iHunch Swagger: Wow, You Really Put in the Zoom Reps this Summer

By Margaret Beckwith, MD

Photo from Ott Maidre

Remember how the formidable athletes in high school had the suave jock swagger? They’d roll up in groups to class or the cafeteria in their hoodies and sweatpants with their shoulders squared up and retracted, sprightly pep in their step and ear-to-ear grins from their exercise induced endorphins. On game day they’d do a little fancy foot work sideway sashay into the classroom and bring a small dose of bouncy, playful energy to the sleepy class.

Regretfully, jock swagger is outdated these days. All the cool kids are sporting the trendier, hyperbolic iHunch swagger. Have you jumped on this vogue train yet? It will only cost you a one way ticket to the spine disaster stop which is more popular than the Times Square-42nd street station in New York City. With an estimated 260 million smartphone users in the USA alone who send a combined average of 6 billion texts/day, it’s no wonder the iHunch is becoming more prevalent and resulting in more physiatry clinic visits, especially as more citizens work from home and engage in virtual meetings around the clock.

It’s not the load that breaks you down; it’s the way you carry it.

iHunch, more formally known as Forward Head Syndrome or Anterior Neck Syndrome has many other colloquial names such as: text neck, computer neck, nerd neck, scholar’s neck, and turtle neck among other coarser names. In 2017 The Spine Journal published a paper entitled, ‘“Text neck”: an epidemic of the modern era of cell phones?’ In which spine surgeons from Beverly Hills, CA voiced concerns about the rise in the number of patients presenting to their office with neck and upper back pain. They noted many of these patients had prolonged smart phone use in common and the spine surgeons were very worried about the spondylotic changes they were seeing in young patients.

Image from HOBO Pace

You may be thinking, “What exactly is so terrible about the forward neck and thoracic hunch that many of us assume when using our computers and phones?” There are a couple of pathological processes at play here. Fundamentally, when assuming neutral or good posture position, the adult neck has 10–12 pounds of force acting upon it. The more we flex our neck forward to look at our screens, the more force we exert through our neck. For example, tilting our neck forward to 45 degrees, which is a very commonly assumed posture in smart phone users, results in 49 lbs of pressure running through our cervical spine. That’s an additional 37–39 lbs than what your cervical spine is used to at baseline! And if you’re soberly engrossed into your texting conversation or YouTube video, you might be flexing your cervical spine at 60 degrees which then puts 60 lbs of force through your neck. At this rate, you might as well be walking around with a military rucksack on your head! Chronically assuming this forward head posture leads to weakened deep neck flexors of the anterior neck which can lead to the chin protruding. Additionally, the iHunch posture leads to hyperactive, over-stretched levator scapulae and tightening of the upper trapezius. Overactivation of these muscles leads to repeated microtrauma which can cause myofibril damage and fibrosis. Over time the strain on these muscles can lead to decreased elasticity and ultimately shortening of these muscles. Furthermore, the thoracic hunch or kyphotic posture leaves the middle back muscles such as the lower trapezius, rhomboids, and erector spinae at risk of becoming stretched out and weak. Alterations in the properties of the muscles around the scapula from thoracic kyphosis can result in scapular dyskinesis and excessive scapular protraction which lead to abnormal acromial depression and associated shoulder pain, especially from subacromial impingement syndrome. And lastly, with time, the chronically flexed thoracic facet joints can freeze and lock due to collagen of the surrounding ligaments, fascia, and capsule shortening which can then immobilize the joints. The overall combined macroscopic effect of the iHunch posture is facet joint compression in the cervical neck which can cause a cascade of complications such as cervicogenic headaches, degenerative disc disease, compression and reduction of foraminal spaces, and referred pain down the upper extremities. This list is by no means exhaustive.

What may come as a surprise to some is that this iHunch posture can have pathological implications for the entire body and not just the spine. As the head moves anteriorly and shifts the center of gravity, the upper body compensates by drifting backwards. This in and of itself results in another center of gravity shift for which the hips will tilt forward as compensation. As the pelvis tilts forward this can aggravate the lower back and cause the hamstrings to tighten leading to lower back pain and muscle spasms. An immobile lower back and forward-tilting pelvis can lead to a pot-bellied appearing lower abdomen, even in someone with a normal BMI who is otherwise fit! The knees may hyperextend to compensate for the anterior pelvic tilt and this may predispose you and your patients to knee and ankle injuries. The hyperextended knees can shift the normal center of gravity from just in front of the heels to directly on the heels which can cause the calf muscles to tighten and result metatarsalgia among other complications. iHunch has quite the domino effect!

Moreover, as seen with hand dominance in certain settings, the perennial overuse of one upper extremity with a computer mouse or one-handed texting can lead to shoulder drop on the dominant side which will lead to the ipsilateral pelvis shifting superiorly while the contralateral pelvis tilts inferiorly. This balance shift can result in the contralateral knee rotating inward which can strain the ankle and lead to ankle eversion and collapse of the arch. It’s the kinetic chain in full swing!

How do we manage and treat these maladaptations of the kinetic chain? Spine, Mind, and brush your teeth.

Just like keeping your mind sharp and preventing cavities, maintaining good spine health requires daily attention and care.

Below are some basics steps that can be followed to improve the spine health of your patients and yourself!

  1. Break the bad habit. Instead of holding your phone around your abdomen or waist, hold it at eye level to minimize forward flexion of the neck.
  2. Ensure your office is optimizing ergonomics. Adjust your computer monitor height so that the top of the monitor is at eye level and slightly tilted away from you. The monitor should be approximately an arm’s length away. Avoid “craning” your neck. Your arms should be relaxed with your forearms parallel to the floor and elbows should be bent between 90–120 degrees. Your arms should be supported by arm rests. Your chair should have a backrest with lumbar curvature support. Your thighs should be parallel to the floor and also flexed at 90–120 degrees like your elbows. Your feet should also be flat on the floor. Instead of dangling your feet, use a foot stool. You should keep key objects such as your telephone, keyboard, and mouse close to your body to minimize reaching. Take breaks from your screen every 25 minutes. A much more comprehensive office ergonomics plan including optimization of a standing desk can be found on Cornell’s ergo web.
  3. Utilize the Corrective Exercise Continuum. Prescribe therapies that balance the weakened and lengthened muscles against the overactive and shortened muscles. This involves a combination stretching, strengthening, myofascial release, and integrating dynamic total body exercise that improve total body coordination and movement patterns. Examples of chronically weakened and lengthened muscles from iHunch include the deep neck flexors such as longus capitis and longus coli as well as the scapular stabilizers and retractors such as the rhomboids, middle and lower trapezius, teres minor, and infraspinatus. Common overactive and shortened muscles include the deep upper cervical extensors such as longissimus capitis, splenius capitis, cervical multifidus, and upper trapezius as well as the shoulder protractors and elevators such as the pecs and levator scapulae. One very simple and traditional exercise that is often prescribed is the chin tuck in which the patient places his/her index and middle finger on his/her chin and guides his/her head into a “double chin” position. Alternatively, some patients find it easier to think of lifting the crown of their heads to the ceiling while keeping their chin parallel to the floor. This position is held for 5–10 seconds, repeated 10x per set and 1–3 sets are completed each day. This effectively strengthens the deep cervical flexors and lower cervical extensors. Best of all, it can be done pretty much anywhere including at the office.
  4. Integrate yoga into your weekly routine. Yoga has been proven to improve muscular strength, reduce tension, stretch muscles and improve range of motion which all collectively help maintain the normal curves of the spine. Yoga is also great for improving awareness of how to activate different muscle groups and learn balanced movement patterns. Even if a twice weekly group yoga class is out of the question, there are plenty of apps and free videos on YouTube led by certified yoga instructors that can be effective tools. I challenge you to integrate a minimum of 15 minutes of vinyasa yoga twice a week into your busy schedule for a month and see if you can appreciate a difference in your posture, your mindfulness to your posture, and/or any improvement in back aches or pains.

The iHunch is becoming more prevalent as technology use soars. Take a few minutes every day to protect yourself, family, friends, and patients from the grave effects of chronic bad posture and resultant breakdown of the kinetic chain. Spine, Mind and brush your teeth.

Margaret is a PGY-3 at Washington University PM&R in St. Louis, MO.




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