How to Fix Neck Pain After Lifting – A Live Treatment

While in the Hamptons, my main man Cody Benz started developing some neck trouble.

We thought it might be helpful for y’all to see what I would do to help a cat like him.

Here you will see me go through an entire treatment session with Cody, while I do my best to explain every decision I make. A major kudos to Daddy-o Pops Bill Hartman for asking some great questions throughout the treatment.

Instead of the typical transcript I provide for these longer videos, I decided to write this up similarly to my neck pain with sitting case study format. I reflected on this case while editing the video, so you’ll see some added thoughts I had while you read through. I would recommend watching the video and reading the case study to get the most out of the material.

Enjoy watching the session.

Subjective

Cody: I was training two days ago and was doing some dumbbell presses. I decided to take some heavy dumbbells for a spin and tweaked my neck. Pain is mostly right-sided in the upper trapezius region.

Was feeling so-so immediately after, but today, after sleeping poorly two nights in a row on an air mattress, my neck is pretty sore.

Aggravating Factors

Flexion and rotation

Relieving Factors

None

Past Medical History

Unremarkable

Objective

*Denotes pain with movement

Cervical Testing (%) Left Right
Flexion 75*
Extension 90
Rotation 100 75*
Sidebend 50 50*

Gross movement tests and top tier examinations do not necessarily guide my treatment. Instead, I use these maneuvers to provide context and meaning for the patient.

While I might change Cody’s shoulder motion, that doesn’t mean squat to him. However, if we find a familiar movement that is painful, and we are able to favorably change either motion or symptoms in that movement, it will create better buy-in.

The lower and upper quadrant tests are shown below. These are what I will later refer to as “guidance tests,” simply because they are what “guide” my decision-making.

Lower Quadrant (degrees or +/-) Left Right
Hip ER 45 25
Hip IR 30 50
Lower Trunk Rotation + +
Straight Leg Raise (SLR) 90 85
Ober’s Test + +
Hip Abduction 20 35

This cluster gives me an idea of degrees of freedom present, or lack thereof, in the lower extremity. With lower trunk rotation in particular, we are attempting to differentiate intercostal tone as a limiter to Cody’s inability to rotate the trunk. The intercostal muscles act as ipsilateral rotators, so if a limitation is present, we could potentially use this as an avenue to intervene on¹.

We can potentially implicate intercostal muscles further if trunk rotation in which the body moves as a unit, such shoulder horizontal abduction (more accurate) or multisegmental rotation (less accurate due to movement complexity) do not present with limitations.

“Complex movements are comparers, nothing more”  ~ Bill Hartman

Cody’s lower quadrant reductions in frontal and transverse plane motion indicate that he is likely more oriented into extension. The closed packed position of most joints involves extension, so the greater a joint is oriented into extension, the greater loss of frontal and transverse plane motion.

To compensate for this multiplanar motion deficits, Cody has picked up extra motion in the sagittal plane per the SLR. This compensatory strategy is fairly common.

Hypermobile SLRs make for reduced force production in the hamstrings. Given that his left SLR is greater than his right, the reduced force production may make “offloading” right sided structures more difficulty. He has better leverage to generate hip extension on the right, albeit poor, considering the right SLR is quite mobile.

With great mobility comes great responsibility…I think that’s how it went.

If Cody has more motion than he should, he’s going to have to pick up “stability” somewhere else. This could potentially be higher up the body for him (neck? Who knows).

Restoring adequate movement variability in the lower quadrant could potentially help free up stabilization demands in the upper quadrant.

Upper Quadrant (degrees or +/-) Left Right
Shoulder Flexion 180 180
Shoulder Horizontal Abd. 20 15
Shoulder ER 80 80
Shoulder IR 45 25
Apical Expansion +
Cervical Axial Rotation +
Mid-Cervical Sidebend -* +

Again, up here we see a similar presentation to the lower quadrant. Cody has limitations in the frontal and transverse planes, yet he picks up extra motion in the sagittal plane per shoulder flexion.

Interestingly enough, Cody’s neck limitations and pain were the reverse of what they were in standing. This difference illustrates how different movement can be when looking at gross vs. fine; active vs. passive.

As of now, I’m no longer using the apical expansion test. It is just too subjective to be meaningful. I haven’t found perfect surrogates as of yet, but looking at infrasternal angle, ribcage flexibility, and 1st rib mobility have provided some clarity. Stay tuned, as I am unsure to what their relevance and reliability is.

Assessment

To me, measuring appendages (arms, legs, neck) helps provide insight as to what is occurring at the axial skeleton. Considering the reductions in frontal and transverse plane motion Cody presented with, I surmised that Cody was more extension-oriented at the axial skeleton.

My typical treatment rule is to address axial position first. Proximal before distal. Axial before appendicular. If we could favorably influence what is occurring in the thorax and pelvis, we may be able to favorably change symptoms occurring at the neck (which I consider an appendage).

Many of these changes, in my opinion, have respiratory influences. As the body extends, the ribs begin to flare upward. This causes the diaphragm to descend, and positions accessory musculature to develop a mechanical advantage for respiration.

My neck…My back…Help with breathing that’s a fact (see what I did there???)

As these muscles shift towards greater respiratory demand, function from a postural/movement standpoint can be reduced. This could potentially be related to the movement limitations Cody is presenting with.

The goal, then, would be to shift accessory muscle function back towards postural function, and shift posturally-oriented muscles (i.e. the diaphragm) back towards respiratory function.

Treatment

Exercise #1: Seated Crossovers

This activity sought to address Cody’s hypermobile SLRs and thorax limitations.

To reduce Cody’s thoracic extension, I left the upper back unsupported. This positioning allows for greater posterior mediastinum expansion upon inhalation.

Using the hamstring as an anchor ought to also reduce lower quadrant extension present, improving degrees of freedom in the remaining planes.

Result:

Comparable Sign Retest Left Right
Cervical Rotation (%) 100 No pain (from 75*)
Cervical Sidebend (%) 75 ¯ pain (from 50*)
Cervical Flexion (%) 90 ¯ pain (from 75*)

Though we got nice symptom changes, Cody still had limited side bending and remaining pain.

I’m not happy.

So I looked at the remaining passive tests to see what limitations remained.

Guiding Tests Left Right
Shoulder IR (deg) 60 (+15 from start) 60 (+35 from start)
Shoulder ER (deg) 90 (+10 from start) 90 (+10 from start)
Shoulder Hor. Abd (deg) 25 (+5 from start) 15 (+5 from start)
Ober’s Test (+/-) + (No change) + (No change)
Cervical Axial Rotation (+/-) + (No change)
Mid-Cervical Sidebend (+/-) – (no pain) + (No change)

Cody definitely improved motion in some areas, but his continual multi-planar limitations indicate Cody is still extension-oriented.

We need something to address these areas.

Exercise #2 – 90/90 T Hip Lift

Given that Cody was still limited in horizontal abduction, and we know the sternal portion of pectoralis major is elongated with this maneuver, I opted to use an activity that placed these guys on stretch. Elongating these muscles would disadvantage their respiratory function.

Providing the manual ribcage drop re-oriented the ribcage in such a manner that a greater pec stretch could be achieved. I could then pull on the pec to further enhance the effect.

Result:

Guiding Tests Left Right
Shoulder IR (deg) 85 (+35 from start) 80 (+55 from start)
Shoulder Hor. Abd (deg) 45 (+25 from start) 45 (+35 from start)
Ober’s Test (+/-) + (No change) + (No change)
Cervical Axial Rotation (+/-) + (slight improvement)

This activity got us some really nice changes in the thorax, despite minimal change in the pelvis and neck. Given that the thorax wasn’t fully restored, I do not have enough information as to what would be causing the neck limitations (i.e. thorax-driven or cranial-driven).

If I were to see Cody again, my big targets would be achieving greater frontal plane adduction and further improvement in thorax motion. An activity such as a standing supported posterior hip stretch with a reach, done on both sides, would be a perfect choice in this example:

Once I finished checking the passive tests, we wanted to see how Cody’s comparable signs looked.

Comparable Sign Retest Left Right
Cervical Rotation (%) 100 No pain (from 75*)
Cervical Sidebend (%) 90 (from 50) 90 (from 50*)
Cervical Flexion (%) 100 w/ slight tension right of C7-T1 at end-range (from 75*)

Despite passive neck limitations, Cody had tremendous improvements in both range and symptoms.

Because I wanted to strive towards perfection with my boi, I needed to find a way to make cervical flexion mo’ betta.

Manual technique #1 – Pin & Stretch to upper trapezius

I used this to reduce local sensitivity and make Cody as comfortable as possible on his way home.

Cody had slight localized tenderness just to the right of C7-T1, so I just provided a sensory input over the region.

Though I am well aware that manual techniques are likely non-specific, I chose a pin & stretch technique over the upper trapezius region. Given that the upper trap would be elongated with cervical flexion, desensitizing that region may improve symptoms.

Result:

Guiding Tests Left Right
Cervical Axial Rotation (+/-) + (slight improvement)

 

Comparable Sign Retest Left Right
Cervical Flexion (%) 100 no symptoms (from 75*)

Overall, Cody was pretty happy with the results achieved. As we hung out the rest of the day, Cody remained asymptomatic.

Post-Treatment Q&A

 

Bill: Would the manual technique have changed if Cody were a female

Answer: After getting informed consent, I would’ve placed my hand on the lower ribcage alone, and not placed my hand on the upper ribcage. If she had said no, I would’ve just coached the hell out of the exercise.


Greg Spatz: Why didn’t you have Cody take his shirt off?

Answer: I didn’t want to break the internet.

Greg’s rebuttal: You can’t take Cody’s shirt off unless you shave it off.


My Question: Is there value in static posture, or even watching people perform gross movements. Does it add anything to the decision-making process or does it just provide clarity to other testing?

Bill Answer: You don’t want to overvalue one small element. Everything contributes. You don’t want to undervalue or overvalue any one thing. You have to put the picture together. The picture we put together through our understanding occurs from a number of things. We are looking at small puzzle pieces in a complex system.

When does posture matter? It matters when it matters. That is hard for people to accept because it’s vague and represents a concept of not knowing, which makes people uncomfortable. Well, get used to being uncomfortable.

Zac: Initially, we were going to this live, but the internet wasn’t willing. But what if I had failed live? Good. Failure is only information, and you now know which areas you need to improve instead. So don’t be afraid to fail, and don’t put too much stake in any one test. Much of what we are doing is trial and error.


Jason Byrne: Were you ever concerned with Cody contracting muscles too hard during the activities?

Answer: Totally. If you are driving excessive amounts of tension during these activities, it’s likely that we wouldn’t have seen favorable changes in our tests.

That said, if the only way I could achieve an exhalation was through high tension, and we led to positive changes in the tests, I would’ve been cool with it.

The big key is the outcome. If I wasn’t getting the outcome I liked, then something needed to change. Perhaps I needed to coach the activity differently, or try a different strategy. It all depends on what results from the prescribed intervention.

The outcome transcends the tests and treatments that are meaningful to you. Changing things that are meaningful to the patient is of utmost importance. Use whatever means necessary to do that.

Bill: Your evidence is the outcome.

Sum Up

That is what a typical session might look like in working with me in person. We overall got a nice change with Cody, and we found some areas Cody could progress with to further enhance his mobility efforts.

To summarize:

  • Address proximal orientation and sagittal plane first
  • Follow with improving frontal and transverse planes
  • Provide local sensory input if symptoms remain after a systemic treatment.
  • Everything matters
  • Be comfortable being uncomfortable

How would you have treated this person? Go ahead a comment below.

References

1 – Hudson AL, Butler JE, Gandevia SC, Troyer AD. Interplay Between the Inspiratory and Postural Functions of the Human Parasternal Intercostal Muscles. Journal of Neurophysiology. 2010;103(3):1622-1629. doi:10.1152/jn.00887.2009.

Photo Credits

Cristian Bortes / bortescristian

Wikipedia