Sensible advice for aches, pains & injuries

Save Yourself from Neck Pain!

All your treatment and self-help options for a crick in the neck explained and reviewed

by Paul Ingraham, Vancouver, Canadabio
I am a science writer and a former Registered Massage Therapist with a decade of experience treating tough pain cases. I was the Assistant Editor of for several years. I’ve written hundreds of articles and several books, and I’m known for readable but heavily referenced analysis, with a touch of sass. I am a runner and ultimate player. • more about memore about
Photo of a woman with neck pain, holding her neck.


This tutorial is for tough cases of chronic neck pain and particularly the phenomenon of neck “cricks” — that nasty stuck feeling. What makes a crick in the neck tick? What are the myths and controversies? What works, what doesn’t, and why? This is a detailed guide, regularly updated with fresh science for over a decade.

Neck pain [MayoClinic] afflicting almost everyone sooner or later. A tutorial like this is overkill if you’ve just woken up with a typical stiff neck. Put some heat on it, maybe do a little stretching, and you’ll probably be fine in a few days.

But maybe it’s a real whopper of a neck crick. Maybe you can hardly move! Or maybe it’s the fifth crick in the neck you’ve had this year. Or maybe you’ve had low-grade but constant, chronic neck stiffness [NHS] ever since that bicycle accident in 2015. Maybe you are starting to wonder if there’s any way to actually reach into your neck, pull out your cervical spine, and put in a replacement unit! You need plenty of good information, because education and fear-reduction may actually be a good neck pain treatment,12 while therapies, drugs, and surgeries have a poor track record.3

About footnotes. There are 222 footnotes in this document. Click to make them pop up without losing your place. There are two types: more interesting extra content,1Footnotes with more interesting and/or fun extra content are bold and blue, while dry footnotes (citations and such) are lightweight and gray. Type ESC to close footnotes, or re-click the number.

and boring reference stuff.2“Boring” footnotes usually contain scientific citations from my giant bibliography of pain science. Many of them actually have pretty interesting notes.

Example citation:
Berman BM, Langevin HH, Witt CM, Dubner R. Acupuncture for Chronic Low Back Pain. N Engl J Med. 2010 Jul 29;(363):454–461. PubMed #20818865. PainSci #54942. ← That symbol means a link will open in a new window.
Try one!

Neck pain myths busted here!

Chronic neck pain matters. The seriousness of chronic pain is often expressed in terms of the hair-raising economic costs of work absenteeism, but it may be much worse than that — a recent Swedish study shows that it probably even shortens people lives.4 The stakes are high. The quality of a life can be ruined, at least. And yet there is an enormous amount of misinformation about neck pain.5 Only low back pain rivals neck trouble for the sheer tonnage of half-baked theories.

For instance, there is a common idea out there that neck pain is related to abnormal cervical spine curvature, perhaps from poor posture. So many professionals believe this over-rated idea that you could probably get a hundred second opinions in a row without hearing otherwise. And yet research has virtually proved that the neck posture hypothesis is wrong or — at the very least — seriously oversimplified and underwhelming.

X-ray of a cervical spine, side view.

Abnormal vertebrae? Who cares …

Research has shown that abnormal curvature of the cervical spine is not closely associated with neck pain.

But the news hasn’t gotten out, and the bogeyman of abnormal neck shape continues to be the basis of lots of expensive manual therapy that doesn’t work particularly well.6 Such ideas can be amazingly persistent. Neck pain myths are as stubborn as neck pain itself. I am sure that in ten years there will still be many professionals fixated on neck posture.

This tutorial carefully debunks many other misconceptions about neck pain — myths about subluxation and the spine being “out,” myths about muscle strain and muscle spasm, myths about arthritis and herniated discs and nerve pinches, and more — and it does it with great care to refer to and explain recent scientific research.7 There’s not much point in criticizing theories about neck pain if I’m just going to push my own unsupported theories, is there?

By the time you are done this tutorial, you are going to know more about your stiff neck than most therapists or even your doctor — perhaps especially your doctor! Most GPs are not really competent to treat neck pain, or any other difficult musculoskeletal problem.8 But before you get too cynical about “mainstream medicine” and run off to an alternative professional like a chiropractor or massage therapist, guess what? No one else is really qualified to treat neck pain either — no one at all, anywhere, because there are genuinely deep scientific mysteries about neck pain.

How can you trust this information about neck pain?

I apply a MythBusters approach to health care (without explosives): I have fun questioning everything. I don’t claim to have The Answer for neck pain. When I don’t know, I admit it. I read scientific journals, I explain the science behind key points (there are more than 230 footnotes here, drawn from a huge bibliography), and I always link to my sources.

For instance, there’s good evidence that educational tutorials are actually effective medicine for pain.? Dear BF, Gandy M, Karin E, et al. The Pain Course: A Randomised Controlled Trial Examining an Internet-Delivered Pain Management Program when Provided with Different Levels of Clinician Support. Pain. 2015 May. PubMed #26039902. Researchers tested a series of web-based pain management tutorials on a group of adults with chronic pain. They all experienced reductions in disability, anxiety, and average pain levels at the end of the eight week experiment as well as three months down the line. “While face-to-face pain management programs are important, many adults with chronic pain can benefit from programs delivered via the internet, and many of them do not need a lot of contact with a clinician in order to benefit.” Good information is good medicine!

And I’ve worked hard for many years to provide the best information about neck pain available anywhere — not just more of it, but better.

However, there are limits to current scientific knowledge about neck discomfort. Not everyone can be helped. There is an alarming lack of honesty in health care about what actually is and is not known about how neck pain works and how to treat it.9 The goal of this tutorial is to help you navigate the maze of medical uncertainty and contradictions, and the many possible causes.

Dr. House: You sir, will, research all the causes in the universe of neck pain.

Dr. Chase: The list is like two miles long

Dr. House: Start with the letter A.

Dr. Greg House & Dr. Robert Chase, House, American TV series

This tutorial does not give you a magic bullet for neck pain, but it does provide readers with many ideas and “upgrades” to their approach to the problem. Most people who think they’ve “tried everything” have not actually tried everything. With some more informed and rational experimentation, many cases neck pain can improve from being almost crippling to manageable.

Who exactly is this tutorial for?

Head pain, face pain, and neck pain are a huge topic. I’ve narrowed the focus of this tutorial to the concept of cricks and chronic unexplained neck pain and closely related symptoms in the upper back and shoulders (upper backs get “cricks” too).

I have excluded detailed discussion of: face and jaw pain; neck pain with prominent nerve symptoms (tingling, numbness, zapping pain) in the arm; headaches10; and fresh whiplash, or other acute neck trauma.11

Most kinds of neck pain share some complications which I do cover in detail here. For instance, whiplash often leads to chronic neck pain.12 And this is particularly true if you had a lot of stress and aches and pains to begin with13 — a strange truth that is relevant to neck pain in general. And so, although this is not a whiplash tutorial, if you are still suffering from neck pain long after a neck injury should have healed, please read on.

And what about a pinched nerve?

Maybe you have a pinched nerve … and maybe you don’t. As with whiplash, this tutorial is useful to many people who have a true nerve root pain (radiculopathy). Even when nerve pain exists — and it does, just much less commonly than it is feared — it may prove to be a surprisingly minor problem that goes away on its own, perhaps when other neck issues are addressed. Severe cases of nerve pain are not addressed directly in this book, but I do put the topic in some perspective — and that can be helpful to many patients, particularly those who aren’t too sure about their diagnosis.

Reading on is a great way to settle this unsettling issue in your mind once and for all. There is a section devoted to the many common misconceptions about nerve pain; another section to help you identify nerve pain (or the lack of it); and a third section about safety issues related to massaging around nerves in the neck.

If you have significant or persistent tingling and numbness in the arms and hands, then the tutorial may be interesting and useful to you, but it will not focus on the options for your problem. Surgery is a more realistic option for patients in this category, but — not being a surgeon — I do not discuss surgery much. The value of this tutorial to such patients is that you might discover a way to avoid surgery.

The evidence that tissue pathology does not explain chronic pain is overwhelming (e.g., in back pain, neck pain, and knee osteoarthritis).

Teaching people about pain — why do we keep beating around the bush?, by Lorimer Moseley, 2–3

Whimsical photograph of a giraffe decorated with illustrated red stars emanating from his neck.

Neck cricks vs. neck pain

Neck cricks and neck pain often go together, affecting about 50% of adults per year,14 ranging in severity from trivial to crippling. In my office, I see as many neck pain cases as low back pain cases. Almost every scientific paper on the subject starts by reeling off the ugly statistics about how many people are afflicted by neck pain, how many dollars it costs our economy every year, and how medically mysterious and tricky it is.

“Crick” is an informal term. You won’t find it in a medical dictionary. But perhaps you should, because it’s a major sub-type of neck pain. It feels like something in a joint is catching or sticking or locking when you try to move, a seemingly mechanical failure. Many neck crick sufferers insist that the problem is not exactly painful, but still extremely unpleasant — a sensation of stuckness that is “irritating” or “uncomfortable” or “stuck” or more like an “itch” or perhaps a “deep itch” than an actual pain.

Because a crick often does not hurt, per se, it is often underestimated and neglected, even by the patient. The use of that word “crick” can trivialize the problem. When it exceeds a certain degree of badness, no one calls it a “crick” anymore — the word feels too lightweight.

Never underestimate the power of a neck crick to make a person perfectly miserable. Not all pain is painful. It is possible to suffer deeply without hurting. A feeling of stuckness can be every bit as bad as severe pain. Cricks will nag and irritate to the point of nearly driving people out of their minds — a serious mental health hazard, no exaggeration. I have seen people showing every sign of severe chronic psychological distress, unable to function well mentally because their neck will not stop harassing them.

I’ve also experienced that state personally, once.

Although it’s like comparing apples to orange cars, I have often had the impression that irritating cases are more tragic than painful cases, causing more emotional distress — suffering — and mental preoccupation than pure pain. There is something profoundly unsettling about this kind of discomfort. I get email from readers around the world who recognize their predicament in these words, and want to reach out just to say, “Yeah, that’s me!

So cricks make neck pain particularly “interesting,” in the sense of the Chinese curse.15 They are a simple sensation that no one can really explain. Not every case of neck pain includes a crick, but the terrible neck injuries and pain problems of today often become the persistent cricks of tomorrow. Pain and nagging stuckness are generally interwoven and the lines between them thoroughly blurred. So this tutorial is about both, but with a strong emphasis on the exasperating phenomenon of a crick.

Part 2


What’s the worst case scenario for neck pain?

In the worst cases, with or without the best treatments available, neck pain and crick can be a life sentence of moderate to severe pain and/or irritation. As noted above, even a “painless” neck crick can still cause great suffering. A severe case can be severe indeed, and seemingly immune to all treatment efforts, without ever having a clear or certain diagnosis.

There are some limits on the severity.16 In terms of duration, though, there are no limits: neck pain can last five minutes, ten hours, several days, weeks or months … or forever. Most cricks are mild and resolve spontaneously, with or without treatment, within a few days or a couple of weeks at the longest. It’s important for fresh victims to know this — the reassurance is important and justified.17

“Contrary to prior belief, most individuals with neck pain do not experience complete resolution of their symptoms and disability.”

However, neck cricks and neck pain do have the potential to last and last. Most patients interested in this tutorial probably already think of their neck pain as chronic. Unfortunately, I have seen many patients with cricks that seem to be permanent. It is something of a myth that neck pain is a temporary problem. Many professionals are prone to reassuring neck pain patients a little too much. Chronic neck pain is usually less debilitating than back pain, and isn’t taken as seriously. And yet neck pain may be even longer-lasting than back pain, which is notorious for its chronicity.18 Only about 50% of patients recovered quickly according to Leaver et al.19 About 35% of cases of neck pain were “persistent” according to a Canadian survey of 1100 adults.20 Côté et al: “Contrary to prior belief, most individuals with neck pain do not experience complete resolution of their symptoms and disability.” Damn.

I know of a case of a mild crick that remains unchanged after about eight years. I know of a serious case that lasted thirty-five years… but was then mostly cured by a few of massages. (His story coming up below.) So it’s hard to say how long a neck crick lasts, because the sky’s the limit. Fortunately, most cricks are indeed short-lived, and even the longest lasting ones still have the potential to be relieved.

So the worst cricks are rare, but when they occur they can cause enough pain to make normal life difficult, and can last pretty much forever. But it’s extremely unpredictable.

Interestingly, women suffer more. According to Côté et al, women are 60% more likely than men to develop neck pain, and 20% more likely to develop chronic neck pain.

And now for a random amusing story about neck pain. (And the key to the joke is knowing that the carpal tunnel is not in the neck — it’s in the wrist!)

Yesterday I saw a guy who repeatedly mentioned that he’s a nurse. When he called he said he was having “carpal tunnel problems.” That’s fine, I can handle that. But when he came in, all he wanted to talk about was his neck pain. I can handle that, too. But I asked him why he’d said he was having carpal tunnel problems when he called. He said “because the carpal tunnel is in the neck.” When I tried to correct him, he argued with me, then walked out. Said he was going to “find a doctor who knows his damn anatomy.”

Dr. Grumpy, Anatomy 101

Three case studies of extreme neck crick horribleness

The one about the guy who had suffered for 35 years and couldn’t stop wrenching his neck around

It was by far the worst case I encountered in my decade as a massage therapist: a middle-aged man who had suffered ever since a serious motorcycle accident in his youth. The overall intensity of pain had been frequently debilitating, but was always greatly aggravated by a maddening sensation of stuckness just under his skull — a whopper of a classic crick, an itch he had been trying to scratch for three and a half decades by squirming and “wrenching” (his word) violently from side to side.

This wrenching behaviour was so severe and so habitual that it was a major feature of his identity, like a tic — and when he stopped doing it, friends and family were amazed.

His story is not only a good example of a worst case scenario, but it’s also instructive about the nature of neck cricks. It’s hard to imagine crick more mechanical than his, and indeed he had received hundreds of temporarily effective chiropractic treatments over the years. They always helped, but never for long. “Usually it would be ‘out’ again within minutes or hours,” he explained to me.21

And yet! This man’s tortured sensation of dislocation was more relieved, and for longer, by simple rubbing of the muscle tissue around the joint. This is a good demonstration that it is sometimes much easier to change the state of a joint by massaging muscles than by cracking joints.

“Usually my neck would be ‘out’ again before I got home from the chiropractor.”

He remained relatively crickless for a couple of years after I last worked with him — for the first time in more than thirty years. “It’s not cured,” he told me much later, “but it’s so much less than it used to be. It’s at least 80% gone. It’s mostly a bad memory.”

Of course, therapy doesn’t always go that well. Skilled therapists can be stumped by cricks, and I have seen several cases where no intervention made much difference, and some cases where chiropractic adjustment seemed to be the magic bullet. Although most cricks respond well to massage therapy, what makes some neck cricks come and go can be quite mysterious.

The one about the guy with the crick that was painless but immune to all therapy

This patient sought therapy for his problem continuously for at least a decade without a trace of relief: a completely invincible crick. He had no pain: he had a mildly irritating but completely unchanging sensation of stuckness in his lower cervical spine.

“It doesn’t really hurt, exactly,” he said. “But it drives me nuts.”

And nothing ever touched it. I was just another therapist who failed. I worked with him for more than ten hours over a few weeks — at least a thousand bucks worth of therapy — and had no effect. It’s like I wasn’t doing anything at all. Occasionally it seemed as though massaging the muscles in the area gave him some minor and temporary relief, but that distinctive feeling of stuckness remained, indomitable. The extraordinary persistence of it is qualified him as a “severe case,” like hiccoughs or an eyelid twitch that just never went away: a minor problem, unless it lasts forever.

The one about the woman whose neck pain was so severe that she had trouble functioning when it flared up

Another case that comes to mind is the opposite: severe, but also more episodic and treatable. With no history of trauma, this patient suffered bouts of stress-induced neck crick, pain, and headache about three or four times per year. She wasn’t just hurting: she was disabled, down for the count and whimpering. (That’s the kind of severity I described as “probably caused by disease” in the last section. But it wasn’t in her case.) The headache was bad, but secondary to the severe pain up one side of the back of her neck and a feeling of stuckness so strong that she couldn’t turn her head at all.

“It feels completely locked,” she said. I thought perhaps it might be too painful to turn, but no: “It hurts whether I turn or not,” she explained. “It doesn’t hurt any more when I try to turn. It just feels stuck.”

Despite the short term successes in treating her & despite how valuable she considered it, it didn’t feel like a success story to me, not when she always came back three months later with more pain.

And yet, despite its severity, this patient seemed more treatable than the other severe examples above. She responded well to massage therapy. She craved pressure on her muscles, and gushed about how much better she felt at the end of every session. Before massage, it took weeks to recover from an episode. With massage, she said she feels better immediately, and was back to normal within just a few days.

And it always came back. And that was really the issue: despite the short term successes in treating her, and despite how valuable she considered it, it didn’t feel like a success story to me, not when she always came back three months later with more pain. How long will this pattern go on for her? What a curse! It was a grim example of how bad neck cricks can be.

“What if there’s something really wrong with my neck?” Safety information!

“How do you know I’m not seriously hurt?”

“Could it be cancer? A tumor?”

Although it’s rare, once in a while neck pain may be a warning sign of cancer, infection, autoimmune disease, or some kind of structural problem like spinal cord injury or a threat to an important blood vessel. Fortunately, most of these ominous situations cause hard-to-miss signs and symptoms other than pain and are likely to be diagnosed correctly and promptly. If you are aware of the “red flags,” you can get checked out when the time is right — but avoid excessive worry before that.

The rule of thumb is that you should start a more thorough medical investigation only when three conditions are met, three general red flags for neck pain:

  1. it’s been bothering you for more than about 6 weeks
  2. it’s severe and/or not improving, or actually getting worse
  3. there is at least one other “red flag” (see below)

And there is one (hopefully obvious) situation where there’s no need to wait several weeks before deciding the situation is serious: if you’ve had an accident with forces that may have been sufficient to fracture your spine or tear nerves. I didn’t really have to tell you that, did I? Well, I did for legal reasons! 😉

In all other cases, you can safely read this tutorial first.

Several more specific red flags for neck pain: a checklist

Check all that apply. Most people will not be able to check many of these! But the more you can check, the more worthwhile it is to ask your doctor if it’s possible that there’s something more serious going on than just neck pain. Most people who check off an item or two will turn out not to have an ominous health issue. But red flags are reasons to check… not reasons to worry.

    Picture of red flags, symbolizing red flags for neck pain with serious causes.
  • Light tapping on the spine is painful.
  • Weight loss without dieting is a potential sign of cancer.
  • Mystery fevers and/or chills (especially in diabetic patients).
  • A fierce headache, and/or an inability to bend the head forward (nuchal rigidity), and/or fever, and/or altered mental state are all symptoms of meningitis (inflammation of the membranes covering the brain and spinal cord, caused by infection or drug side effects).
  • A severe headache that comes on suddenly is colourfully called a “thunderclap headache”! Most are harmless, but they should always be investigated.22
  • There are many possible symptoms of spinal cord trouble in the neck,23 mostly affecting the limbs in vague ways that can have other causes, but especially poor coordination, weakness, and shooting pains (including “sciatica” in the legs24). Bizarrely, cord compression may even cause fibromyalgia.25
  • Unexplained episodes of dizziness and/or nausea and vomiting may indicate a problem with stability of the upper cervical spine. Such symptoms should never be dismissed by alternative health professionals as “detoxification.” )
  • Steroid use, other drug abuse, and HIV are all risk factors for a serious cause of neck pain.
  • If you are feeling quite unwell in any other way, that could be an indication that neck pain isn’t the only thing going on.26
  • The main signs that neck pain might caused by autoimmune disease specifically include: a family history of autoimmune disease, gradual but progressive increase in symptoms before the age of 40, marked morning stiffness, pain in other joints as well as the low back, rashes, difficult digestion, irritated eyes, and discharge from the urethra.

For more detail and ideas, see When to Worry About Neck Pain…and when not to!

Part 3


The (weird and unclear) nature of the beast

There is a considerable amount of scientific mystery, debate and controversy about the nature of neck pain, and the solutions for it. It’s a medical muddle. As with the common cold and flu, we just don’t “get it” yet.

A detailed article in the January issue of 2009 of Pain Physician states clearly that “very little is known about the causes of neck pain.”27 No one should ever confidently claim to know the One True Cause of neck pain, because there are probably many true causes — many of them undiagnosable, or not reliably diagnosable — because we cannot (and may never be able to) look deeply into the living neck.

There is one type of explanation to beware of, the most popular-yet-vague idea in all of neck pain lore: the idea that your neck is “out.” People say “my neck is out,” and they really mean it: they aren’t thinking of it as a general term that might encompass any number of more specific issues. They truly suspect that a vertebral joint is partially dislocated, and this is almost certainly not the case. This pernicious idea is based mostly on the chiropractic concept of “subluxation,” which will be addressed in detail below. There can certainly be something wrong with your neck joints — that much is clear — but it’s probably a misleading and potentially anxiety-producing oversimplification to imagine that the joint is partially dislocated or out of place. It’s not really like that — it can’t be.

Photograph of a woman receiving a neck massage.

Because most neck pain is probably at least partially caused by muscle dysfunction, massage is one of the best therapies available. However, we’ll be reviewing all the treatment options.

This mess of possible causes is made more confusing by the fact that they all share at least one thing in common: an “equalizing factor” which tends to make them all seem surprisingly similar. No matter what it was that started the pain, painful muscular dysfunction almost certainly complicates it,28 and may even become the dominant problem. Meanwhile, painful muscle dysfunction itself is poorly understood, and probably underestimated as a factor by many (or most) health care professionals — even while some medical experts devote their careers to it,29 the medical majority still has a muscle blind spot,30 and even massage therapists may overlook it — surprisingly, massage therapy training does not go into much detail about the physiology of muscle pain or treatment methods.

So, nothing is certain, anything is possible, and nothing about neck pain can surprise me any more: not even the knowledge that — and this is so odd — neck pain is more common in short people.31 I’m a short person! And I have quite a bit of neck pain! Apparently that association is a fact, but it’s a fact that I can’t even begin to explain. In this tutorial I have written about what seems to be true and useful for most people, most of the time, and I’ve supported it with the best evidence available.

My chiropractor says this is because the top of my neck attaches to my head. Is that a common problem?

from the “chiropractors say the darndest things” file, as reported by Dr. Grumpy (Only Outside Sleepy Hollow)

Why does a crick feel the way it does?

“The best evidence available” ain’t saying much, unfortunately: the science of neck pain is undeniably limited, and the science of “crick” sensations specifically is nearly nonexistent.

“The neck is rife with structures that potentially could and probably do cause various painful conditions.”

Janet Travell, David Simons, and Lois Simons, Myofascial Pain and Dysfunction: The Trigger Point Manual, 1999 , p247

The amount of “crick” in a case of neck pain varies, like seasoning in a recipe. However, most cases of neck pain involve at least some crick — and what is that sensation anyway? What makes a crick feel the way it does? What’s going on in there? We’ll explore this over the next few sections.

After my decade of clinical experience, my preferred explanation33 — not necessarily “correct,” but the most useful explanation for most people, most of the time — is the idea of “minor intervertebral derangement” (MID).3435 A MID is basically a minor mechanical malfunction in your spine, causing pain directly through mild trauma. A MID is probably not even as painful as a toe stub in most cases, or no more, but certainly painful enough to provoke a reaction. Here are some possible examples of MIDs:

  • Compression sprain.There are a pair of small, dime-sized joints on either side of every intervertebral joint, the facet joints.36 Their cartilaginous surfaces can be “bruised” when compressed, somewhat like a thumb jam.37 This might happen if you “zigged” when you should have “zagged” — a poorly coordinated movement of the neck.38 Minor compressions of this sort are probably extremely common, and mostly painless. Joint surfaces are not particularly sensitive to pressure.39
  • Synovial membrane pinch. Joint capsules — connective tissue wrappings — around the facet joints can probably be pinched between the joint surfaces, basically at random, and probably for the same reason that compression sprains occur (the “zigged when you should have zagged” theory). This has never been demonstrated scientifically to the best of my knowledge, but it is plausible. Unlike cartilaginous joint surfaces, synovial membranes (the lining of the capsule) are extremely sensitive.
  • Violent joint popping. The facet joints also “pop,” like knuckles. Although many people are used to the sensation of joint cracking in their necks, for others it is a surprising, uncomfortable, and even alarming sensation. A violent “crack” could constitute a minor MID.40
  • A nerve pinch. Although less of a problem than most people suppose (more about that in a while), irritation to nerves exiting the cervical spine is possible. Once again, a poorly coordinated movement can result in a momentary yank or pinch on nerve tissue. The sensation may be more alarming than actually damaging (but alarm is what makes things painful, not damage).

Note that none of these examples necessarily involve an on-going mechanical problem with the joint, just a painful, temporary disturbance. In most cases, the persistent feeling of a crick is probably not a product of an MID itself, but of its consequences: the irritation of the MID itself quickly dies down, and is overtaken by a variety of neurologic and muscular reactions, which are probably dominated by the pain of muscle knots.

More to come on the nature of this muscular reaction — it’s the most important idea in this tutorial. But first, let’s make sure that this business of a “mechanical malfunction” component of neck pain is thoroughly addressed. There’s a strong, intuitive desire to interpret neck pain as some kind of a mechanical failure of the neck joints, especially they idea that they are “out” of place in some sense. Is it reasonable?

Subluxation: can your neck be “out”?

[Illustration of hands twisting a spinal column]

A defining feature of cricks is that something feels out of place or jammed, there may indeed be a joint dysfunction. But one fascinating, plausible possibility is that the crick sensation may be where the explanatory buck stops: that is, maybe the joint just feels wonky. Pain distorts body image — our mental image of our own anatomy. An odd little 2008 paper demonstrated that people with back pain really feel like their vertebrae are deviated to the painful side even when they aren’t.41

It’s a straightforward idea, so simple it probably isn’t satisfying, but this phenomenon could be potent and persuasive. We are used to more or less trusting our sensations. If it feels out, we assume it must be out. But it ain’t necessarily so: sensation can be incredibly deceptive. This could be the main reason for the stuck and janky quality of crick-ish neck pain. (It’s illusory quality doesn’t make it any less of a problem, of course: there’s still something wrong that’s powering the illusion.)

Or maybe that joint really is “out” in some sense. Let’s deal with that directly now: what about more literal, non-illusory subluxations?

Many experts, including quite a few chiropractors, actually deny that spinal subluxations exist in any meaningful sense.

There can certainly be something wrong with your spinal joints — there are a few possibilities — but “subluxation” and spinal joints being “out” are not defined clearly enough to be useful, and are probably quite misleading.

“Subluxation” is mainly a chiropractic idea of some kind of spinal joint dysfunction, with many shades of meaning — too many — depending on who is talking about it. However, it is inextricably entangled with the idea of a spinal joint being “out” of place, and it is this sense of the word that needs some debunking. Some chiropractors attribute great importance to subluxation. Most believe that subluxations cause neck and back pain, and — significantly — many also believe that they cause a wide variety of other health problems and so they “use spinal manipulation to treat visceral disease” (Homola). Subluxation theory has been both popular and controversial for many decades now, and it has never achieved medical respectability. Many experts, including quite a few chiropractors, actually deny that spinal subluxations exist in any meaningful sense.

It’s problematic that spinal manipulative therapy — the umbrella term for all kinds of spinal joint “adjustment” — is so often based on such a confusing and controversial concept. Subluxation has too much baggage to be a useful term. Let’s use more modern and specific terminology, and get away from the idea of spinal joints being “out.”

The controversies about subluxation theory are described thoroughly in a special supplement to this tutorial. You can also just read some highlights below, in this book’s section about treating neck pain with spinal adjustment.

Hey, wait a sec… aren’t MIDs and subluxations pretty similar ideas?

Reader J.B. asked this question in mid-2014, and I thought maybe I’d been caught in a glaring inconsistency.42 Lucky for me, there are some clear differences (and exploring them should be informative).

Although the chiropractic idea of “subluxation” is a hot mess, it does have two defining characteristics that have been consistent over the decades:

  1. the idea of joints being “out”
  2. the idea that they mainly matter because their out-ness has an on-going deleterious effect on nerve roots

The notion of an MID can’t be completely distinguished from the first, but it avoids the second completely.

Here’s another, trickier difference: chiropractor subluxation is mostly seen as a persistent pathological state of the joint. That is, the joint gets into and stays in a problematic state, allegedly something they can feel, or visible on an X-ray, or possibly apparent only with motion. In contrast, a MID is a transient mild trauma — an incident with painful consequences, not a persistent state of affairs. That’s the important distinction.

There is some conceptual overlap. For instance, if you do give yourself a little compression sprain of a zyapophyseal joint, ow, it’s plausible that the consequences would include not just irritation but some persistent joint dysfunction as well (e.g. the nervous system trying to move the spine without further compression the irritated surfaces).

Another possibility: the feeling of stuckness without being stuck

Some considerations:

  • Consider how exquisitely sensitive we are to the presence of a grain of sand between the teeth: the tiniest obstruction, and we are fully and uncomfortably aware that something is in the way of our bite.
  • Or consider that we can detect even the slightest movement in our joints — if someone pushes on the tip of your shoe while your eyes are closed, no matter how gently, you will know.
  • And consider how irritating it can be for our freedom of movement to be limited! The feeling of needing to stretch your legs after being stuck in an airline seat can be almost overwhelming.

These hair-trigger sensations are powered by a rich sense of position and movement (proprioception, the “sixth sense”), and by a basic physiological need to constantly, physically stimulate all tissues in order to remain healthy. Stagnant tissues quite literally die — bed sores are the obvious example (and the stakes are life and death — it was an infected bed sore that killed Christopher Reeve in 2004). Thus we are programmed to detect and respond strongly to the slightest stagnancy. And this is, in a general way, is probably how a joint dysfunction can be so uncomfortable without actually having anything obviously “mechanically” wrong. Like the grain of sand between your teeth, even a tiny bit of joint “stuckness” is probably obvious to our nervous systems.

This could all occur without the slightest visible, palpable or X-rayable problem.

We can almost certainly feel “out” without being “out.” But what about the scenario — routine in neck cricks — where you literally can’t turn to one side or the other? That seems to be more than just a feeling of stuckness.

Stuck! What limits your range of motion?

So you can’t shoulder check while driving. You can barely move your head to get a shirt on. You can’t tilt your head to shave.

I can’t tell you how many hundreds of times I have heard such descriptions from my patients and readers. And friends. And family. And bank tellers, and convenience store cashiers. Seemingly anyone who has a neck and the power of speech has, at some point, had this unpleasant experience and told me about it. They are stuck — really stuck.

And I’ve been there, too. I’ve been stuck there.

Many cricks only involve a minor, vague feeling of stuckness, while others result in a more literal limited range of motion. Such stuckness may even occur with relatively little pain, and it is in such cases that the feeling of stuckness is the most vivid — it just won’t move. Surely there is something truly stuck or “outta whack” in the neck when you can barely move it?

Yes, there just might be. In some sense…


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Part 3.5



This document and all of was, for many years, created in my so-called “spare time” and with a lot of assistance from family and friends. Undying thanks to my wife, Kimberly, for countless indulgences large and small, and for being my “editor girlfriend”; to my parents for (possibly blind) faith in me, and much copyediting; and to Mike Gobbi, buddy and digital mentor, for many of the nifty features of this document (hidden and obvious). And thanks to all of the above, and many others, for many (many) answers to “what do you think of this?” emails.

Thanks finally to every reader, client, customer, and big tipper for your curiosity, your faith, and your feedback and suggestions and stories. Without you, all of this would be pointless.

And a few thanks to some health professionals who have been particularly inspiring to me: Dr. Rob Tarzwell, Dr. Steven Novella, Dr. David Gorski, Sam Homola, DC, Dr. Harriet Hall, Simon Singh, and Dr. Stephen Barrett.

Reader Comments

Here is what some readers have said about the neck pain tutorial over the years. Feedback is always welcome. I focus on the positive in this section, but I want to acknowledge that I certainly do receive some criticisms as well. In many cases I respond by making improvements to the tutorial. However, the vast majority of feedback is enthusiastic. Thanks, everyone!

I never had severe neck pain except for the occasional bad day, but it was stubborn. I’ve never really had any relief from it ever, always a low grade ache. Every therapist I ever saw told me it was posture, and every doctor said it was arthritis (even though it started in my 20s). Your tutorial clearly explain several other possibilities, and it’s mostly under control now just from a little bit of self-treatment of my muscles once every week or two. It’s not “cured,” but it’s about a hundred times less irritating than it was. Thank you!

— Laurie Pappas, Denver, unusually busy home-maker, mother of seven

After Googling ‘neck knot’ I read an article on some ask-the-clinician site which was pretty useless, and then tried yours. It was exactly the information I was looking for! Your article affirmed some of my own theories and enlightened me with more detailed information. You’re a thorough and organized writer.

— Cheryl Sosebee, artist

After thirty-five years with severe constant neck pain, I am 80% better, and I feel like I can actually enjoy the rest of my days. Paul Ingraham helped me understand that the problem with my neck wasn’t ‘structural.’ Even though it felt like something was ‘out,’ that’s not really what was happening. I’d seen every kind of therapist you can imagine, and no one ever explained it so clearly. I had my doubts at first, but the results of applying his ideas have been nothing short of miraculous. I used to wrench my neck all day long, always twisting and turning trying to get away from that damn crick! And now? People who don’t even know me that well are saying to me, ‘Hey, Elliott... you’re not twisting your neck around the way you used to!’ If you’ve got a stiff neck, I can’t recommend Paul Ingraham’s perspective on it strongly enough.

— Trevor Elliott, real estate speculator

One more special comment. In the Spring of 2009, I received an incredible endorsement from Jonathon Tomlinson, a GP in Hackney, East London, praising the whole website and every tutorial:

I'm writing to congratulate and thank you for your impressive ongoing review of musculoskeletal research. I teach a course, Medicine in Society, at St. Leonards Hospital in Hoxton. I originally stumbled across your website whilst looking for information about pain for my medical students, and have recommended your tutorials to them. Your work deserves special mention for its transparency, evidence base, clear presentation, educational content, regular documented updates, and lack of any commercial promotional material.

— Dr. Jonathon Tomlinson, MBBS, DRCOG, MRCGP, MA, The Lawson Practice, London

High praise indeed! Thank you, Dr. Tomlinson — testimonials just don’t get much better than that.

Further Reading

What’s new in this tutorial?

The first version of this document was created in 2002. It was upgraded and expanded several times before I started keeping track of updates put it up for sale in September of 2007. It was revised and expanded to book-length in the summer 2009, and continues to be updated as new scientific information becomes available, and in response to reader requests and suggestions.

Regular updates are a key feature of tutorials. As new science and information becomes available, I upgrade them, and the most recent version is always automatically available to customers. Unlike regular books, and even e-books (which can be obsolete by the time they are published, and can go years between editions) this document is updated at least once every three months and often much more. I also log updates, making it easy for readers to see what’s changed. This tutorial has gotten 69 major and minor updates since I started logging carefully in late 2009 (plus countless minor tweaks and touch-ups).

Upgraded (, section #2.2) — Several good red flag clarifications and a couple interesting new references about spinal cord compression. See section #2.2, “What if there’s something really wrong with my neck?” Safety information!

Science update (, section #3.15) — Significant revision and some important new citations more firmly establishing the link between psychological and lifestyle factors and poor recovery from neck pain. Previously this section relied too much on similar evidence about other problems: it is now more neck-centric. See section #3.15, A recipe for persistent neck pain — what are the risk factors?

Science update (, section #5.22) — Added some useful new indirect evidence about SMT for migraine (Chaibi et al). See section #5.22, Spinal manipulative therapy (SMT): Adjustment, manipulation and cracking of the spinal joints.

Edited (, section #3.11) — Added some important footnotes and clarifications. See section #3.11, The most important tissue issue in most neck pain: muscle.

Edited (, section #4.4) — Thorough revision and modernization. Although I revised this section just five years ago, it needed it again! See section #4.4, Estimating the importance of trigger points in your own case.

New section (, section #5.23) — More than a thousand new words on the topic of neck cracking. See section #5.23, Popping your neck joints: bad habit, or self-treatment?

Science update (, section #5) — Revised the introduction to treatments for clarity and completeness, added new references, and a new short paragraph about risks and harms. See section #5, Treatment: What can you do for a crick in the neck?

Major update (, section #5.3) — Broadened scope of section to include all pain killers. Added a summary of opioids, and a guide to experimenting with the over-the-counter ones; added more science; merged and edited previously separate sections on rebound pain and muscle relaxants. See section #5.3, Pain killers and muscle relaxants.

Correction (, section #4.4) — Removed overconfident statements about the clinical significance of the effects of psychoactive drugs, plus related minor updates. See section #4.4, Estimating the importance of trigger points in your own case.

Minor update (, section #4.2) — Some editing and new caveats. See section #4.2, Nerve blocks (medial branch blocks) as a method of diagnosis.

Update (, section #3.2) — Added new intro to section about distorted body image. See section #3.2, Subluxation: can your neck be “out”?

Science update (, section #5.3) — Added citation about the efficacy of ibuprofen for headache. See section #5.3, Pain killers and muscle relaxants.

Science update (, section #3.5) — Added some particularly good science to shore up the personal anecdote added in January. See section #3.5, Could it be arthritis? Is your spine degenerating? Probably not, no.

Improved (, section #4.1) — Added a new key point about how to recognize the pain of a nerve root pinch. See section #4.1, How can I tell if there’s a pinched nerve?

Science update (, section #1) — New footnote supporting the use of education (like this tutorial!) to treat chronic pain. See section #1, Introduction.

Minor update (, section #3.5) — Added a good personal ancedote…because my spine is degenerating! Also, a footnote about surprisingly painless joint damage. See section #3.5, Could it be arthritis? Is your spine degenerating? Probably not, no.

Science update (, section #5.22) — Added some hard evidence on the minor (non-lethal) risks of SMT from Carlesso 2010. See section #5.22, Spinal manipulative therapy (SMT): Adjustment, manipulation and cracking of the spinal joints.

Science update (, section #3.16) — Added an interesting reference to Carlesso 2013 with some discussion of the implications. See section #3.16, Neck pain versus back pain: some similarities and differences.

Science update (, section #5.5) — Added a humility citation, conceding the absence of scientific evidence that massage helps neck pain. Also, modernization summary of trigger point therapy. See section #5.5, Introduction to treating your own neck trigger points.

Science update (, section #3.1) — Added a little more information about the nature of uncovertebral joints. See section #3.1, Why does a crick feel the way it does?

Upgraded (, section #2.2) — More and clearer red flag details, especially about spinal cord trouble (myelopathy). See section #2.2, “What if there’s something really wrong with my neck?” Safety information!

Major update (, section #5.16) — Completely rewritten and greatly expanded, with much more science, emphasizing strength as a worthwhile treatment option. See section #5.16, Build your neck muscle strength and endurance.

Revised (, section #5.17) — Editing and some new science about changing head posture. See section #5.17, Will strength improve neck posture/curvature?

Minor update (, section #2) — More data on neck pain recovery rates See section #2, Prognosis: What’s the worst case scenario for neck pain?

Minor addition (, section #3.10) — Added a patient anecdote about a strange muscle spasm experience…which I know all too well. See section #3.10, Is it a spasm? Nope, probably not a spasm either: the muscle spasm myths (plural).

Minor update (, section #3.8) — Added an expert quote. See section #3.8, Does abnormal curvature hurt? Not much! The neck posture myth.

Science update (, section #4.1) — Added brief example of nerve pinch by vertebral artery twistiness. See section #4.1, How can I tell if there’s a pinched nerve?

Science update (, section #3.7) — Added three good references and a diagram about how much “wiggle” room nerve roots have. See section #3.7, Is it a pinched nerve? I doubt it! The nerve pinch myth.

Expanded (, section #5.12) — Added about 350 words about neck circle safety. See section #5.12, Mobilizations or “wiggle therapy”.

Science update (, section #3.12) — Added a new good-news study about massage for neck pain. See section #3.12, The case for myofascial trigger points as a major neck pain villain.

Minor update (, section #2) — Upgraded references on neck pain recovery rates. See section #2, Prognosis: What’s the worst case scenario for neck pain?

Science update (, section #3.12) — Added some important acknowledgements that the science of trigger points is a bit half-baked, and linked out to much more information for the curious. See section #3.12, The case for myofascial trigger points as a major neck pain villain.

More content (, section #3.2) — Explanation of the difference between a subluxation and an MID. See section #3.2, Subluxation: can your neck be “out”?

Science update (, section #5.22) — Added citation to a key 2012 study of the effectiveness of adjustment for neck pain. See section #5.22, Spinal manipulative therapy (SMT): Adjustment, manipulation and cracking of the spinal joints.

New (, section #4.10) — A new section, but also a summary of an existing free article. See section #4.10, Digital Motion X-Ray.

Minor update (, section #5.26) — Added a (fascinating) footnote about the myth of anaesthetic paralysis. See section #5.26, Reality checks: some popular treatments that don’t work at all (or not nearly as well as you would hope).

Minor yoga update (, section #5.13) — Added a reference and paragraph about the risks of yoga, which are minor but real, especially for neck pain. See section #5.13, Will stretching help neck pain? Much?

Minor science update (, section #5.13) — Added a tiny, flawed study about yoga for neck pain (for what little it’s worth). See section #5.13, Will stretching help neck pain? Much?

New evidence (, section #5.15) — Rare good news: the first good quality scientific test showing that reducing fear is actually good medicine. The section got a decent editing as well. See section #5.15, Relaxation and the confidence cure.

New section (, section #5.7) — No notes. Just a new section. See section #5.7, A massage success story.

Science update (, section #1.1) — Added evidence that the stakes are high with chronic pain: it may even shorten lives. See section #1.1, Neck pain myths busted here!

Science update (, section #3.12) — Added a key reference about the effectiveness of massage for back pain, with the (safe) assumption that it probably applies to neck pain as well. See section #3.12, The case for myofascial trigger points as a major neck pain villain.

Science update (, section #3.10) — A new study shows that massage therapists cannot reliably find the side of pain by feel — good evidence that no gross spasm (or other structural factor) is usually involved. See section #3.10, Is it a spasm? Nope, probably not a spasm either: the muscle spasm myths (plural).

Minor update (, section #5.11) — Added some creative problem-solving for hot climates. See section #5.11, Avoid drafts at night.

Minor update (, section #5.19) — Added a minor but odd note about “sensory annoyances” like hats and collars. See section #5.19, Ergonomics are probably more important than posture.

Minor update (, section #3.9) — Added some unusual research about the risks heavy metal “head-banging” — a fun example, for perspective. See section #3.9, Is it a strain? Probably not! The muscle strain myth.

More content (, section #3.2) — Added scientific cases studies, examples, pictures and video of true dislocation and abnormal anatomy to help drive home the point that even significant spinal joint dysfunction can be surprisingly harmless … never mind subtle joint problems. See section #3.2, Subluxation: can your neck be “out”?

trivial update (, section #1.2) — Trivial but fun. Added an amusing quote about neck pain diagnosis from the TV series, House. See section #1.2, How can you trust this information about neck pain?

Minor science update (, section #5.13) — Cited a study about yoga and stretching for back pain. See section #5.13, Will stretching help neck pain? Much?

New section (, section #3.13) — This section is a summary of an important concept that’s been available in a free article since late 2008, but also needed to be emphasized here. Now it is. See section #3.13, From the frying pan of injury pain to the fire of trigger point pain.

Minor update (, section #1.1) — Added a reference about the poor overall quality of online information about common injuries. See Starman et al. See section #1.1, Neck pain myths busted here!

Added a fun thing (, section #5.14) — I can’t believe I didn’t know about inflatable neck extenders until now! See section #5.14, Pull my neck! The potential of traction.

New section (, section #4.5) — More information about an important characteristic of muscle-dominated neck pain. See section #4.5, “Out of nowhere”: seemingly random episodes of neck pain.

Major update (, section #4.4) — Totally renovated section: re-written, reformatted, expanded, upgraded. A few new checklist items were added, most were expanded, and all were clarified. A separate and handier “quick” checklist was added to the existing “slow” checklist. See section #4.4, Estimating the importance of trigger points in your own case.

Major update () — Major improvements to the table of contents, and the display of information about updates like this one. Sections now have numbers for easier reference and bookmarking. The structure of the document has really been cleaned up in general, making it significantly easier for me to update the tutorial — which will translate into more good content for readers. Care for more detail? Really? Here’s the full announcement.

Upgraded (, section #5.22) — New artwork from artist Gary Lyons, plus some important new references. See section #5.22, Spinal manipulative therapy (SMT): Adjustment, manipulation and cracking of the spinal joints.

Updated (, section #5.13) — Updated with an important story about a disastrous example of neck stretching that backfired. Not just for customers: this particular section is a short version of a new free article. See section #5.13, Will stretching help neck pain? Much?

Minor update (, section #1.1) — Some good new science cited in the introduction, about the overall effectiveness of manual therapies. See D'Sylva et al. See section #1.1, Neck pain myths busted here!

Major Update (, section #3.2) — Rewriting and expansion of the Special Supplement on spinal manipulative therapy. See section #3.2, Subluxation: can your neck be “out”?

Update (, section #3.9) — New science confirms that helmets do not cause neck injuries — they just keep your head safe. However, minor injury remains likely and problematic. See section #3.9, Is it a strain? Probably not! The muscle strain myth.

New cover () — At last! E-book finally has a “cover.”

Science update (, section #5.26) — Updated with a summary of a bizarre experiment with muscle relaxants that had quite surprising results. See section #5.26, Reality checks: some popular treatments that don’t work at all (or not nearly as well as you would hope).

Minor update (, section #5.17) — Update with another recent study showing that strength training doesn’t work. See section #5.17, Will strength improve neck posture/curvature?

Major update (, section #5.17) — Completely overhauled and substantially expanded, and polished several relevant bibliographic records. See section #5.17, Will strength improve neck posture/curvature?

Rewritten (, section #3.8) — Completely overhauled and substantially expanded, and polished several relevant bibliographic records. See section #3.8, Does abnormal curvature hurt? Not much! The neck posture myth.

Science update (, section #5.26) — Added an interesting reference about how muscle relaxants are surprisingly ineffective. See section #5.26, Reality checks: some popular treatments that don’t work at all (or not nearly as well as you would hope).

Minor update (, section #3.12) — Shored up substantiation of the relationship between migraines and trigger points. See Fernández-de-Las-Peñas et al, and another paper by Fernández-de-Las-Peñas et al, and also Calandre et al. See section #3.12, The case for myofascial trigger points as a major neck pain villain.

New section (, section #4.3) — First new section since the huge update in the fall, a short-but-useful section. See section #4.3, A poke in the disc! Cervical provocation discography as a method of diagnosis.

Huge upgrade () — Over the past several months, the neck pain tutorial has more than quadrupled the amount of information it offers, and it is now book-length at more than 40,000 words. Almost every single section was overhauled, and many new sections were added. Dozens of references to more recent scientific research were integrated and their significance explained, including several good new studies less than six months old.


  1. Dear BF, Gandy M, Karin E, et al. The Pain Course: A Randomised Controlled Trial Examining an Internet-Delivered Pain Management Program when Provided with Different Levels of Clinician Support. Pain. 2015 May. PubMed #26039902.

    Chronic pain may be treatable with tutorials like this one. Researchers tested a series of web-based pain management tutorials on people who had been suffering for more than six months. No matter how much (or little) help they had from doctors and therapists, they all experienced significant reductions in disability, anxiety, and average pain levels, for at least three months. So keep reading!

  2. Brison RJ, Hartling L, Dostaler S. A randomized controlled trial of an educational intervention to prevent the chronic pain of whiplash associated disorders following rear-end motor vehicle collisions. Spine. 2005 Aug 15;30(16):1799–807. PubMed #16103847.

    This is one of a few studies showing a benefit to education for neck pain specifically. Researchers showed a reassuring educational video to more than 200 patients with “whiplash associated disorders” (i.e. whiplash injuries that become chronic neck cricks), and found that they had less severe symptoms than patients who received no educational intervention. The effectiveness of education probably depends a lot on the type of neck pain and the type of education, making it very hard to study. A recent review of the scientific literature found that most such studies are negative (see Haines or Ainpradub), but I believe that there are still reasons to be optimistic about education for pain problems. Above all, it depends on the type and quality of the education! The right education may be effective, and the wrong could even be harmful. The fact that some education has been shown to be beneficial is promising.

  3. The best recent evidence of this is a 2008 study in Journal of the American Medical Association that showed that “spine-related expenditures have increased substantially from 1997 to 2005, without evidence of corresponding improvement in self-assessed health status” (see Martin). In other words, a lot of expensive medical care is not helping. This interesting paper was summarized well by Parker-Pope in the New York Times. BACK TO TEXT
  4. Jansson C, Mittendorfer-Rutz E, Alexanderson K. Sickness absence because of musculoskeletal diagnoses and risk of all-cause and cause-specific mortality: A nationwide Swedish cohort study. Pain. 2012 May;153(5):998–1005. PubMed #22421427.

    Can pain shorten your life? A large Swedish study of four million Swedes looked for a correlation between increased mortality and work absenteeism due to painful musculoskeletal conditions. They found the first ever evidence that people who have musculoskeletal pain may have “an increased risk of premature death.” The researchers adjusted their data for “several potential confounders.” It’s a plausible and disturbing conclusion. The costs of pain are often expressed in terms of hair-raising stats on the economics of work absenteeism — but they may be much greater still.

  5. In 2010, the Journal of Bone & Joint Surgery reported that “the quality and content of health information on the internet is highly variable for common sports medicine topics,” such as knee pain and low back pain — a bit of an understatement, really. Expert reviewers examined about 75 top-ranked commercial websites and another 30 academic sites. They gave each a quality score on a scale of 100. The average score? Barely over 50! For more detail, see Starman et al. BACK TO TEXT
  6. The standard techniques of physiotherapists, massage therapists, and chiropractors all produce generally poor results with neck pain: they work a little bit, sometimes, with some people, temporarily. Truly good success stories are rare. This lacklustre performance was confirmed in 2010 by a new study of studies (a meta-analysis) in Manual Therapy (see D'Sylva). Although the science is complex and limited and about 75% of studies had to be eliminated from consideration due to likely bias, one thing was clear: manual therapy isn’t exactly curing a lot of neck pain. It has “low to moderate quality evidence” that it’s helpful, compared to advice and exercise alone. BACK TO TEXT
  7. We have recently emerged from something of a dark period in the scientific study of neck pain. Always something a poor cousin to low back pain research, there was a surprising lack of analysis of neck pain research available — perhaps because of a lack of research to analyze. According to the journal Spine in early 1998, “No comprehensive systematic literature reviews have been published on interventions for neck pain and its associated disorders in the past decade” (see Hurwitz). However, since then there have been many important new studies, and much more analysis. Although this tutorial is many years old, it was significantly renovated throughout 2009 to include this new science, and will continue to be updated indefinitely. BACK TO TEXT
  8. Doctors lack the skills and knowledge needed to care for most common aches, pains, and injury problems, especially the chronic cases, and even the best are poor substitutes for physical therapists. This has been proven in a number of studies, like Stockard et al, who found that 82% of medical graduates “failed to demonstrate basic competency in musculoskeletal medicine.” It’s just not their thing, and people with joint or meaty body pain should take their family doctor’s advice with a grain of salt. See The Medical Blind Spot for Aches, Pains & Injuries: Most physicians are unqualified to care for many common pain and injury problems, especially the more stubborn and tricky ones. BACK TO TEXT
  9. Borenstein DG. Chronic neck pain: how to approach treatment. Current Pain & Headache Reports. 2007 Dec;11(6):436–439. As recently as 2009, these experts wrote that, “despite its frequency as a clinical problem, there are few evidence-based studies that document efficacy of therapies for neck pain.” I agree: the really good studies can practically be counted on your fingers and toes, and the field is basically still in its infancy. And yet, of course, there are tens of thousands of doctors and therapists out there who will happily tell you that they “know” how to treat your chronic neck pain. Take it with a grain of salt. There are good ideas out there, but no honest professional should feel confident. BACK TO TEXT
  10. Many headaches are probably caused by neck issues: “cervicogenic” headaches are “from the neck,” a whole class of headaches (and somewhat controversial actually, and therefore interesting). A future edition of the tutorial will probably cover them, but for now it’s big enough. If headache is your main problem, and it seems to be related to neck pain, the tutorial is worthwhile. For patients who are experiencing headaches and migraine without clear neck pain, I recommend other resources, such as Jim Cottrill’s excellent migraine blog. I do have a modest tension headache tutorial. BACK TO TEXT
  11. While face and jaw pain often do occur with neck pain, and there is probably a relationship between them, they involve many special issues. This tutorial does not address them in any detail. BACK TO TEXT
  12. Freeman MD, Croft AC, Rossignol AM, Centeno CJ, Elkins WL. Chronic neck pain and whiplash: A case-control study of the relationship between acute whiplash injuries and chronic neck pain. Pain Res Manag. 2006;11(2):79–83. PubMed #16770448. PainSci #57032.

    From the abstract: “… it is reasonable to infer that a significant proportion of individuals with chronic neck pain in the general population were originally injured in a motor vehicle accident.” See also Atherton.

  13. Atherton K, Wiles NJ, Lecky FE, et al. Predictors of persistent neck pain after whiplash injury. Emerg Med J. 2006 Mar;23(3):195–201. PubMed #16498156. PainSci #56091.

    480 people with neck pain after car accidents completed questionnaires three times during the year after their accident. 128 (27%) reported neck pain every time. “The greatest predictors of persistent neck pain…relate to psychological distress and aspects of pre-collision health rather than to various attributes of the collision itself.” In other words, people who went into the accident with the most stress and body pain were the most likely to suffer chronic neck pain. For a short article discussing this research, see A Recipe for Chronic Neck Pain After Whiplash.

    The findings are generally confirmed by more research since. See Carstensen.

  14. Bahr R, Mæhlum S. Clinical guide to sports injuries. Human Kinetics; 2004. p106. BACK TO TEXT
  15. Interestingly, the “interesting” curse is probably not Chinese, but English or American. According to Wikipedia, “The Chinese language origin of the phrase, if it exists, has not been found, making its authenticity doubtful.” Also interesting, regardlessof its provenance, is that it is the first of three curses, the other two being: (1) may you come to the attention of those in authority, and (2) may you find what you are looking for. BACK TO TEXT
  16. Neck pain that escalates steadily to crippling levels over weeks or months is more likely to be caused by disease. If this is your problem, please review the safety section! Also, although the worst cases of neck pain can certainly cause “severe” pain, I only mean severe for neck pain and not “off the scale” pain that blots out the sun and makes it impossible to function or work. The worst non-ominous neck pain is roughly the intensity of the worst tension headaches…but definitely not like a full-blown migraine, child birth, or rheumatoid arthritis. BACK TO TEXT
  17. Leaver AM, Maher CG, McAuley JH, et al. People seeking treatment for a new episode of neck pain typically have rapid improvement in symptoms: an observational study. J Physiother. 2013 Mar;59(1):31–7. PubMed #23419913. This study of 180 patients who sought treatment for a new case of neck pain found that 53% of them “recovered completely within three months.” The authors believe that “physiotherapists should reassure people with a new episode of neck pain that rapid improvement in symptoms is common, modifying this advice where applicable based on risk factors.” BACK TO TEXT
  18. Kjellman G, Oberg B, Hensing G, Alexanderson K. A 12-year follow-up of subjects initially sicklisted with neck/shoulder or low back diagnoses. Physiotherapy Research International. 2001;6(1):52–63. PubMed #11379256.

    Checking up on 200 patients who were diagnosed with neck or back pain 12 years prior, this study showed that neck pain was quite a bit more persistent than back pain: “Only 4% of the neck/shoulder group reported no present discomfort compared with 25% of the low back group.”

    But it’s hard to be sure, of course, because there are so many ways of measuring. The most optimistic estimates for back pain I’ve seen, from a 1994 paper (Coste et al), reported 90% recovered within two weeks — definitely better than most of the neck pain data. Another rather hopeful example is Costa et al, which showed that Chronic Low Back Pain Is Not So Chronic. At the other end of the scale, the least promising recovery data about back pain is about the same as what Côté et al found for neck pain.

    Yes, I just cited Coste, Costa, and Côté — completely coincidental. 😃

  19. I cited Leaver above as good news, because half of patients with new cases recover within three months. But it’s obviously good-and-bad-news science, because of the other half: “almost half of those who seek treatment do not recover completely within three months.” Which is actually quite a high number. BACK TO TEXT
  20. Côté P, Cassidy JD, Carroll LJ, Kristman V. The annual incidence and course of neck pain in the general population: a population-based cohort study. Pain. 2004 Dec;112(3):267–73. PubMed #15561381. BACK TO TEXT
  21. That’s the notorious “parking lot” effect in manual therapy: you get relief, but so briefly that you’re already back in trouble again by the time you get out to the parking lot! BACK TO TEXT
  22. Thunderclap headaches have many possible causes, several dozen of them (see Devenney et al). Most are benign, but many are frightening and even deadly, and there’s no way to tell the difference without expert help. If you are having sudden, severe headaches, please see your doctor. BACK TO TEXT
  23. Symptoms caused by spinal cord trouble are called “myelopathy.” And there are a lot of possible symptoms: it depends on which part of the spinal cord is affected. And many of them can have other causes. And it may worsen slowly and erratically over long periods. You can’t really confirm a myelopathy diagnosis without professional help, so please consult a doctor if you’re suspicious. Some of the most common symptoms are poor hand coordination; weakness, “heavy” feelings, and atrophy; diffuse numbness; shooting pains in the limbs (especially when bending the head forward); an awkward gait. BACK TO TEXT
  24. Chan CK, Lee HY, Choi WC, Cho JY, Lee SH. Cervical cord compression presenting with sciatica-like leg pain. Eur Spine J. 2011 Jul;20 Suppl 2:S217–21. PubMed #20938789. PainSci #53701. BACK TO TEXT
  25. [Internet]. Holman A. Using Dynamic MRI to Diagnose Neck Pain: The Importance of Positional Cervical Cord Compression (PC3); 2017 January 12 [cited 17 Jan 20].

    A remarkable article for a medical audience, technical and scholarly but cogent, exploring fascinating potential connections between PC3 and/or Chiari malformation and fibromyalgia and chronic widespread pain.

  26. But “unwell” is awfully vague and can have many causes — only consider it a red flag if it’s quite clear and has developed in roughly the same period as the neck pain. BACK TO TEXT
  27. Benyamin RM, Singh V, Parr AT, et al. Systematic review of the effectiveness of cervical epidurals in the management of chronic neck pain. Pain Physician. 2009;12(1):137–57. PubMed #19165300. PainSci #55398. BACK TO TEXT
  28. Dommerholt J. Persistent myalgia following whiplash. Curr Pain Headache Rep. 2005 Oct;9(5):326–30. PubMed #16157061.

    From the abstract, “Myofascial trigger points may play a crucial role in maintaining sensitization [of muscle tissue after whiplash.]”

  29. Drs. Janet Travell and David Simons devoted their career to the study of soft tissue pain and myofascial pain syndrome, and published the incredibly authoritative “red texts” on the subject (Myofascial Pain and Dysfunction). Simons and Mense have continued that work with the recent text, Muscle Pain. Clair Davies’ excellent popularization of the red texts, The Trigger Point Therapy Workbook, has sold extremely well in recent years, is endorsed by a dozen medical experts, and has generally resulted in patients knowing more about muscle pain than doctors. Dr. John Sarno of New York is one of the world’s most successful back and neck pain clinicians, and in his writings independently develops essentially the same theoretical conclusions as Travell and Simons. Vancouver’s own Dr. Chan Gunn has spent twenty years working on an extremely well-reasoned alternative hypothesis for soft tissue pain, and has developed one of the world’s more novel and effective therapies for trigger points, intramuscular stimulation. There are many others. These are all experts who present a compelling case of the importance of muscle pain. BACK TO TEXT
  30. Self-confessed medical ignorance about neck pain is common. One textbook declares, “The [neck pain] epidemic is difficult to explain from a biomechanical perspective. The patient seldom has definite pathophysiological changes or specific clinical signs.” (Clinical Guide to Sports Injuries, p27). It’s always refreshing to hear medical experts honestly saying “I don’t know,” but it is disturbing how ignorant they seem to be of the explanation that follows naturally from the work of the experts mentioned above (Travell, Simons, Mense, Sarno, Gunn), serious medical researchers and gifted clinicians who have literally devoted their entire careers to understanding how muscle probably explains the epidemic of neck and back pain. Their publications seem to be ignored by the medical mainstream. BACK TO TEXT
  31. Poussa MS, Heliovaara MM, Seitsamo JT. Predictors of neck pain: a cohort study of children followed up from the age of 11 to 22 years. Eur J Spine. 2005 Dec;14(10):1033–6. PubMed #16133076.

    This study examined 430 children over several years and found that “short stature at 11 years of age predicted the incidence of neck pain,” and therefore concluded that “Short stature may be a risk determinant of neck pain.”

  32. Brismée JM, Sizer J, Dedrick GS, Sawyer BG, Smith MP. Immunohistochemical and histological study of human uncovertebral joints: a preliminary investigation. Spine (Phila Pa 1976). 2009 May;34(12):1257–63. PubMed #19455000.

    This is quite a technical paper about some special joints unique to the cervical spine: unconvertebral joints (AKA Luschka’s joints or neurocentral joints). An interesting (though still rather technical) summary is provided by an unknown author (see “Uncovertebral joints and neck pain”). It suggests “that the structure is synovial in nature” and that “the uncovertebral joints are potential pain generators in the cervical spine.”

    Basically, an uncovertebral joint consists of small overlapping lips of bone extending from the top and bottom edges of vertebral bodies. It’s a strange, maybe-a-synovial-joint-and-maybe-not structure so obscure that it barely has a Wikipedia page. And yet arthritic overgrowth at this joint may be one of the most common causes of pinched cervical nerve roots (or even the spinal cord)

  33. The idea of my “preferred explanation” deserves some clarification. I most certainly do not “know” exactly what actually makes a crick feel like a crick. However, I have settled on a working theory over the years, an explanation that (1) is reasonably consistent with available scientific evidence and my clinical observations, while still leaving plenty of theoretical leeway for interpretation and anomalies; and (2) is also communicative. This second quality is actually terribly important in a working theory: as long as it is actually sensible, so much the better if it is also a compelling piece of imagery that helps readers “get it”! I also vastly prefer the imagery of the MID to the imagery of the spine being “out,” which tends to aggravate patients’ fears that their spine is fragile. BACK TO TEXT
  34. Maigne R. Manipulation of the spine. In Basmajian JV (ed): Manipulation, Traction and Massage, Baltimore: Williams & Wilkins. 1986. BACK TO TEXT
  35. Hertling D, Kessler R. Management of common musculoskeletal disorders. 3rd ed. Lippincott; 1996. p. 574.

    Darlene Hertling clearly elucidates Maigne’s ideas about MIDs (Maigne), with reference to the thoracic spine. Likely the idea can be sensibly applied to other sections of the spine as well.

  36. “Facet” is the easier but technically incorrect term for them. The proper term is one of the gnarliest in all of anatomy: zygapophysial joint. BACK TO TEXT
  37. This is sometimes called a compression sprain, though it is not technically a “sprain” and cartilage can’t bruise because it contains no blood vessels. A more common example of this injury is a “thumb jam,” especially in rugby, where the thumb joint is bent back and/or harshly slammed together, traumatizing the joint surfaces. In the case of a typical minor MID, the forces are likely to be much smaller. BACK TO TEXT
  38. When you turn your head, a large number of muscles have to coordinate, literally dozens of them. Some of them have to contract. Some of them have to relax, so that they don’t resist movement. And they have to do this fast and in more less perfect harmony. It doesn’t always work out, and one error is all it takes. BACK TO TEXT
  39. Indeed, they are so insensitive that only traumatic compression might actually cause a problem. Even extremely strong movements in a healthy neck, smushing the facet joints together as firmly as possible, causes no discomfort — or, if it does, it’s coming from other tissues, like the synovical membranes (see next item). BACK TO TEXT
  40. Your emotional reaction is relevant: if it scares you, the incident can provoke a cascade of significant neurologic consequences. Context is everything. Even as a “cracky” person, used to the sensation, occasionally I have had joint pops so dramatic that I felt alarmed. BACK TO TEXT
  41. Moseley GL. I can't find it! Distorted body image and tactile dysfunction in patients with chronic back pain. Pain. 2008 Nov;140(1):239–43. PubMed #18786763.

    In this small, unusual study, six patients with low back pain were asked to draw their perceptions of their back and spine. For comparison, a group of ten patients with no recent back pain were asked to do the same exercises. They were encouraged to “draw what it feels like” rather than how it actually looked.

    “All the patients, and none of the controls, showed disrupted body image of the back” on the same side and level as the pain. For instance, they did not have a clear sense of the outline of their trunk.

    Most intriguingly, patients with back pain on just one side illustrated vertebrae deviated towards the painful side (without any obvious actual deviation).

  42. Somehow, over a period of many years, the similarity of these concepts, and my potential hypocrisy, never once crossed my mind! How can I be skeptical about subluxations, but use “minor intervertebral derangements” as a key concept? Fishy! BACK TO TEXT

There are 180 more footnotes in the full version of this book. I like footnotes, and I try to have fun with them.

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