Scott Smith’s client put up with his neck pain for a year, fearful of the consequences of seeking relief
I recently saw Sam, a young man of 27 who’d been having pain on the right side of his neck for a year. He reluctantly told me that he was a keen skydiver, performing four or five jumps most weekends throughout the year. During the week he was a tradesman doing a lot of heavy overhead work.
Sam was able to locate his pain to the exact joint it was coming from, but he couldn’t identify what exactly was aggravating the problem. He was very frustrated because deep down he suspected it was his beloved skydiving that was causing the pain, but no way did he want to stop doing it.
Sam is right handed, the pain was on the right side of the neck and he performs repetitive high-loaded movements with his right arm at work, generally above head height.
After careful questioning, Sam was able to work out that the pain was worse after skydiving, but not just then: work, too, would cause a flare-up of the problem.
I asked him to show me the positions he would assume while skydiving and we discussed why these placed tremendous demands on the muscular system and strain on the low cervical joints. The fully opened-out skydiving position requires a great deal of thoracic extension and good scapular control with the arm overhead. The contraction of the upper and lower trapezius must be coordinated to produce upward rotation; serratus anterior simultaneously provides compression of the inner edge of the shoulder blade against the chest wall.
The skydiver also has to have good range of movement in, and muscular control of the low cervical spine in order to avoid an over reliance on the upper cervical spine.
Sam had pain in his neck when he turned and bent his head towards the right. He was also unable to look up and extend without pain and was very limited in this movement. He said that both movements had caused him pain for up to 12 months and his range of movement had not changed over that time.
He did not have a lot of muscular development around his neck and back and overall was quite lean and muscularly underdeveloped. He did, however, have some areas of increased muscle tone, especially in his upper and mid trapezius and particularly in his levator scapulae muscle (see Fig 2, right).
He demonstrated a great deal of increased tone in his right-sided midthoracic erector spinae muscle. When I was trying to work out why this should be, I looked at what other muscles attach on to adjacent areas and worked out that the lowest fibres of lower trapezius attach there. In fact the lowest fibres attach as far down as the twelfth thoracic vertebra.
So you could postulate that having weak lower traps could lead to over-firing of the upper traps and levator scapulae and the middle fibres of the erector spinae. The increased tone in the upper scapular muscles is a very common finding in neck and shoulder patients, but the overactivity of the erector spinae was something I had not looked at carefully before.
As a practitioner you should always look at adjacent areas to evaluate what effect they might be having on the site of the problem. For example, when a swimmer has shoulder pain, you would always want to check their thoracic spine for mobility and muscular control issues. Sam’s thoracic range of extension and rotation was limited but he was also using an increased degree of muscular contraction in his erector spinae in an attempt to gain greater mobility. Sam had an increased kyphosis in his mid-thoracic region, and passive testing showed these segments to be very stiff.
In setting Sam’s treatment regime, I focused on:
* regaining the muscular control of the lower trapezius in this overhead position
* improving his passive thoracic mobility to reduce the strain on the low cervical spine
* soft tissue massage on the thoracic erector spinae muscle on the affected right side
* local joint mobility and soft tissue massage at the sites where the upper and middle trapezius attach on to the low cervical spine.
One dynamic method to increase thoracic mobility is to use a firm foam roller. I asked Sam to perform this exercise (see Fig 3, above) for about 30 seconds, three to four times, preferably every day but definitely on the days when he was skydiving. The client moves up and down the thoracic spine, taking care not to move above the shoulder blade area nor below the lowest ribs. They also have to keep their pelvis in a neutral position and should have their hands behind their head or crossed over behind their ears to control the strain on the neck.
This is a fairly high-level exercise in that the client has to control their pelvis so that they do not drop into an over-arched position and also to feel the movement going through their thoracic spine rather than their neck. The lower back control is very important because the lumbar spine will be under strain in the skydiving position.
Sam was very thorough in following his home programme. Once he was able to recruit the correct musculature (using lower trapezius in the overhead position instead of levator scapulae), he was able to reduce the strain on his mid cervical spine and his symptoms quickly resolved.
A great deal of his loss of movement had come from his lack of muscular control. He was not exceptionally stiff in his cervical joints – but he just could not control the forces he was placing on his spine.
As with most keen amateur sportsman, Sam was not very happy to reduce the time he spent performing his sport. Fortunately he was able to modify the load at work, which gave him a window of opportunity to rest the injured joints and retrain his motor control.
Once Sam had regained his range of motion and adequate muscular control, I encouraged him to work on his upper body musculature at a local gym under the instruction of a personal trainer. He was to work on scapular stability under high load, such as reverse flyes lying on his stomach. The added strength he would gain this way should protect him against any future repetition of his neck pain and allow him to continue enjoying his extreme sport.