the occipital condyles of skull.
  • Articulates with the axis.
  • Transverse ligament divides neural canal of this vertebra into dorsal large spinal foramen for spinal cord and ventral small for odontoid process of axis vertebra.
  • Has foramen transversarium for vertebral artery.[21]

Axis[edit | edit source]

  • The second cervical vertebra.
  • Vertebral body of axis has odontoid process which passes through the odontoid foramen of the atlas.
  • The axis is specialised to serve as a pivot to rotate the skull around.
  • Oval articular pad lies on each side of front vertebral body near the base of the odontoid process and fit into the articular facets of atlas.[21]

Vertebrae (C3-C7)[edit | edit source]

Vertebra anatomy
  • Typical cervical vertebra (C3-C7)
  • The vertebral body is flat.
  • These vertebrae have bifid spinous processes.
  • It has long transverse processes.
  • It has vertebral foramen.[21]

Intervertebral Disc (IVD)[edit | edit source]


Each IVD is a complex structure made up of three main components: a thick outer ring of fibrous cartilage called the annulus fibrosus, a more gelatinous core called the nucleus pulposus, and the cartilage vertebral endplates.[19]

The functions of IVD include:[19]

  • Load cushioning
  • Reducing stress caused by impact (shock absorber)
  • Weight dispersion
  • Allowing for movement of individual vertebrae
  • Allowing for the passage of nutrients and fluid to the spine and spinal cord

Joints[edit | edit source]

Craniocervical region

Lower cervical spine

  • Cervical intervertebral joints: saddle-shaped and consist of two concavities facing each other at 90°[22]
  • Facet joints: the superior facets of the cervical spine face upward, backward, and medially; the inferior facets face downward, forward and laterally.[23]

Ligaments[edit | edit source]


There are six major ligaments to consider in the cervical spine. The majority of these ligaments are present throughout the entire vertebral column.

Muscles[edit | edit source]

The musculature of the neck is comprised of a number of different muscle groups.

Movement Muscles[24]
Flexion Longus colli


Scalene anterior

Longus capitis

Rectus capitis anterior (head only)

Extension Levator Scapulae

Splenius cervicis

Splenius capitis


Erector spinae

Rectus capitis posterior, major and minor (head only)

Lateral flexion Scalene anterior, medius and posterior


Splenius capitis


Erector spinae

Rectus capitis lateralis (head only)

Rotation Semispinalis cervicis


Scalene anterior

Splenius cervicis and capitis


Inferior oblique (head only)

Rectus captitis posterior major (head only)

Mechanism of Injury / Pathological Process[edit | edit source]

Forward head dramatically increases the weight of the head on the spine, and the effect and amount of weight are powerfully and incrementally enhanced by varying degrees.[5]

An average of cervical spine angle in flexion when texting is 37 to 47 degrees.[25]

A study has shown that head weight increases to 18.14 kg at 30 degrees and 22.23 kg at 45 degrees[5], and this can lead to inflammation of the ligaments, muscles, and nerves in the neck, resulting in permanent arthritic damage with increased curvature of the spine.[1]

Texting and Mobile Usage Does to Your Spine.jpeg.jpeg

A concern with children was raised due to their larger heads in relation to their body size than adults, thus they have an increased risk of potential damage on neck caused by text neck.[1]

Clinical Presentation of Text Neck[edit | edit source]

Head 1.jpg

Damage caused by untreated text neck can be similar to occupational overuse syndrome or repetitive stress/strain injury.

A paper[1] proposed that the most common presentation of Text Neck is neck pain, stiffness and soreness. The main symptoms include:

  • Stiff neck: soreness and difficulty in moving the neck is usually present when trying to move the neck after long usages
  • Pain: can be localized to one spot or may be diffused over an area, usually lower part of the neck. Can be described as dull aching or can also be sharp or stabbing in extreme cases
  • Radiating pain: there can often be radiation of pain into the shoulders and arms.
  • Muscular weakness: shoulders muscles namely, trapezius, rhomboids and shoulder external rotators are often weak
  • Headache: sub-occipital muscle tightness can lead to tension type headaches.

In addition to these common symptoms there can also be:

Whereas, the symptoms indicated above were not given any supporting evidence in the article.[1]

  • No evidence of the correlation between text neck and pain has not been found.[10][11][12]
  • Mousavi-Khatir et al (2016)[6] found the increased range of motion in cervical flexion after 10 minutes’ neck flexion and suggested the possibility of creep in the posterior ligaments of the spine due to forward head posture. This can affect the length-tension relationship of posterior cervical muscles and the stability provided by the posterior ligaments, and increase the activation of erector spinae, which may result in disc herniation led by the abnormal movements between vertebral segments.[3] However, the study[6] measured only range of motion and amplitude of neck muscle after 10 mins’ cervical flexion, not a change in actual ligaments. Thus, this hypothesis[3] has not been proven.

Diagnostic Procedures[edit | edit source]

Full medical examination:[8]

A complete medical history, including duration of electronic device usage and the onset of symptoms, must be collected prior to the medical examination. Pain should be assessed primally such as intensity, character, frequency and radiation to the neck or lower back.


After conducting a physical examination and collecting the patient's medical history, an X-ray can be advised. An X-ray of the neck shows curvature (usually curved backwards).

Management[edit | edit source]


Prevention is the key when it comes to Text Neck. The following recommendations from a systematic review[17] of Text Neck should be kept in mind while using smartphones or other hand held devices:

  1. Avoid excessive usage and take frequent breaks
  2. Avoid prolonged static postures
  3. Position the device such that it reduces stresses both on the head/neck and the upper extremities
  4. Avoid high repetitions of movements such as prolonged typing or swiping
  5. Avoid holding large or heavy devices in one hand for long duration

Rehabilitation is found to be very effective in treating the stress injury resulting from Text Neck. Rehabilitation can be designed as a 2-4 week program starting with soft tissue mobilization, Grade 1 and 2 joint mobilization, active and passive stretches of tight muscles and progressing to muscle strengthening, posture retraining and home exercise program.[7]

In acute cases, pain relief is the main goal. It can be achieved by:

In extreme chronic cases pain medication, injection into the facet joint or trigger point or acupuncture can be done.[1]

Different techniques can also be used to treat text neck:

  • Kinesio-taping: Kinesio-tapes are light, thin, elastic material that helps to decrease pain and spasm, improve blood circulation, decrease swelling strengthen weak muscles, main neck alignment while not restricting joint movement[27].
  • Progressive resistance exercise (PRE): Progressive resistance exercise to the neck muscles is proven to be effective in the treatment of neck pain. PRE improves the muscle’s ability to produce force, if a muscle has no capacity to produce force due to injury or disease progressive resistance can be used to rehabilitate the muscle[28][29].
  • Global postural re– education (GPE): A study has shown that GPE is effective in reducing neck pain and disability when done for a long duration. Global postural re– education aids to elongate and stretch muscles of the neck that have been shortened, this is done by using active movement and contraction of antagonist muscles to improve muscle balance and postures[30].

References[edit | edit source]

  1. 1.0 1.1 1.2 1.3 1.4 1.5 1.6 Neupane S, Ifthikar Ali UT, Mathew A. Text-Neck Syndrome-Systemic review. Imperial Journal of Interdisciplinary Research. 2017;3(7):141-148. Accessed 18 July 2019.
  2. The Text Neck Institute. Definition of Text Neck [Internet]. [Updated 2022]. Available from: https://www.text-neck.com/definition-of-text-neck.html [Last accessed: 7/12/2022]
  3. 3.0 3.1 3.2 3.3 Fiebert I, Kistner F, Gissendanner C, DaSilva C. Text neck: An adverse postural phenomenon. Work. 2021;69(4):1261-1270. doi:10.3233/WOR-213547
  4. 4.0 4.1 4.2 Shahar D, Sayers MGL. Prominent exostosis projecting from the occipital squama more substantial and prevalent in young adult than older age groups [published correction appears in Sci Rep. 2019 Sep 18;9(1):13707]. Sci Rep. 2018;8(1):3354. Published 2018 Feb 20. doi:10.1038/s41598-018-21625-1
  5. 5.0 5.1 5.2 David D, Giannini C, Chiarelli F, Mohn A. Text Neck Syndrome in Children and Adolescents. Int J Environ Res Public Health. 2021;18(4):1565. Published 2021 Feb 7. doi:10.3390/ijerph18041565
  6. 6.0 6.1 6.2 Mousavi-Khatir R, Talebian S, Maroufi N, Olyaei GR. Effect of static neck flexion in cervical flexion-relaxation phenomenon in healthy males and females. J Bodyw Mov Ther. 2016;20(2):235-242. doi:10.1016/j.jbmt.2015.07.039
  7. 7.0 7.1 Sharan D, Mohandoss M, Ranganathan R, Jose J. Musculoskeletal disorders of upper extremities due to extensive usage of hand held devices. Annals of Ann Occup Environ Med. 2014; 26(22). Accessed 18 July 2019.
  8. 8.0 8.1 8.2 Jyothsna G. Text Neck Syndrome in Adolescents: How to Stem the Tide?. International Journal of Pediatric Nursing IJPEN.:35.
  9. Kim HJ, Kim JS. The relationship between smartphone use and subjective musculoskeletal symptoms and university students. Journal of physical therapy science. 2015;27(3):575-9.
  10. 10.0 10.1 Richards KV, Beales DJ, Smith AJ, O'Sullivan PB, Straker LM. Neck Posture Clusters and Their Association With Biopsychosocial Factors and Neck Pain in Australian Adolescents. Phys Ther. 2016;96(10):1576-1587. doi:10.2522/ptj.20150660
  11. 11.0 11.1 Correia IMT, Ferreira AS, Fernandez J, Reis FJJ, Nogueira LAC, Meziat-Filho N. Association Between Text Neck and Neck Pain in Adults. Spine (Phila Pa 1976). 2021;46(9):571-578. doi:10.1097/BRS.0000000000003854
  12. 12.0 12.1 Mahmoud NF, Hassan KA, Abdelmajeed SF, Moustafa IM, Silva AG. The Relationship Between Forward Head Posture and Neck Pain: a Systematic Review and Meta-Analysis. Curr Rev Musculoskelet Med. 2019;12(4):562-577. doi:10.1007/s12178-019-09594-y
  13. 13.0 13.1 Toh SH, Coenen P, Howie EK, Straker LM. The associations of mobile touch screen device use with musculoskeletal symptoms and exposures: A systematic review. PLoS One. 2017;12(8):e0181220. Published 2017 Aug 7. doi:10.1371/journal.pone.0181220
  14. Beth M. Debunked: The absurd story about smartphones causing kids to sprout horns. [Internet]. [Updated 21/6/2019]. Available from: https://arstechnica.com/science/2019/06/debunked-the-absurd-story-about-smartphones-causing-kids-to-sprout-horns/ [Last accessed: 7/12/2022]
  15. Isaac SB. ‘Horns’ are growing on young people’s skulls. Phone use is to blame, research suggests. [Internet]. [Updated 25/6/2019]. Available from: https://www.washingtonpost.com/nation/2019/06/20/horns-are-growing-young-peoples-skulls-phone-use-is-blame-research-suggests/?noredirect=on [Last accessed: 7/12/2022]
  16. Oberlo. How many people have smartphones in 2022. Available from https://www.oberlo.co.uk/statistics/how-many-people-have-smartphones (accessed 1 July 2022)
  17. 17.0 17.1 17.2 17.3 Toh SH, Coenen P, Howie EK, Straker LM. The associations of mobile touch screen device use with musculoskeletal symptoms and exposures: a systematic review. PLoS One 2017; 12(8): e0181220. Accessed 18 July 2019.
  18. McGill Text neck Available from: https://www.mcgill.ca/oss/article/technology-general-science/text-neck-epidemic-truly-over ( accessed 21.3.2021)
  19. 19.0 19.1 19.2 19.3 Frost BA, Camarero-Espinosa S, Foster EJ. Materials for the Spine: Anatomy, Problems, and Solutions. Materials (Basel). 2019;12(2):253. Published 2019 Jan 14. doi:10.3390/ma12020253
  20. Kaiser JT, Lugo-Pico JG. Anatomy, Head and Neck, Cervical Vertebrae. Available from: https://www.ncbi.nlm.nih.gov/books/NBK539734/ [last accessed: 2/12/2022]
  21. 21.0 21.1 21.2 Vipula, Atula. The Osseous System. Chapter 5 in: Human Anatomy and Physiology for Undergraduate students of Pharmacy, Nursing, Physiotherapy and other Paramedical Sciences. New Delhi: Laxmi Publications Pvt Ltd, 2018.
  22. 22.0 22.1 22.2 Forrester-Gale, G and Paneris, I. The Cervical Spine. Chapter 9.1 in: Jull et al (Editors). Greive’s Modern Musculoskeletal Physiotherapy. Elsevier, 2015.
  23. 23.0 23.1 Davis, M. Cervical Spine. Chapter 3 in: Orthopedic Physical assessment. Saunders, 2013.
  24. Palastanga, N., & Soames, R. (2012). Anatomy and human movement (6th ed.). Edinburgh: Churchill Livingstone.
  25. Lee S, Kang H, Shin G. Head flexion angle while using a smartphone. Ergonomics. 2015;58(2):220-226. doi:10.1080/00140139.2014.967311
  26. Kwon JW, Son SM, Lee NK. Changes in upper-extremity muscle activities due to head position in subjects with a forward head posture and rounded shoulders. J Phys Ther Sci. 2015. 27; 6:1739–1742. Accessed 18 July 2019.
  27. Kothare, H., Patil, C., & Muley, R. Immediate effects of kinesio taping on upper trapezius muscle on subjects having text neck. International Journal of Physiology, Nutrition and Physical Education 2019; 4(2): 131-133
  28. Jain, D., Jawade, S., & Chitale, N. Effectiveness of Progressive Resisted Exercise along with Conventional Exercise and Conventional Exercise Program alone in Subjects with Text Neck Syndrome. JPRI, 33(59B): 536-542, 2021; Article no.JPRI.78599
  29. Taylor NF, Dodd KJ, Damiano DL. Progressive resistance exercise in physical therapy: a summary of systematic reviews. Phys Ther. 2005 Nov;85(11):1208-23. PMID: 16253049.
  30. Bonetti F, Curti S, Mattioli S, Mugnai R, Vanti C, Violante FS, Pillastrini P. Effectiveness of a 'Global Postural Reeducation' program for persistent low back pain: a non-randomized controlled trial. BMC Musculoskelet Disord. 2010 Dec 16;11:285. doi: 10.1186/1471-2474-11-285. PMID: 21162726; PMCID: PMC3020172.