Joint hypermobility is characterized by an excessive range of motion and relaxation of the soft tissue, even when movement is according to the physiological pattern.1 Lower cervical spine contributes significantly to the head and neck flexion, extension, and rotation, and it is a common place of instability origin, often associated with increased muscular tension.2-4

A 19-year-old female, nonprofessional volleyball player presented to a clinic with gradually worsening occipital headaches and cervical spine pain that had been present for the past 3 months. She attributed the onset of symptoms to an intensive training she underwent at a preparation camp. The pain initially occurred after workouts, typically at the end of the day, and also while sitting. It was accompanied by a feeling of tension in the posterior neck and shoulder girdle muscles. She reported episodes of pain exacerbation lasting several days, along with occasional vertigo associated with rapid head movements. The patient denied any head or cervical spine injury.

Physical examination confirmed generalized joint hypermobility, classified as grade 5 according to the Beighton score (bilateral hyperextension of the elbow and knee joints exceeding 10 ° and a positive test for placing the palms flat on the floor while bending forward with straight knees), as well as instability of the lower cervical spine (forward head posture, loss of cervical lordosis, tenderness on palpation of the spinous processes from C2 to C5, increased tightness and tenderness of the trapezius, levator scapulae, and suboccipital muscles bilaterally, increased mobility of the entire cervical spine and its individual segments, positive posterior shear test result, and vertigo during rapid head movements).

Anteroposterior and lateral cervical spine X-rays were ordered, including a functional image with anteversion and retroflection.

Differential diagnosis excluded congenital, traumatic, degenerative, and neurological causes.

The treatment included physiotherapy (education, corrected head posture, postisometric relaxation techniques with myofascial release, pressure mobilization of trigger points, stretching, and isometric and strengthening exercises) once a day, and unassisted exercises twice a day for an initial 2-week period (Figure 1A–1E). The patient was advised to modify her training regimen by avoiding sudden head movements and prolonged positions of maximal flexion or extension of the cervical spine. The primary goal of the treatment was to correct the head and cervical spine alignment, reduce hypertonicity of the longus colli muscles, and strengthen the deep cervical muscles responsible for the spinal stability.

Figure 1 A–C – cervical spine X ray images indicative of a loss of cervical lordosis in a neutral position (A), features of instability of spinal segments C2–C5, such as anterior and posterior translation in the sagittal plane above 3 mm, angular motion between extension (B) and flexion (C) views over 9 °, and facet joint remodeling. No other significant radiologic findings, such as fractures, advanced spondylosis, or osteophyte formation, were noted. D, E – myofascial release therapy of the suboccipital muscles

In this patient, training overload involving repeated flexion and extension movements of the neck (chronic “whiplash” injuries) was the main factor contributing to the development of lower cervical instability. The therapeutic intervention resulted in the correction of head posture, reduction of all symptoms, and a return to full sports activity after 2 weeks of therapy. The patient continued to perform regular stretching and strengthening exercises. Control physical examinations at 6-week follow-up showed no complaints and maintained corrected head posture; however, the Beighton score remained unchanged.

A therapeutic approach emphasizing posture education, accompanied by regular stretching and strengthening exercises, can effectively reduce symptoms and facilitate a safe return to physical activity in patients with generalized hypermobility syndrome.1,5