• Good advice for aches, pains & injuries

Save Yourself from Neck Pain!

A complete guide to chronic neck pain and the disturbing sensation of a “crick”

Paul Ingraham, updated

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 huge, book-length guide, regularly updated with fresh science for over a decade.

Neck pain [MayoClinic] afflicts almost all of us 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 2017. 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

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, even from doctors. Most GPs are not really competent to treat neck pain, or any other difficult musculoskeletal problem.6

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 differently. And yet research has virtually proved that the neck posture hypothesis is either dead wrong or at least an underwhelming non-problem. For instance, we know that “text neck” is not actually a thing, despite much fear-mongering to the contrary: regularly staring down at a phone has no clear connection to any kind of neck trouble.7

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 reassuring 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.8 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.9 I have no tidy, too-good-to-be-true theory of neck pain to replace any of these ideas with, but there are certainly lots of miscellaneous recommendations.

Who exactly is this tutorial for?

Head pain, face pain, and neck pain are huge topics: this tutorial focuses on cricks and chronic unexplained neck pain and closely related symptoms in the upper back and shoulders (upper backs get “cricks” too).

It is not about 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 Some safety information is provided below for the rare cases of neck pain that may be caused by disease, but otherwise this page is not about disease-causes of neck pain.

Many kinds of neck pain involve complications that 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.

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.

“Crick” is an informal term, but perhaps it should be, 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.

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 troubled nerve root (radiculopathy). Even when such pain exists — less than people assume — it may prove to be a surprisingly minor problem that goes away on its own, or 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.

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

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.

In the next section, I’ll discuss one of the main mechanisms that may drive neck pain chronicity: “sensitization.”

Neck pain as the tip of the sensitization iceberg

“Sensitization” is the tendency of the nervous system to get into a rut and start over-reacting to stimuli, an alarm system getting set off too easily.21 This is a well-described property of pain,22 the crown jewel of modern pain science,23 and evidence that either there is no God or only a cruel one. As a general rule, the longer any kind of pain lasts, the more likely sensitization is to become a factor, and even to take over and become the main problem.

Sensitization can complicate any chronic pain problem, and as my career lengthens I find myself writing about it more and more: all painful roads seem to lead to this topic. There is great variety in acute pain, but chronic pain is often defined by sensitization, regardless of how it all started.

And yet pain can also begin with sensitization, too. Certain kinds of pain — especially neck pain, back pain, and abdominal pain — can be the tip of a sensitization iceberg. And that’s why I’ve chosen to introduce this idea in the context of prognosis and “worst case scenarios” — because sometimes neck pain is just the beginning of something much more sinister. There’s a risk of scaring you here, so let’s keep a level head and remember that the vast majority of neck pain goes away and is not the tip of an evil iceberg … and there’s still plenty of hope even when it is.

But I’m not going to sugarcoat it: it is something you need to be aware of.

The gender connection

Interestingly, women suffer from neck pain much more than men do. (There’s got to be a joke at the expense of husbands here somewhere.) 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, suspiciously, women also suffer from higher rates of other kinds of chronic pain — the overwhelming majority of fibromyalgia, for instance. Fibromyalgia is a diagnostic label for unexplained chronic widespread pain and fatigue (among other things), which is seems to involve a lot of sensitization. It often begins with stubborn regional pain in guess what regions? The neck and shoulders, the low back, the abdomen. Many fibromyalgia patients start their journey to hell with recurrent episodes pain in these areas, and then eventually the pain spreads and other classic fibromyalgia symptoms start to appear.24

Why women? No one knows. (But I do have a pet theory about this, which I’ll relegate to a footnote because it’s too speculative to clutter the main text with.25)

Which came first, the neck pain chicken or the sensitization egg?

How do we know that neck pain can be the beginning of sensitization? Could the neck pain just be ordinary neck pain at first, and then sensitization sets in over time as a complication … and then spreads, like an infection? Yes, it’s possible. But most people who end up with sensitization can recall subtle, early symptoms of sensitization dating all the way back to the beginning of their troubles. Neck pain was the main problem and other clues were overlooked or filed under “odd,” too vague and minor to interpret.

But surely sometimes the chicken does come first! In this other worst case scenario, sensitization didn’t start it, but it is the main reason that your neck keeps hurting — even if it never progresses to causing widespread symptoms. Probably most chronic pain gets complicated by sensitization eventually, if not all of it, and some chronic cases are chronic not because there’s still something wrong with your neck tissues after all these years, but simply because your brain has set up a permanent ban on full neck movement (and pain is the main way the brain does that). This is why every chronic pain patient needs to know about sensitization.

To sum up, central sensitization is involved in two kinds of worst case scenarios for neck pain:

  1. Neck pain may simply be the first, worst symptom of sensitization (along with, perhaps, back and/or abdominal pain).
  2. Neck pain may become chronic due to sensitization that develops as a reaction to some original problem, a permanent case of “false alarm” that stays confined to the neck.

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.26

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.

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.”

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.

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

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

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.”38 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,39 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,40 the medical majority still has a muscle blind spot,41 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.42 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 explanation44 — not necessarily “correct,” but the most useful explanation for most people, most of the time — is the idea of “minor intervertebral derangement” (MID).4546 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…


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90,000 words
76 sections
374 footnotes

all myths & controversies
all diagnostic issues
all treatment options
  • 1 Introduction
  • 1.1 Neck pain myths busted here!
  • 1.2 Neck cricks vs. neck pain
  • 1.3 And what about a pinched nerve?
  • 2 Prognosis
    What’s the worst case scenario for neck pain?
  • 2.1 Neck pain as the tip of the sensitization iceberg
  • 2.2 Three case studies of extreme neck crick horribleness
  • 2.3 “What if there’s something really wrong with my neck?” Safety information!
  • 3 Etiology
    The (weird and unclear) nature of the beast
  • 3.1 Why does a crick feel the way it does?
  • 3.2 Subluxation: can your neck be “out”?
  • 3.3 Another possibility: the feeling of stuckness without being literally stuck
  • 3.4 Stuck! What limits your range of motion?
  • 3.5 Why is neck pain so common? Spatial summation of cryptic insults
  • 3.6 Could it be arthritis? Is your spine degenerating? Probably not, no
  • 3.7 Is it a herniated disc? Does it matter? The herniation myth
  • 3.8 Is it a pinched nerve? Rarely! The nerve pinch myth
  • 3.9 Does abnormal curvature hurt? Not much! The neck posture myth
  • 3.10 Is it a strain? Probably not! The muscle strain myth
  • 3.11 The potential importance of muscle tissue
  • 3.12 Is it a spasm? The spasm puzzle
  • 3.13 The case for myofascial trigger points as a major neck pain villain
  • 3.14 From the frying pan of injury pain to the fire of trigger point pain
  • 3.15 More about muscle malfunction: what’s going on in a trigger point?
  • 3.16 A recipe for persistent neck pain — what are the risk factors?
  • 3.17 Neck pain versus back pain: some similarities and differences
  • 4 Diagnosis
    How do I know what type of neck pain I have?
  • 4.1 How can I tell if there’s a pinched nerve?
  • 4.2 Diagnostic numbing of facet joints
  • 4.3 A poke in the disc! Cervical provocation discography as a method of diagnosis
  • 4.4 Estimating the importance of trigger points in your own case
  • 4.5 “Out of nowhere”: seemingly random episodes of neck pain
  • 4.6 A classic diagnostic sign: “I woke up with it”
  • 4.7 Connections between neck pain, headaches, and migraines
  • 4.8 Miscellaneous medical causes of neck pain and how to stop worrying about them
  • 4.9 What happened to my barber? Neck pain powered by atlantoaxial instability
  • 4.10 Digital Motion X-Ray
  • 4.11 How can you tell if you’re sensitized?
  • 5 Treatment
    What can you do for a crick in the neck?
  • 5.1 Some important things to keep in mind about placebos
  • 5.2 Surgical options
  • 5.3 Needles for neck pain: nerve blocks for facet joints and related treatments
  • 5.4 Kill it with fire! Treatment by nerve destruction
  • 5.5 Pain killers and muscle relaxants
  • 5.6 A tale of two tutorials
  • 5.7 Introduction to treating your own neck trigger points
  • 5.8 Basic self-massage for neck trigger points
  • 5.9 A massage success story
  • 5.10 The role of massage tools in neck massage
  • 5.11 Can you damage neck nerves by self-massaging?
  • 5.12 Heat and ice both provide good bang for buck, but please err on the side of heat
  • 5.13 Accidental icing: avoid drafts at night
  • 5.14 Mobilizations or “wiggle therapy”
  • 5.15 Will stretching help neck pain?
  • 5.16 Pull my neck! The potential of traction
  • 5.17 Relaxation and the confidence cure
  • 5.18 Build your neck muscle strength and endurance
  • 5.19 Will strength improve neck posture/curvature?
  • 5.20 “Core” neck strength: training the deep cervical flexors
  • 5.21 Coordination training for the neck
  • 5.22 Ergonomics are probably more important than posture
  • 5.23 Microbreaking
  • 5.24 Pillow talk: the evidence about pillows is soft
  • 5.25 Spinal manipulative therapy (SMT): Adjustment, manipulation and cracking of the spinal joints
  • 5.26 Popping your neck joints: bad habit, or self-treatment?
  • 5.27 Bracing yourself
  • 5.28 The usual suspects: tackling the things that make all kinds of pain worse
  • 5.29 The fascinating case of acupuncture
  • 5.30 “Acupuncture”: Dry needling for trigger points (acupuncture’s weird cousin)
  • 5.31 Reality checks: some popular treatments that are particularly silly
  • 6 Executive Summary
    All the treatment options summarized
  • 7 Appendices
  • 7.1 Reader feedback … good and bad
  • 7.2 Acknowledgements
  • 7.3 Further Reading
  • 7.4 What’s new in this tutorial?
  • 7.5 Notes
dots before headings indicate updated sections ?There’s a detailed description of all updates at the bottom of the tutorial, and it’s nice to be able to see what’s new at a glance in the table of contents. Any section updated in the last 400 days is marked (hotter colours = fresher updates).

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Q. Does the book offer a “cure” for neck pain? A. No. I sell education about a notoriously tricky condition, not false hope. There’s nothing “too good to be true” here.

Q. Buy more & save 50%! A. Get a “boxed” set of all nine tutorials for great savings.MORE

Q. What’s with that surprise price tag?! A. I know it can make a poor impression, but I have to make a living and this is the best way I’ve found to keep the lights on here. Of course many people turn away, but 57,600 people have gone for it.?This is a tough number for anyone to audit, because my customer database is completely private and highly secure. But if a regulatory agency ever said “show us your math,” I certainly could. This count is automatically updated once every day or two, and rounded down to the nearest 100. It includes all individual and bundled books for sale on since 2007, and excludes a trickle of earlier sales, donations, and gifts. If money is tight, just ask me for free or discounted access.

Q. Can I read it on my iPad, Kindle, etc? A. Yes. Any Internet-enabled gadget works fine. (The e-Ink Kindles are not a good choice.)

Q. Satisfaction guaranteed, right? A. Of course—and no time limit.

Q. Can I buy this anywhere else? Amazon? A. Not yet. Maybe someday.

Q. Can I lend it? A. Yes, with a 3-person limit.

Q. Can I give it to my clients? A. I have a generous lending policy, but not that generous. 😉 Please recommend buying it, or consider my bulk purchase program.

Q. Why do you want my postal code? A. To prevent fraud (strongly recommended by my payment processor), and to identify customers for login and repeat business.

Q. Are you going to send me e-mail? A.  Just a receipt.

Q. Why should I trust you with my credit card? A. I will never see it: it goes straight from your screen to Stripe, a payment processing service with a great reputation for Doing Things Right. They handle all the high-tech security.

You can also keep reading more without buying. Here are some other free samples from the book, and other closely related articles on

Logos for Visa, Mastercard, and Amex.I accept Visa, Mastercard, and American Express. Discover and JCB are not supported for now, but I hope that will change in the not-too-distant future. Note that my small business does not handle your credit card info: it goes straight to the payment processor (Stripe). You can also pay with PayPal: for more information, click the PayPal button just below.
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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 370 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.

But 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. The goal of this tutorial is to help you navigate the maze of medical uncertainty and contradictions, and the many possible causes.

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.

All of that is hopefully worth more than several sessions of physical therapy, at a fraction of the cost.

Logos for Visa, Mastercard, and Amex.I accept Visa, Mastercard, and American Express. Discover and JCB are not supported for now, but I hope that will change in the not-too-distant future. Note that my small business does not handle your credit card info: it goes straight to the payment processor (Stripe). You can also pay with PayPal: for more information, click the PayPal button just below.
PayPal logo
read on any device, no passwords
refund at any time, in a week or a year
call 778-968-0930 for purchase help

Part 3.2


Reader feedback … good and bad

Testimonials on health care websites reek of quackery, so publishing them has always made me a bit queasy. But my testimonials are mostly about the quality of the information I’m selling, and I hope that makes all the difference. So here’s some highlights from the kind words I’ve received over the years … plus some of the common criticisms I receive, at the end. These are all genuine testimonials, mostly received by email. In many cases I withold or change names and identifying details.

Thank you for such helpful, intelligent information on neck issues. I am so thankful that I read your information and no more. You answered every lingering question and are persuasive in counselling calm and patience.

~Virginia Avila, Retired Teacher & Attorney

You book is so comprehensive and outlines a lot of what I have also found, with more explanation and scientific backing, and then expands upon it. I purchased it this afternoon and have read it almost cover to cover all afternoon and evening!

~Tanvir England

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 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

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

One more noteworthy endorsement, with regards to this whole website and all of my books, submitted by a London physician specializing in chronic pain, medical education, and patient-advocacy (that’s a link to his excellent blog):

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

What about criticism and complaints?

Oh, I get those too! I do not host public comments on for many reasons, but emailed constructive criticism, factual corrections, requests, and suggestions are all very welcome. I have made many important changes to this tutorial inspired directly by critical, informed reader feedback.

But you can’t make everyone happy! Some people demand their money back (and get it). I have about a 1% refund rate (far better than average in retail/e-commerce). The complaints of my most disatisfied customers have strong themes:


Thanks to every reader, client, and book customer for your curiosity, your faith, and your feedback and suggestions, and your stories most of all — without you, all of this would be impossible and pointless.

Writers go on and on about how grateful they are for the support they had while writing one measly book, but this website is actually a much bigger project than a book. was originally created in my so-called “spare time” with a lot of assistance from family and friends. Thanks to my wife for countless indulgences large and small; to my parents for (possibly blind) faith in me, and much copyediting; and to friends and technical mentors Mike, Dirk, Aaron, and Erin for endless useful chats, repeatedly saving my ass, plus actually building many of the nifty features of this website.

Special thanks to some professionals and experts who have been particularly inspiring and/or directly supportive: Dr. Rob Tarzwell, Dr. Steven Novella, Dr. David Gorski, Sam Homola, DC, Dr. Mark Crislip, Scott Gavura, Dr. Harriet Hall, Dr. Stephen Barrett, Dr. Greg Lehman, Dr. Jason Silvernail, Todd Hargrove, Nick Ng, Alice Sanvito, Dr. Chris Moyer, Lars Avemarie, PT, Dr. Brian James, Bodhi Haraldsson, Diane Jacobs, Adam Meakins, Sol Orwell, Laura Allen, James Fell, Dr. Ravensara Travillian, Dr. Neil O’Connell, Dr. Tony Ingram, Dr. Jim Eubanks, Kira Stoops, Dr. Bronnie Thompson, Dr. James Coyne, Alex Hutchinson, Dr. David Colquhoun, Bas Asselbergs … and almost certainly a dozen more I am embarrassed to have neglected.

I work “alone,” but not really, thanks to all these people.

I have some relationship with everyone named above, but there are also many experts who have influenced me that I am not privileged to know personally. Some of the most notable are: Drs. Lorimer Moseley, David Butler, Gordon Waddell, Robert Sapolsky, Brad Schoenfeld, Edzard Ernst, Jan Dommerholt, Simon Singh, Ben Goldacre, Atul Gawande, and Nikolai Boguduk.

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 121 major and minor updates since I started logging carefully in late 2009 (plus countless minor tweaks and touch-ups).

JulyOptimized: A rewrite inspired by recent work on a dedicated article about vulnerability to chronic pain. This chapter is now both shorter and yet actually broader in scope. [Section: The usual suspects: tackling the things that make all kinds of pain worse.]

JulyScience update: Added a citation to Mäntyselkä about the relationship between neck pain and being out of shape. [Section: A recipe for persistent neck pain — what are the risk factors?]

MayScience update: Updated references related to the relationship between trigger points and headache. [Section: The case for myofascial trigger points as a major neck pain villain.]

AprilExpanded: Miscellaneous improvements, and I added discussion of the “space making” surgeries (e.g. posterior cervical laminoforaminotomy). [Section: Surgical options.]

MarchMinor upgrade: Added some information about the craving for stretch, its implications, and the problem with trying to stretch the suboccipitals. [Section: Will stretching help neck pain?]

FebruaryNew section: No notes. Just a new section. [Section: Why is neck pain so common? Spatial summation of cryptic insults.]

JanuaryNew section: No notes. Just a new section. [Section: The usual suspects: tackling the things that make all kinds of pain worse.]

2018Upgraded: There’s a new sub-section about the role of stress in any kind of chronic pain, and bunch of revision so that the section is more focused on the concept of vulnerability. This is a setup for more practical advice, still to come, about how to attempt to be less vulnerable. [Section: A recipe for persistent neck pain — what are the risk factors?]

2018Expanded: Added quite a lot of information, especially about risks and harms and how needling supposedly works. This is now a fully-fledged topic summary. [Section: “Acupuncture”: Dry needling for trigger points (acupuncture’s weird cousin).]

2018Major addition: Added a substantial new sub-topic: “What if it’s about the coordination, not strength/endurance?” And a minor but fun addition about the DCFs being the “psoas of the neck.” Added anatomy diagram. [Section: “Core” neck strength: training the deep cervical flexors.]

2018Rewritten: I started over from scratch on the topic of “spasm.” What I’d written previously was much too simplistic. This chapter is now bigger and more interesting. [Section: Is it a spasm? The spasm puzzle.]

2018Substantial editing: Merged content from the back and neck pain tutorials, resulting in major upgrades to two important sections in both books. [Section: How can I tell if there’s a pinched nerve?]

2018Substantial editing: Merged content from the back and neck pain tutorials, resulting in major upgrades to two important sections in both books. [Section: Is it a pinched nerve? Rarely! The nerve pinch myth.]

2018Complete book edit: Top-to-bottom edit of the book, the first ever. Described in more detail in a blog post.

2018Minor update: Added the revelation that literally all of the very weak studies supporting DCF training are probably fraudulent. [Section: “Core” neck strength: training the deep cervical flexors.]

2018New section: A new standard chapter for most tutorials summarizing several key concepts about placebo. [Section: Some important things to keep in mind about placebos.]

2018New section: No notes. Just a new section. [Section: “Core” neck strength: training the deep cervical flexors.]

2018Revised: Substantial miscellaneous modernization. In particular, much more useful information on the critical distinction between “poor posture” and “postural stress.” [Section: Ergonomics are probably more important than posture.]

2018Science update: Added several references about the long term risks of joint popping, a paragraph about the short-term risks, and a citation about what causes joint popping. [Section: Popping your neck joints: bad habit, or self-treatment?]

2018Revision: Clarified the important distinction between hazard and risk. [Section: Spinal manipulative therapy (SMT): Adjustment, manipulation and cracking of the spinal joints.]

2018New section: More information about dry needling in its own chapter now, a neglected sub-topic; it has always been covered in the companion book about trigger points, but a good summary here in the neck pain book is long overdue. [Section: “Acupuncture”: Dry needling for trigger points (acupuncture’s weird cousin).]

2018Revision: Substantial improvements, harmonizing with the ergonomics revision. Much stronger focus on the scientific case for microbreaking despite the lack of evidence that stagnacy is a problem in the first place. Added a practical tip, and a comic. [Section: Microbreaking.]

2018Upgrade: Added much more detail about the crisis in orthopedic surgeries — very important context — and more detail to the descriptions of surgical options. [Section: Surgical options.]

2018Major improvements: Extensive new material about the relationship between neuropathy and neck pain, focused on clues that neuropathy is a factor in a case of chronic neck pain. [Section: How can I tell if there’s a pinched nerve?]

2018Minor improvement: Added a footnote about the long-term risks of poor neck posture and text neck. [Section: Does abnormal curvature hurt? Not much! The neck posture myth.]

2018Re-write: I threw 90% of this section away and started over with a much stronger focus on the interesting question of whether or not “cervicogenic headache” is even a thing. It’s a like-new section, now with much more useful diagnostic clues. [Section: Connections between neck pain, headaches, and migraines.]

2018Minor science update: Added some references about the reliability of subluxation diagnosis. [Section: Subluxation: can your neck be “out”?]

2017Science update: Cited Chumbley et al on traction for neck pain in … fighter jet pilots! [Section: Pull my neck! The potential of traction.]

2017New section: No notes. Just a new section. [Section: Kill it with fire! Treatment by nerve destruction.]

2017Change of position: After reviewing the same scientific papers previously cited more carefully, I decided that they were much less promising than I originally thought. The section has flip-flopped from optimism to pessimism about nerve blocks without a single change in what’s actually cited, just a change in the level of diligence in interpreting the science. I’ve also added more detail and references. [Section: Diagnostic numbing of facet joints.]

2017Science update: Brought some more science to this discussion, especially Sandler et al on a link between stretching and back pain, and Tunwattanapong et al with modestly good news. Plus a bunch of editing. [Section: Will stretching help neck pain?]

2017Upgraded: Added much more information about massage “endangerment sites,” discussion of the potential relevance of neuritis, extensive clarifications and editing. [Section: Can you damage neck nerves by self-massaging?]

2017Science update: Finally added some basic information about “text neck” — mostly that it’s not actually a thing, and a good example of bogus information about neck pain. [Section: Neck pain myths busted here!]

2017Science update: Finally brought a little science to support the claim that trigger points complicate injury. More needed, but it’s a start. [Section: From the frying pan of injury pain to the fire of trigger point pain.]

2017Revision: This section was aging poorly. Reviewing it recently, it seemed too much like I was defensively explaining a pet theory (and I suppose I was). So I’ve done some thorough revision to bring it up to my current standards: less overconfidence, more science. [Section: The case for myofascial trigger points as a major neck pain villain.]

2017Upgraded: Added some more detailed safety advice and discussion of vibrating massage tools. Removed and de-emphasized a couple tools. Better images. Thorough editing the whole section. [Section: The role of massage tools in neck massage.]

2017New tip: Added a weird bonus strengthening tip based on Smith et al, which showed that clenching leg muscles reduced pain everywhere in patients with chronic neck pain. [Section: Build your neck muscle strength and endurance.]

2017Science upgrade: More evidence on how much (or little) pain is caused by cervical disc herniations, plus other miscellaneous citations and clarifications. Removed the claim that herniations actually decrease with age — the reference for that was no longer persuasive. [Section: Is it a herniated disc? Does it matter? The herniation myth.]

2017Revision: Added an example of SMT injury and a footnote about fearmongering, and then found myself editing the whole section. [Section: Spinal manipulative therapy (SMT): Adjustment, manipulation and cracking of the spinal joints.]

2017Minor update: Widespread minor improvements to complete the integration of central sensitization into the book. The neck pain book is now fully sensitive about sensitization!

2017Minor update: Integrated discussion of central sensitization, reframing the “confidence cure” as treatment for central sensitization. [Section: Relaxation and the confidence cure.]

2017Science update: Light editing, plus a new paragraph and citation to Morikawa et al, an odd little study showing that neck massage is relaxing, or possibly more. [Section: Introduction to treating your own neck trigger points.]

2017Edited: Several minor miscellaneous clarifications and elaborations, and some additional references. [Section: Pain killers and muscle relaxants.]

2017Revised: Thoroughly revised section and, unfortunately, a reversal from optimism to pessimism about the efficacy of nerve blocks. [Section: Needles for neck pain: nerve blocks for facet joints and related treatments.]

2017Expanded: Added important red flag information about artery tears with pain as the only symptom. [Section: “What if there’s something really wrong with my neck?” Safety information!]

2017Revision: Modernization and expansion; added more information about surgical options in particular. [Section: Surgical options.]

2017New section: Tips and a checklist for trying to estimate how much your neck pain might be about sensitization. [Section: How can you tell if you’re sensitized?]

2017Correction: An evidence-based correction regarding computer display position. [Section: Ergonomics are probably more important than posture.]

2017Big upgrade: Continued to beef up the science of psychological risk factors, and also added much more about other kinds of risk factors. The section almost doubled in size. [Section: A recipe for persistent neck pain — what are the risk factors?]

2017Science update: Two key new citations to support the idea that the state of muscle tissue is a big factor in neck pain. [Section: The potential importance of muscle tissue.]

2017Science update: A paragraph about genetic vulnerability to persistent neuropathic pain. [Section: Is it a pinched nerve? Rarely! The nerve pinch myth.]

2017New section: Substantial new section about sensitization, an important perspective on chronic neck pain. [Section: Neck pain as the tip of the sensitization iceberg.]

2017Science update: Solid little science update based on Nakashima et al, showing huge numbers of intervertebral disc bulges in healthy people. [Section: Is it a herniated disc? Does it matter? The herniation myth.]

2017Upgraded: Several good red flag clarifications and a couple interesting new references about spinal cord compression. [Section: “What if there’s something really wrong with my neck?” Safety information!]

2016Science update: 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. [Section: A recipe for persistent neck pain — what are the risk factors?]

2016Science update: Added some useful new indirect evidence about SMT for migraine (Chaibi et al). [Section: Spinal manipulative therapy (SMT): Adjustment, manipulation and cracking of the spinal joints.]

2016Edited: Added some important footnotes and clarifications. [Section: The potential importance of muscle tissue.]

2016Edited: Thorough revision and modernization. Although I revised this section a mere five years ago, it needed it again! [Section: Estimating the importance of trigger points in your own case.]

2016New section: More than a thousand new words on the topic of neck cracking. [Section: Popping your neck joints: bad habit, or self-treatment?]

Older updates — Many older updates are listed in a separate document, for anyone who cares to take a look.


  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!

    (See more detailed commentary on this paper.)

  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. 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.
    Cartoon of a man sitting in a doctor’s office. The doctor is holding a clipboard with a checklist with just two items on it: stress related and age related. The caption reads: “An extremely general practitioner.”

    Cartoon by Loren Fishman,

  7. Damasceno GM, Ferreira AS, Nogueira LA, et al. Text neck and neck pain in 18-21-year-old young adults. Eur Spine J. 2018 Jan. PubMed #29306972. 

    This study of 150 young adults found no link between neck pain and poor posture while texting, so-called “text neck.” The possibility of a link emerging over many years of text-neck posture has yet to be investigated, but this suggests that any long term link is probably minor, or there would be at least some detectable short-term link.

  8. 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
  9. 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
  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. And see also my own 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, regardless of 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. A more detailed definition: Pain itself often modifies the way the nervous system works, so that a patient actually becomes more sensitive and gets more pain with less provocation. This is often called “central” sensitization because it’s driven by the central nervous system, by changes in the spinal cord and brain (although there’s also peripheral sensitization). Sensitized patients are not only more sensitive to things that should hurt, but sometimes also to ordinary touch and pressure as well (allodynia). Their pain also often “echoes,” fading more slowly than in other people. Sensitization is closely associated with all the more serious chronic pain conditions. BACK TO TEXT
  22. Woolf CJ. Central sensitization: Implications for the diagnosis and treatment of pain. Pain. 2010 Oct;152(2 Suppl):S2–15. PubMed #20961685.  PainSci #54851.  BACK TO TEXT
  23. “Modern pain science” refers to the abandoment of the idea that pain is a relatively simple response to tissue damage. Instead, it’s an unpredictable top-down alarm system that responds to tissue conditions and many other variables, and has as much power to “mute” pain as it does to produce it. See Pain is Weird. BACK TO TEXT
  24. Debilitating fatigue, fragmented and shallow sleep, mental fog, depression, difficulty recovering from exercise. The quality of the pain may change from more ordinary “aches and pains” to more exotic and varied, more disconnected from reality, pain that just make no sense. BACK TO TEXT
  25. Here’s my chain of reasoning:

    1. One of the fascinating possible causes of fibromyalgia symptoms is intermittent spinal cord pinching (positional cervical cord compression, or “PC3,” a form of myelopathy, which is described in detail in the fibromyalgia article).
    2. It’s plausible PC3 is also associated with a certain amount of stubborn neck pain (which is indeed one of the most common troublesome areas in fibromyalgia patients).
    3. Finally, perhaps this scenario is more common in women for some reason, such as anatomical differences in the spine. A major 2016 study contradicts this point — women appear to have “milder evidence of degenerative cervical myelopathy” than men — but there are so many complex variables here that the hypothesis doesn’t need to be thrown out. And there are other reasons why women might be more vulnerable to positional cervical cord compression.
  26. 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
  27. 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
  28. Arnold M, Cumurciuc R, Stapf C, et al. Pain as the only symptom of cervical artery dissection. J Neurol Neurosurg Psychiatry. 2006 Sep;77(9):1021–4. PubMed #16820416.  PainSci #53624. 

    A study of 245 patients with spontaneous cervical artery dissection found that 20 (8%) of them suffered just one symptom — distinctive pain — even in five who had multiple dissections. It took about a week to diagnose most of them. Only two had neck pain alone, and six had headache alone; twelve had both.

  29. Kerry R, Taylor AJ. Cervical arterial dysfunction: knowledge and reasoning for manual physical therapists. J Orthop Sports Phys Ther. 2009 May;39(5):378–87. PubMed #19411768. 

    A discussion of the clinical challenge of cervical artery dissection that presents with pain as the only symptom.

  30. Maruyama H, Nagoya H, Kato Y, et al. Spontaneous cervicocephalic arterial dissection with headache and neck pain as the only symptom. J Headache Pain. 2012 Apr;13(3):247–53. PubMed #22350749.  PainSci #53625. 

    A small study of just 7 patients with pain as the only symptom of spontaneous cervical artery dissection. There was disconcerting variety in presentation, but the pain was consistently severe, unfamiliar, unilateral, and mostly sudden onset. “Cervicocephalic arterial dissection should be suspected when patients complain of intense unilateral posterior cervical and occipital pain or temporal pain.”

  31. Arnold “Pain topography, dynamics, quality and intensity were heterogeneous.” In other words, there are almost certainly some cases that are effectively impossible to distinguish from ordinary neck pain and headache. BACK TO TEXT
  32. Maruyama et al: “All but one patient [of seven] with migraine considered the pain to be unique and unusual compared with previously experienced headache or neck pain episodes. Nevertheless, pain was often interpreted initially as migraine or musculoskeletal in nature by the patient or the treating doctor.” Arnold et al: “Pain was different from earlier episodes in all but one case [of 20].” BACK TO TEXT
  33. Remember the F.A.S.T. signs of stroke: face drooping, arm weakness, speech difficulty … time to call 911! Non-stroke (or pre-stroke) symptoms associated with artery tears: neck swelling, reduced vision and/or visual disturbance, constricted pupil, drooping eyelid, pulsatile ringing in the ears, decreased taste. BACK TO TEXT
  34. 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
  35. 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. 

    A report on two cases of cervical spinal cord impingement causing leg pain — both examples of pain at a location unusually remote from a subtle lesion (referred pain) — both successfully treated surgically. Notably, both cases involved previous lumbar spine problems.

    Interestingly, such distant referred pain is tangentially relevant to the hypothetical phenomenon of cervical spinal cord irritation causing fibromyalgia (see Using Dynamic MRI to Diagnose Neck Pain).

  36. [Internet]. Holman A. Using Dynamic MRI to Diagnose Neck Pain: The Importance of Positional Cervical Cord Compression (PC3); 2017 January 12 [cited 17 Sep 1].

    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.

  37. 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
  38. 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.  BACK TO TEXT
  39. 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.]”

  40. 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
  41. 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
  42. Poussa MS, Heliovaara MM, Seitsamo JT, at al. 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.”

  43. 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). 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)

  44. 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
  45. Maigne R. Manipulation of the spine. In Basmajian JV (ed): Manipulation, Traction and Massage, Baltimore: Williams & Wilkins. 1986. BACK TO TEXT
  46. 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.


There are 328 more footnotes in the full version of the book. I really like footnotes (and I try to have fun with them).

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