Forward Head Posture, is the scientific term for, you guess it, forward head posture. This occurs when there is an advancement of the cervical spine, causing unwanted strain on the vertebra and the muscles of the neck as well as an array of other ailments we will briefly discuss below. If you suffer from reoccurring neck tension this may provide you with a starting point for some help. My objective in writing this today is to share information that can be beneficial for some in a preventative way with regards to Forward Head Posture and the main area I prefer to address when someone presents for this issue or for reoccurring neck pain and tension. The good news is that in most cases it can be proactively corrected but you should start addressing it as soon as you can as this posture can worsens if you leave it and do nothing. Below, I will explain the various influences impacting Forward Head Posture but without making it too lengthy I will focus on why the role of the hyoid is important with regards to this and not go into too much ergonomic detail with regards to thoracic posture and anterior shoulder rolls (both of which are very important with Forward Head Posture as well). At the end I will explain in detail a few things you can do at home to reverse the progress and proactively prevent any further advancement. Whether you’re working from home and have nagging neck tension or you feel fine and just want to run through a self evaluation, I encourage it; the benefits are well worth your 9-minute read.
My familiarity with the hyoid bone has been growing for some time and given the current pandemic and many people working from home, I have been working on more and more people for chronic neck and upper back tensions that seemingly all relate back to this little bone. This is not to say that the hyoid in any way is the cause for Forward Head Posture, but due to the nature of the Forward Head Posture, regardless of the initial cause, releasing the hyoid bone can be a first step in helping you realign your neck and get the most out of stretching and maintaining proper posture. Many of the people I see do in fact have ergonomic set up issues going on due to working from home or in an office that has not been properly fitted for them. This has aggravated and heightened their awareness of already ongoing chronic posterior muscle tensions. The use of laptops and cell phones, which create a forward flexion of the neck have also been strong contributors to this condition over the years and increasing in popularity.
Let’s start off with location; the hyoid bone moves every time you speak, swallow, and to a lesser degree, breathe. It is the only bone in the human body that does not officially articulate with any other bone; it floats about in the front of your neck via muscular, ligamentous, and cartilaginous attachments. Well, it doesn’t actually float; there are several ligaments and muscles attached to it as you can see in the image below. Consequently, due to all of these muscles’ insertion points, and due to the hyoid being involved in some of our most repetitive and necessary movements, the release of these structures, which is simple but important, can actually help a whole array of discomforts you may feel in your jaw, neck, and upper back as well as headaches and some cases of vertigo and sleep disorders.
The two main functions of the hyoid bone are to hold down the tongue, which is right above it, and to hold up the larynx, which is just below it. It is also involved in opening the jaw due to the insertion points of the suprahyoid muscles. For a small bone the hyoid is attached to several important areas. Let’s look at some of the structures inserting onto the hyoid and their role in our daily functions.
The base of the skull: Via the stylohyoid ligament, the hyoid bone is linked to the styloid process of the temporal bone. On the image below, you will see the location of the styloid process. It is important to note that is rare cases, calcification of the styloid process is found on x-rays. Often an incidental finding which produces no symptoms, in some individuals, headaches, dizziness and other symptoms can arise due to the compression that can be caused to vital nerves. When symptomatic it is called Eagle syndrome, but many with these elongations are asymptomatic and would never be aware. The cause of the calcification requires further research.
The mandible and tongue: Mainly via the digastric muscles, but also other smaller muscles, the tongue is held to the hyoid. Tongue releases do wonders to release the hyoid and prevent the Forward Head Posture pull forward. The position of the hyoid can vary slightly with regards to angle and anterior positioning among individuals and it can also change slightly over time due to posture (Forward Head Posture) or due to a tight digastric muscle. It has been shown that those with a tight lingual frenulum; the short thick band that attaches the tongue to the floor of the mouth can also influence the positioning and function/movement of the hyoid. The degree of thickness of the lingual frenulum can vary from very loose to very tight, in some individuals being diagnosed with a tongue tie at birth.
The larynx: Via the thyrohyoid membranes which boarder the superior border of the thyroid cartilage the hyoid is attached to the larynx. The hyoid bone is important in swallowing as well as in vocal projections. Interestingly there was a study done that showed that group singing can be beneficial in patients with Parkinson disease, due mainly to the fact that singing can strengthen the muscles that hold up the larynx. Because the hyoid is involved in singing, and also in swallowing, strengthening these muscles, allows for better control of swallowing for the patients with Parkinson’s. One of the many benefits that singing can have. That being said, singer who do so often, need to take special care of their hyoid and the muscles inserting upon them in order to keep them in shape. My personal experience working on those who sing with frequency and fervor has been that releasing their hyoid regular prevents upper back and neck tension reoccurrence.
The Scapula: The omohyoid muscles attaches to both the scapula and the hyoid. Looking at the picture below, it should be easy to envision how a forward roll of your scapula could influence the hyoid, and vice versa where a tight and rigid omohyoid muscles due to restriction of the hyoid, could contribute to posterior neck and upper back pain. This tiny muscle is actually quite a big deal.
So how does all of this contribute to Forward Head Posture or rather, how does releasing the hyoid bone reverse the effects of Forward Head Posture and allow you to easier correct your posture? We’re getting there but first let me tell you about a recent case that came into the clinic: To be honest, people rarely come in and tell me their digastric muscle feels tight or that their hyoid needs to be released (except those that have been seeing me for years and know they are due to come in). A little while back I had an 86 year old woman present with bilateral nerve pain and numbing into both hands. She had a known history of severe arthritis from C5 to T2 and the classic Dowager’s hump posture at the cervicothoracic junction of C7-T1. She had previously seen her Dr and tried cortisone injections, which did not help. I knew her nerve pain was due to the compression of the nerves on her neck but given her arthritis she wasn’t a candidate for any time of vertebra mobilisation. While doing her history she recounted to me that she had had a cyst on her neck at age 5 that her mother was never really able to fully explain to her, just that it was a cyst and was surgically removed at a hospital in Montreal (80 years ago). Upon evaluation the muscles in her neck, specifically, SCM (sternocleidomastoid muscle), Scalene, and the digastric were very hard in the tendons at the insertion points, even harder. When she spoke or swallowed there was an audible click (her hyoid bone against the thyrohyoid membranes and the larynx). I was able to release a lot of the scar tissue (from where her cyst had been removed) and muscle tightness in her anterior neck to the point that she was able to do some gentle retraction of her neck on her own creating an elongation of the cervical spine and reducing the pressure in her neck. I was unable to completely provide relief for her as her case was quite severe and quite progressive over many years, but I thought to myself, had she only known in her twenties and thirties to do self massage on her scar tissue and the muscles in her anterior neck along with gentle cervical traction, could she have prevented the pain she was now living with (and it begs the question, prevent her Forward Head Posture and Dowager’s hump altogether?). She is now doing self massage daily in her anterior neck and the student physiotherapists at her CHSLD are overseeing her gentle retraction (autonomously) of the cervical spine until she can see her family doctor again. Her nerve pain has decreased significantly. She is an example of a very severe case but more and more people in their thirties and forties with Forward Head Posture and with a preventative approach, if they have an opportunity to avoid pain, shouldn’t they be given the tools to do so? It is important to address the postural issues and work set up, but from my experience, maintaining a neutral posture of the cervical spine is easier when there aren’t tensions in the anterior neck pulling you forward. Forward Head Posture can be thought of as cyclical regardless of the initial cause of poor posture or too much laptop or cell phone screen time. If the posture advances forward and the anterior muscles tighten, those tight muscles continue to advance your forward flexion. If you do a self evaluation and regularly address any anterior neck tensions you have, you could save yourself a lot of pain and discomfort in your posterior neck both in the present tense and preventatively as you age.
In my previous post I discussed how Forward Head Posture can impact breathing due to tight respiratory accessory muscles. I hope the takeaway today is that reversing a forward head posture is 1). Possible and 2). Important to help you feel better and prevent worsening over time. Check out the last post for more information specific to breathing better and sleeping better. Releasing the hyoid can help you in more ways than one.
Muscles attaching to the hyoid bone:
· Superior. Middle pharyngeal constrictor muscle. Hyoglossus muscle. Genioglossus. Intrinsic muscles of the tongue. Suprahyoid muscles. Digastric muscle. Stylohyoid muscle. Geniohyoid muscle. Mylohyoid muscle.
· Inferior. Thyrohyoid muscle. Omohyoid muscle. Sternohyoid muscle
Evaluation:
· Using your thumbs, feel for the digastric muscle below and posterior to your chin.
· Does it feel supple or rigid?
· Now, using a gloved index finger, open your mouth and feel beneath one side of your tongue and then the other
· Do both sides feel supple, rigid or perhaps one side feels firmer than the other?
If you found any of these to be rigid or firm or you are known to have ankyloglossia (tongue tie), these self releases could help you.
Self Release Techniques for the suprahyoid and tongue muscles
1). Submandibular and digastric self massage
· Using your thumbs gently massage underneath your mandible starting at the back angle and working toward the chin
· Allow the thumbs to sink in as deeply as is comfortable
· When you find points of tension stop and hold for 10 seconds or until you feel a release
· Continue for between 5 and 10 minutes a few times per week
2). Suprahyoid release
· In a comfortable position place a gloved index finger underneath one side of your tongue (inside the mouth)
· Place your other index finger underneath and posterior to your chin (outside the mouth)
· Using the two fingers together, find points of tension, hold for 10 seconds and release
· Continue to find points of tension underneath the tongue and hold for 10 seconds before releasing
· Repeat for the other side of the tongue.
The release of the hyoid bone does not take into consideration other posture needs that can be addressed to prevent Forward Head Posture. As a starting point, releasing the hyoid can allow ease of doing gentle mandible retraction and cervical elongation, subsequently making you more aware of your posture. The intention would be for you to simultaneously correct and address your scapular region by relaxing the shoulder blades, for example, while you type at a laptop or computer. Preventing a forward pull of the neck, can prevent the upper back and neck tensions felt in your levator scapula and trapezius muscles but you still need to be consciously aware of your posture to prevent any indirect forward posture. Releasing the hyoid makes this more achievable.
Reference List:
Bakker, B.S., Bakker, H.M., Soerdjbalie-Maikoe, V. & Dikkers, F.G. (2019). Variants of the hyoid-larynx complex, with implications for forensic science and consequence for the diagnosis of Eagle’s syndrome. Scientific Reports.
Kim, M.S., Cha, Y.J., Choi, J.D. (2017). Correlation between forward head posture, respiratory functions, and respiratory accessory muscles in young adults. Journal of back and musculoskeletal rehabilitation. 30. 4: 711-715
Macari, AT, Ziade, G, Turfe, Z, Chidiac, A, Alam, E (2016). Correlation between the position of the hyoid bone on lateral cephalographs and formant frequencies Journal of Voice
Miller, R. Schutte, HK (2019). The effect of tongue position on spectra in singing Journal of Singing
Pettit, N.J. Auvenshine, R.C. (2018). Change of hyoid bone position in patients treated for and resolved of myofascial pain The Journal of Craniomandibular & Sleep Practice
Volume 38, 2020 - Issue 2 Pages 74-90 | Published online: 31 Jul 2018
Stegemöller, EL, Hibbing, P, Radig, H. (2017). Therapeutic singing as an early intervention for swallowing in persons with Parkinson's disease Therapies in Medicine