Dear Dr. Chris: I am looking to engage your experience for advice on how best to recover from chronic neck pain that began abruptly after a workout about 10 months ago.¬† After completed a few sprint triathlons, I was gradually preparing for the Olympic distance.¬† One day, I had worked on my laptop for an hour or so, and later gone for a 1 mile swim and a 20 mile bike.¬† That evening the dull ache started.¬† Pain after biking is greatest, then running, and only mildly from swimming.¬† Working at the computer for an hour or so (even with screen at eye height and a good computer chair) also brings on the pain.¬† An MRI showed nothing that wasn't age appropriate. The physiatrist who examined has had no experience dealing with older athletes.¬† The local PT exercises (chest on exercise ball, raise weights in front, side, and back) seem to help some, but I thought with your experience you might be able to advise me on how to deal with this chronic pain so it won't create any lasting problems for me.
- Steve, Cambridge, MA
Hello Steve. I'm sorry to hear your neck is bothering you, but you are not alone.¬† The incidence of cervical pain in cyclists is quite common, accounting for nearly 49% of all overuse injuries in cyclists,1 and 46.7% of triathletes noting cervical pain at some point during their careers.2 Interestingly, while the duration of pain increases with age, the frequency of neck pain (in the general public, anyway), does not increase with age.3 There is good support for the finding of general weakness in the cervical flexors (those muscles that pick your head up off the floor when laying on your back) in individuals which have chronic cervical pain as well.4 Given that your pain did not start with a particular incident (e.g., "I did x activity, and the pain started"), and the fact that daily posture for desk-jobs and the postural demands of your chosen sport fail to focally strengthen the cervical flexors, I suspect these muscles (or lack thereof) form source of your problem.
Other possibilities do exist, and given that I have not evaluated you in person, I cannot rule-out such things as a vertebral misalignment, disc issue, stenosis, and/or several other causes of neck pain.¬† But given your generally unremarkable MRI, the lack of specific activity causing the injury, and a mild benefit to some exercises, if I had to place a bet, I put it on the muscles in the front of your neck.¬† Good evidence exists in support of general cervical strengthening exercises as being beneficial for chronic neck pain,5 and particularly for cervical flexion strength.4 The previous PT exercises (from your description) emphasized the trapezius muscle (upper, middle, and lower), which can be helpful given that this muscle has fibers attaching to the spine through the cervical and thoracic (upper and middle) spine.¬† But with regard to specific action on the spine, these muscles only work to help stabilize in really one or maybe two directions (cervical extension, and some rotation).
Enter two functional items:¬† general everyday posture and sport-specific posture.
With regard to general posture, I like that you are trying to work on proper ergonomics.¬† I suggest using two mirrors so that you can see yourself in profile while looking straight ahead.¬† Do not cheat yourself - stand (or sit) as you normally do.¬† I suspect you might be surprised to see how far forward your head sits in regard to your torso.¬† This is very common, and leads to chronic weakness of the cervical flexors from general disuse of these muscles.¬† If your head is always forward, the muscles that pick it up as if you were laying on your stomach are always being used (keeping your head from falling forward), and those that pick it up as if you were laying on your back are rarely engaged.¬† Most people think they have good posture, particularly if they view themselves as they always have (from the front).¬† It's hard to see change that way.¬† However if you look from the side (as described above), your ear should line up over your shoulder, which should line up with the little bump that sticks out from the top of your thigh (even with your wrist as you stand with arms at your side), all of which should be just slightly in front of your ankle.¬† At the risk of being critical, I will be extremely surprised if that is your posture already when you are not thinking about it.¬† I am keenly aware that I must think about my position every few minutes when I'm doing well with my posture and every few seconds when I'm not (such as now, when I'm typing and thinking about what I'm writing rather than my posture).¬† It is really difficult to maintain good posture.¬† Good posture is an active process, using muscles to actively maintain a neutral alignment of the skeletal system, rather than relaxing at the end-length of muscles and tendons and ligaments.¬† While the latter is far more energy-efficient, it has long-term implications because those tissues being used to maintain the position will eventually adapt to that position and stretch.¬† Matching tissues on the opposite side of the joint will adapt to being held in a shortened position.¬† Over time, this combination of lengthening on one side, shortening on the other side, atrophy of some muscles and exclusive use of other muscles, no wonder it's so hard to maintain good posture!¬† You have to reverse the atrophy of unused muscles and undo adaptive shortening and lengthening (note: ligaments, once stretched, will predominantly stay stretched, but muscles can continue to lengthen or shorten throughout life, depending on how we constantly use them).
With regard to sport-specific posture, cycling places stress on the muscles the same way that a forward head posture will.¬† This is especially true in the aerobars, where you are effectively looking "up" all the time.¬† This position will also tend to irritate structures associated with "age related changes" in your neck if they are going to be irritated.¬† You will see few fast runners with good cervical position, and notable examples of this in our sport are Rutger Beke, Chris McCormack, and the indomitable Mark Allen.¬†¬† Hard to say if head/neck position directly effects running prowess, as I am aware of no research investigating the relation of cervical flexor muscle endurance and running economy, but I suspect a relationship exists.¬† A good performance-related rational for trying to maintain good neck strength and endurance.
So my suggestion is to have a good PT assess your neck, looking not only for mechanical faults but also a good strength profile.¬† And in my opinion, if you don't hear the word "posture" mentioned (either good or bad), you are in the wrong place.¬† Remember that it takes a while to gain strength and endurance (revisit the beginning of any training season if you need a refresher on the frustrations of that topic), so it'll take some time to see the benefit of the exercises.¬† Stay consistent and it'll happen.
1.¬†¬†¬†¬†¬†¬†¬†¬†¬†¬†¬† Wilber CA, Holland GJ, Madison RE, Loy SF. An epidemiological analysis of overuse injuries among recreational cyclists. Int J Sports Med 1995;16:201-6.
2.¬†¬†¬†¬†¬†¬†¬†¬†¬†¬†¬† Villavicencio AT, Hernandez TD, Burneikiene S, Thramann J. Neck pain in multisport athletes. J Neurosurg Spine 2007;7:408-13.
3.¬†¬†¬†¬†¬†¬†¬†¬†¬†¬†¬† Leboeuf-Yde C, Nielsen J, Kyvik KO, Fejer R, Hartvigsen J. Pain in the lumbar, thoracic or cervical regions: do age and gender matter? A population-based study of 34,902 Danish twins 20-71 years of age. BMC Musculoskelet Disord 2009;10:39.
4.¬†¬†¬†¬†¬†¬†¬†¬†¬†¬†¬† Harris KD, Heer DM, Roy TC, Santos DM, Whitman JM, Wainner RS. Reliability of a Measurement of Neck Flexor Muscle Endurance. PHYS THER 2005;85:1349-55.
5.¬†¬†¬†¬†¬†¬†¬†¬†¬†¬†¬† Kay TM, Gross A, Goldsmith C, Santaguida PL, Hoving J, Bronfort G. Exercises for mechanical neck disorders. Cochrane Database Syst Rev 2005:CD004250.