The Neck Pain Troubleshooting Guide
Tension headaches. The creak in the neck that won’t go away. A low, throbbing hum in your scalenes. The “tight” upper traps that, no matter how much they are massaged, don’t ever seem to loosen up.
Neck pain affects 25% of the general population in the west each year.1 For weekend warriors and those for whom fitness is a hobby, murmurs of neck pain before class, or the subtle rub of the neck muscles are common occurrences. Are there ways to effectively reduce neck tension and improve mobility? How do you maintain your fitness and strength when neck pain is thrumming in the background?
First, there is a general rule of thumb when it comes to training with any sort of pain. If there is pain during an exercise and you can’t figure out a way to modify the exercise so there isn’t pain, don’t do the movement. Eliminate it for a little while and see if you can address the issue while giving the area a chance to heal, instead of repeatedly hitting your head against a wall (figuratively speaking).
If you always have pain the next day after doing a specific movement, the same concept applies. Don’t do the movement for a little while. None of this is forever, but be kind to your body when there is pain, and give it an opportunity to get on the path of healing.
What's In a Neck?
The neck consists of 7 cervical vertebrae. Those vertebrae allow us to move our head in several different ways. We can nod, move the head forward and back, rotate the head from side to side, and tilt the head.2
There are several layers of muscles that enable these movements to take place. Rather than getting too hung up on which muscle does what, think of the muscles as the conduit for movement. They allow varied movement of the head to occur. They also keep the head still. We could say the muscles provide movement (mobility) and stillness (stability).
When you think of all of the movements the head can make, it shouldn’t be too surprising there are muscles that run along the front of the neck, side of the neck, and back of the neck. These muscles attach at various places on the torso, connecting the head to the torso. Let’s look at this a little more closely.
- The primary muscles that let you nod your head are the sternocleidomastoid and the splenius capitus. The sternocleidomastoid spans from the cheek bone to the center of the sternum, where the collarbones meet. The splenius capitus connects the first 6 thoracic vertebrae to the cheek bone.
Why does this matter? If you are experiencing tightness while nodding your head, maybe you work on mobility and stability at the collarbone and sternum, or the upper rib area. If you only fixate your attention on the place where there is pain, you are ignoring the fact that joints work together to create movement.
- The primary muscles that shake the head no are also the sternocleidomastoid and splenius capitus. While there are others, for the purpose of today’s discussion, let’s assume we can address issues with shaking the head in a similar manner to issues with nodding the head. We will talk about mobility in a little bit, but I find over and over again the act of turning one’s head is a skill that is retained through practice.
- The muscles that tilt the head from side to side are called the scalenes. They run from the cervical (neck) vertebrae to the upper ribs.
- The muscles that elevate the shoulders and shorten the neck are called the upper trapezius and levator scapulae. The trapezius is a big, trapezoidal-shaped muscle that spans from the base of the neck all of the way down to the lumbar sacral area, and connects to the collarbone and shoulder blade. The levator scapulae connects the cervical vertebrae to the shoulder blade. These are the muscles that are frequently blamed when the upper back and neck feels tight.
- Finally, there are muscles that act as stabilizers for the neck, just like there are muscles that stabilize the lumbar spine. These muscles are often referred to as deep cervical flexors; their anatomical names are longus capitus and longus colli. Think of these as the transverse abdominis muscles of your neck.
What do all of these muscles have in common? Most of them connect to the torso. So if you have neck pain, your training program should involve not just strengthening and mobilizing the neck, but also your shoulder, shoulder blade, and ribs.3 Let’s look at how to successfully train and not make neck pain worse.
The Neck and Your Breath
We will begin by looking at breathing. Several of the muscles in the neck are also accessory muscles of respiration. What this means is if you are in a situation where you need to breathe a little more rapidly than normal, extra muscles of the neck will kick in.
For instance, say you are stranded on an island in the dark and you need to run away from a mysterious creature. Breathing will involve your neck muscles. Or you are performing 50-yard dash repeats at near maximal effort. Your neck muscles will stand out when you finish as you inhale and exhale forcefully.
Most of the time, the neck muscles don’t really need to do much during respiration. The muscles of the thorax, primarily the diaphragm, can take care of breathing needs during rest and low levels of activity. This works through expansion of the chest and rib cage area, as well as movement of the abdomen, which occurs when the diaphragm expands and displaces organs.4
What happens if the neck muscles are being used every single breath? When you consider the average person takes 12-16 breaths a minute; over the course of a day, that’s over 17,000 breaths. That’s a lot of activity for muscles that are considered an accessory.
There are two easy tests to see if you fall into the category of neck breather. The first is to look in the mirror as you breathe. Watch your shoulders. Do they elevate when you inhale and drop when you exhale? If yes, please see intervention below. If no, congratulations! You don’t do what I like to refer to as the shoulder hiccup.
The next test is to lie on your back with your knees bent and your feet flat on the floor. Place one hand on your belly and one on your chest. Inhale, notice which hand lifts the most. Exhale, see if you can feel your hands sinking. If the only activity you can feel is the hand on the chest lifting and lowering, chances are you are using the neck muscles a little more than you need to during passive breathing. If you only feel the lower hand moving up and down, that is a discussion for another day. Ideally, there would be a little bit of movement under both hands.
If you found yourself thinking, “yes, I totally do that,” during either of the tests above, warming up and cooling down with breathing exercises is a great way to improve awareness and change your habit. The exercises below encourage different breathing patterns. They also have the added benefit of getting you in touch with your deep abdominal stabilizing muscles and mobilizing your thoracic spine.
Prone Belly Breathing:
- Lie down on your belly, with your arms in a diamond shape (see picture below).
- Inhale through your nose, feel the breath move into your low back. Exhale, feel the belly sink. Repeat 3 breaths.
- Next, breathe into the back of your rib cage. Feel the area expand. Exhale, feel the ribs soften inward. Repeat 3 breaths.
- Then inhale, breathe into the upper ribs/armpit area. Feel expansion. Exhale, feel the softening. Repeat 3 breaths.
Child’s Pose Breathing:
- Rest back in your child’s pose, either with your hands by your sides, or with your forehead resting on the backs of the hands.
- Inhale through your nose. Feel the mid-back expand.
- Exhale slowly for a count of 8.
- Repeat 4 breaths, feeling the ribs expand on the inhale and exhaling slowly.
- With your knees bent, place the feet on a wall or let your heels rest on a bench.
- Place your hands on the lower portion of the ribs.
- Inhale through your nose for a count of 4.
- Exhale for a count of 8, using your hands to feel how the ribs come down and in.
- As you inhale, see if you can keep flaring up towards the ceiling.
- Repeat 4 breaths.
- Lie on your back with your knees bent, feet flat on the floor, hands resting wherever is comfortable.
- Inhale through your nose.
- Exhale out your mouth by taking the tongue behind the top teeth and making a hissing sound.
- Exhale all of your air completely out.
- Complete 4-6 breaths.
Once you have performed the exercises for a week, re-test yourself by checking your breathing patterns in the mirror, and lying on your back with a hand on your belly and chest. Are you still using your neck every time you inhale? When you lie on your back and feel where the inhale goes, do both your chest and belly move?
There are two questions to ask yourself when it comes to neck pain:
- Can you keep your neck still when doing movements with your extremities?
- Can you move your neck and keep the rest of your torso still
If the answer to the first question is no, then it’s time to consider stability. Think of stability as the ability to keep your head still, in a pain-free position, while the rest of you moves. Let’s use the kettlebell swing as an example.
When you swing a kettlebell, you hinge at the hips, the torso moves as a unit, and the power from your hips propels the bell forward. Seems pretty simple, right? Without diving too much into technique, if you are using the swing as a way to improve strength and power at the hips, there shouldn’t be any buckling in the lumbar spine or head. However, it isn’t unusual to see people leading the movement with their eyes and neck. This makes it less of a hip hinge, and a little more of a hip/neck hinge. From an efficiency standpoint, if your strategy is the latter, you are losing power and unnecessarily using your neck, ultimately decreasing movement efficiency.
If your head is involved with initiating the hip hinge pattern or has difficulty staying still, a way to gain proprioceptive awareness of the area is to lie down on your back with your head resting on the ground, your knees bent, and your feet flat on the floor. Very gently nod your chin up and down. Feel the pressure against your head change as you move your chin. After performing 4-6 of these, see if you can find a place that feels centered, like a halfway point between the chin being lifted and the chin being down. Observe what this feels like as you take 4-6 breaths.
Once you have a strong sense of your head position, turn over onto a hands and knees position. Can you find the same head position now that the floor is no longer available as a reference point? If so, can you maintain that position while you step one hand forward and back? Where is the most comfortable gazing point for your eyes when you maintain this position? Can you keep your jaw relaxed and breathe?
Your Neck Pain Might Be From Somewhere Else
If you have neck pain, don’t just focus on the stability of the head. Check your ankle mobility and see if you have a sense of how your feet rest against the ground. Can you use the feet (without clawing the toes) to provide stability up into your pelvis? Are you able to make a circle with just your ankle in a smooth and controlled fashion?
Another area to pay attention to if you have neck pain is your pelvis. Can you keep your pelvis still while you perform hip movements? When you flex the hip, for instance, where do you feel the movement coming from? Can you flex the hip without rotating the pelvis?
Your eyes, ears, feet, and proprioceptors in your joints work together to tell your brain where you are located in space and maintain your balance.5 When you have pain in your neck, check in with the rest of your body to see how coordinated and integrated your movement is.
How to Mobilze Your Neck
Maybe you’re thinking, “but I have a hard time rotating my head. My neck feels tight. These other things really don’t apply.” Let’s look at mobility.
I mentioned earlier that the muscles that control the neck allow it to do a lot of different things. Whenever I teach mobility, I do it in the following order: forward/back (or up/down), side to side, rotation, circles (if applicable). The short sequence below goes through the movements and incorporates eye work. Many times when I work with clients who struggle with turning their head, teaching them to differentiate between the eyes and neck improves their neck mobility.
If you find this sequence challenging, using it as a warm-up before your workout can make things feel looser and a little more mobile. It also improves proprioception, which enables you to change your head position if you begin to feel tightness. You can’t correct what you can’t sense.
Fix Your Neck and It All Gets Easier
Training with neck pain requires patience, listening to your body, and finding positions that feel comfortable. Breathing exercises, stability exercises, and mobility exercises can all make a difference; so can improving your sense of where the head is located in space. Like with back pain, stress and anxiety can make pain worse.6
Fortunately, one of the best ways to counter anxiety is through exercise, so figuring out how to continue your movement practice without aggravating your neck can have a powerful impact on your overall well-being. Be curious about how you move and your habits. Be strong when you need to be strong and flexible when you need to be flexible. Only then will you begin to feel a sense of control over how you move and how you feel.
Where it hurts might not be where the problem lies:
1. Karlsson, Linn, Björn Gerdle, Esa-Pekka Takala, Gerhard Andersson, and Britt Larsson. "Associations between psychological factors and the effect of home-based physical exercise in women with chronic neck and shoulder pain." SAGE Open Medicine 4 (2016): 2050312116668933.
2. Moore, Keith L., Anne MR Agur, and Arthur F. Dalley. Essential Clinical Anatomy. Wolters Kluwer Health, 2015.
3. Gross, Anita, Theresa M. Kay, Jean‐Philippe Paquin, Samuel Blanchette, Patrick Lalonde, Trevor Christie, Genevieve Dupont et al. "Exercises for mechanical neck disorders." The Cochrane Library (2015).
4. Yeampattanaporn, Orawan, Keerin Mekhora, Wattana Jalayondeja, and Jatuporn Wongsathikun. "Immediate effects of breathing re-education on respiratory function and range of motion in chronic neck pain." (2014).
5. Gollhofer, Albert, Wolfgang Taube, and Jens Bo Nielsen. Routledge Handbook of Motor Control and Motor Learning. Routledge, 2013.
6. Gustavsson, Catharina, and Lena von Koch. "Applied relaxation in the treatment of long-lasting neck pain: a randomized controlled pilot study." Journal of Rehabilitation Medicine 38, no. 2 (2006): 100-107.
Disclaimer: This information is not intended to replace medical advice. If you suffer from neck pain, consult your doctor.