When it comes to neck pain, as a strength coach, I (generally) don’t touch that with a ten-foot pole. It’s case dependent of course, but more often than not, if someone I’m working with walks in with a some significant discomfort in their neck I 1) start hyperventilating into a paper bag and 2) immediately refer out to a someone who has more diagnostic and manual therapy skills.

This is not to say, however, that there aren’t any avenues to take if you’re a personal trainer or strength coach. It’s not like you can’t do anything. In today’s guest post physical therapist, Dr. Michael Infantino, goes into great detail on some things to consider if you ever find yourself in this predicament.

Enjoy.

The Gym Is a Pain In My Neck: Two Movements To Cure Them All

Are you struggling with neck pain?

Does the gym make it worse?

Do you find yourself looking at a lot of informative websites for ways to resolve these issues, but wish it were compactly put in one place?

Does this sound like an infomercial?

Well it’s not!

But for just $29/month you can… just kidding.

This article is here to solve all of those problems. Neck pain is often blamed on poor form when exercising. This is absolutely true. Unfortunately this does not answer a crucial question, “why?” Discovering WHY your form is poor is the goal. On top of that, people often fail to recognize other human errors that are contributing to their symptoms. We will provide a guide for figuring out why you have neck pain and how to resolve it.

In most cases, pain attributed to the gym can be tied to the following:

1. Limitations in the necessary mobility to perform a movement
2. Limitations in the skill needed to perform a movement
3. Limitations in the capacity to perform a movement (Strength and Endurance)
4. Human error [Electrolyte and Fluid balance, Self-Care, Rest, Sleep, Breathing, Posture, Medication and Fear.]

Limitations in MOBILITY: 2 movements to cure them all!?

Limitations in your ability to put yourself in optimal positions during almost any upper body movement are a result of two movement limitations.

Limitations in these positions can lead to a host of different complaints. For the sake of time we are going to pick on NECK PAIN. If you are struggling with one exercise you are likely struggling with another, you just might not realize it.

Position #1: Shoulder Extension Test

Movements: Push Up, Pull Up, Row, Dip, Pull Up (top), Jump Rope, Punching someone in the nose because they have one of those weird miniature poodle mixes.

Attempt to perform the ^^THIS^^ motion

Instructions: Keep the neck retracted while extending the shoulders just beyond the trunk without the following:

• Increased forward head position
• Forward shoulder translation
• Shoulder shrug

 

If you are unable to replicate the picture above you likely have a MOBILITY problem.

If you can’t perform this motion when you aren’t under load, you will definitely struggle when you are. Especially with repeated repetitions and the addition of weight.

Target Areas for Treatment

Soft Tissue Mobility

• Pecs
• Serratus Anterior
• Upper Traps

 

Stretches and Joint Mobilization

1. Chin Retraction

 

2. Thoracic Extension (arms overhead)

 

3. Open Book Stretch

 

After working these bad boys out I want you to RE-CHECK the test position.

Is it better?

If not, you need to keep working on it.

Assuming you now have the necessary MOBILITY to perform this motion, we need to make sure you have the required SKILL with the particular movement you are interested in.

 Skill: the necessary strength, stability and coordination to perform the most basic form of a loaded movement (pull up, push up, dip, row, etc.).

Are you able to maintain a good position in the:

• Bottom of your push up
• Row
• Top of your pull up
• Bottom of your dip
• Jump roping
• As you load the arm for a hay maker!

We aren’t as complex as you might think. Many of our daily activities are broken into a few movement patterns.

Follow this sequence:

1. Create the mobility necessary to perform the pattern in its most basic form. (In this case, Position #1 and #2).
2. Ensure you have the skill needed to perform your desired movement (Push Up, Pull Up, etc.)
3. Build capacity with that movement (Endurance and Strength).

If you don’t have the skill to perform a specific exercise or movement, you need to practice. Look at the above definition of skill to make that judgement. If you don’t have the baseline strength to perform one good push up, pull up, dip or row, see below for regressions that will allow you to maintain good form as you work your way back to mastering these moves.

Here are some ideas:

Push Up: Inclined position (Ex. against weight bench or counter), knee push ups

Pull Up: Assisted with a band, inverted row

Dip: Assisted with a band, bench dip

Row: Kind of an outlier since this move typically doesn’t require body weight. Use a weight that allows good form. TRX Row and inverted row are body weight options. Adjust the angle of your body to reduce the difficulty.

 

The goal here is to demonstrate the ability to maintain proper form throughout each movement with a regression that is appropriate for you.

Joe Muscles next to you may need to take 50 lbs. off his 200 lb. weighted belt during his pull-ups to maintain good form. You may need to work on getting one pull up with good form without any extra weight.

Most of us have one or two good pull ups in our bag of tricks to whip out for an “impromptu” Instagram post. Preventing injury is going to require you to build the strength and endurance to exceed Instagram’s one-minute time cap. DAMN you Instagram!

Adding repetitions and weight to the regression will help you work your way back to a standard pull up, row, dip, push up, etc.

I can’t emphasize this point enough.

We all have high expectations of ourselves. Neck pain after 10 reps is not necessarily a “push up” problem. It may be the fact that you did three other exercises before push ups that started to fatigue the neck. The push up was the breaking point. You need to have a realistic expectation of your current ability, or capacity.

Position #2: Overhead Test

Movements: Overhead Press, Pull Up (bottom position), Snatch

Instructions: Lie on your back with knees bent. Tuck chin (neck flat to ground) with arms flat to the ground in the start of a press position. Press arms overhead by sliding arms along the ground.

Common Faults:

1. One or both arms come off the floor at any point in time.
2. Compensatory forward head or extended neck position to keep arms on floor
3. Compensatory spine arch to keep arms on the floor

 

Assuming you repeatedly tried to replicate this position without success, once again we have a MOBILITY PROBLEM.

Target Areas for Treatment

Soft Tissue Mobility

• Pecs
• Lats
• Rhomboids

Stretches and Joint Mobilization

• Chin Retraction
• T-Spine Drop In (or T Spine Extension)
• Open Book Stretch (Add: External Rotation at Shoulder)
• 1^st Rib and Scalene mobility

 

After finding the weak link, it is time to RE-CHECK. If it looks better, great let’s move on. Similar to Position #1, assuming you now have the pre-requisite MOBILITY to perform this motion we need to make sure you have the SKILL necessary.

*If you are having trouble improving your mobility or resolving pain, seek the advice of a qualified medical provider or fitness professional.

Can you maintain the same control and form during your overhead press, snatch, hang position of your pull up (or any variation- kipping pull up, toes to bar)? If not, we need to REGRESS the move. Unlike the shoulder extension position, many of the overhead exercises can be regressed by reducing the weight or working on single arm presses instead of two arms. Other regressions include:

Regressions:

Overhead press: Landmines (Tony goes into more depth in this article).

 

Snatch: Cleans, Single arm overhead kettlebell squat, single arm overhead lunge

Pull up (bottom): use a resistance band for support, inverted row

Human Error

Now that you have mastered Position #1 and #2, it is time to make sure that you are limiting HUMAN ERROR.

I think everyone should have someone in their life that serves as an extra pair of eyes. Even the best fitness trainers and medical providers in the world have a hard time being objective toward different areas of their own life. Barbers don’t cut their own hair, right? Not positive about that one. Either way, you can’t go wrong with some quality feedback!

Most of us are quick to blame the boulders in our life when it comes to pain, but we overlook the pebbles.

With pain we can’t overlook the pebbles.

The pebbles are diet, water intake, sleep, and self-care habits.

Patients usually tell me that they are doing “better than most” or that they are “pretty good” about optimizing these areas of their life. It isn’t until their spouse shows up to the appointment that we get the whole truth.

I love it!

Proper Fluid and Electrolyte Balance

Paying attention to what you consume pre and post workout is important. Proper fluids and electrolyte intake prior to exercise can help delay muscle fatigue and cramping.

Many people can get by with less than optimal effort when it comes to this category. However, if you are having neck pain you need to give yourself the best chance at success.

“At least 4 hours before exercise, individuals should drink approximately 5-7 mL·kg⁻¹ body weight (~2-3 mL·lb⁻¹) of water or a sport beverage. This would allow enough time to optimize hydration status and for excretion of any excess fluid as urine” (Sawka, 2007).

This is not always possible, I understand. Do your best. Some is better than none.

Warm Up

Proper warm up is also important.

Engaging in a warm up that gradually increases heart rate and muscle flexibility is a great way to prime the muscles. Dramatic increases in blood pressure and heart rate can lead to less than optimal muscle performance and increased risk of exertion headache during your workout.

Your warm up should be focused on getting the heart rate up; along with preparing the body for the movements you are going to perform during your workout (squat, push up, deadlift, clean, etc.).

Maybe you should try out THIS warm-up?

Recovery

Taking the time to stretch and do some soft tissue work after exercise will help reduce muscle soreness in the days following your workout (Gregory, 2015).

Leaving your body more prepared for the next workout. It is a great way to improve muscle extensibility and eliminate trigger points that aren’t allowing your muscles to perform effectively (Lucas, 2004).

Adequate rest is also important for recovery.

Going hard every day and not getting adequate sleep does not allow your body to grow and repair itself. Neglecting proper recovery leads to a less than optimal immune system and central nervous system.

Sleep deficits can also lead to an increase in the intensity of pain and alterations in mood. This is some serious shiznit. Can’t express enough how important this category is. I am a huge fan of the “grind.” It just sounds cool. You aren’t meant to grind everyday though, so please take some time to recover.

Breathing and Posture

Proper breathing is something that is often overlooked, but may be contributing to neck pain.

Gritting it out is cool, I highly recommend it. It builds character.

However, regularly holding your breath or clinching of your teeth when exercising can lead to increased tension around the neck. This could end up resulting in tension headaches as well.

Many of us without realizing it spend most of our day performing shallow breaths. We often over utilize the neck musculature. Shallow breathing into the chest can increase tension in these muscles and even increase feelings of anxiety.

It is recommended that people learn how to perform relaxed diaphragmatic breathing to reduce tension in the neck muscles. Staying in sustained postures throughout the day can also be contributing to your neck pain.

Many studies continue to show that sustained postures throughout the day (typically with office workers), especially with a forward head position, can increase neck pain and headaches (Ariëns, 2001).

Symptoms are also more common in people that hate their job.

Really off topic, but it is true …

Consider how stress in your life (emotional or physical) is amplifying your feelings of pain. Emotional pain and physical pain are HEAVILY connected. Check out this video by Tony to learn a little more about proper breathing strategies.

 

The Advil Fix

This may not seem to fit with the other categories.

Nonetheless, it is super important.

Side effects related to over the counter anti-inflammatory use are becoming common knowledge. Every now and then I run into someone that isn’t aware of the potential risks of regular use.

Popping over the counter anti-inflammatories (i.e. advil) before or after your workouts IS NOT recommended.

It’s like sweeping the dirt under the rug.

“The most common side effect from all NSAIDs is damage to the gastrointestinal tract, which includes your esophagus, stomach, and small intestine. More than half of all bleeding ulcers are caused by NSAIDs, says gastroenterologist Byron Cryer, MD, a spokesperson for the American Gastroenterological Association.”

Fear

One of the reasons that I started RehabRenegade.com was to help share information like this with as many people as possible. Many of the complaints I get in clinic can be fixed SUPER QUICK. Having a basic understanding of how to care for yourself and knowledge of the body can remove the “threat” of pain.

Red flags (serious pathology) represent less than 2% of the cases that are seen in a clinical setting (Medbridge, Chad Cook: Cervical Examination).

The Internet can be a blessing and a curse.

It can either lead you down the right road or scare the living crap out of you. We all know that any injury or illness is usually presumed to be cancer after a late night search on WebMD. Here are some discussions and advice I found on the inter-web related to neck pain in the gym.

Great intentions, but poor advice.

We tend to blame everything on a “pulled muscle,” whatever that means.

Rest?

What year is it?

We stopped recommending straight rest in like 1902.

By all means, take time off from the gym.

This doesn’t give you free rain to lie in bed all day watching re-runs of Game of Thrones.

It’s true… you may have over done it. Your muscles were overworked. Likely leading to a nice amount of local inflammation and some trigger points. The more constructive advice would be to perform some soft tissue work, light stretching and low intensity non-painful exercise to keep that area mobile.

Resorting to pain medication is not a healthy option. Last but not least, mentioning damaged discs and compressed nerves never makes someone feel at ease. Trauma to the neck may be a reason for disc injury. Overdoing your push ups and pull ups is NOT.

Fun Fact: The prevalence of disk degeneration in asymptomatic (without symptoms) individuals increased from “37% of 20-year-old individuals to 96% of 80-year-old individuals. Disk bulge prevalence increased from 30% of those 20 years of age to 84% of those 80 years of age” (Brinjikji, 2015).

Positive findings on MRI are common in people without pain. Don’t get too caught up in images and diagnoses. Do the things we know are healthy. If you hit the gym hard this morning and then followed that up with a CROISSAN’WICH from Burger King, and a cigarette at lunch we have bigger fish to fry.

First and foremost, muscle and joint strain at the neck commonly refers pain to the head. We call this a cervicogenic headache. Rest assured that it is very rare that you have a more serious pathology requiring immediate medical attention. Give the tips in this post a shot, if it doesn’t help by all means see a medical professional. The worst thing you can do is show up to your medical provider without attempting to improve your flexibility, tweak your form or get adequate rest.

If I had a dollar for every time a therapist told someone they had the tightest (fill in the blank) they have ever seen I would be a little better off.

If this poor girl wasn’t worried enough… Now she has the tightest back he has ever seen… really?

As providers we need to be very careful with our words. It is really easy for us to turn neck pain into chronic neck pain.

It is called an iatrogenic vortex.

When people get tied up in the medical system too long they often see symptoms worsen or develop other unexplained diagnoses.

Overview

In most cases, pain attributed to the gym can be tied to the following:

1. Limitations in the necessary mobility to perform a movement
2. Limitations in the Skill needed to perform a movement
3. Limitations in the Capacity to perform a movement (Strength and Endurance)
4. Human Error [Electrolyte and fluid balance, Self-Care, Rest, Sleep, Breathing, Posture, Medication and Fear]

You could be one small modification away from eliminating your neck pain.

The big takeaway here is to make sure you have the ability to perform various exercises with good skill.

From there, you need the knowledge and self-awareness to know when you have exceeded you capacity.

You also need to look at the big picture to ensure that you are checking the boxes when it comes to living a healthy life. If you are someone that often finds yourself worried or anxious when injury sets in please take a step back and look at the big picture. Use this article to see where your gaps are. If you still can’t get relief please see a medical provider. Nothing makes medical providers happier than working with patients who demonstrate a willingness to learn and grow.

About the Author

Dr. Michael Infantino is a physical therapist. He works with active military members in the DMV region. You can find more articles by Michael at RehabRenegade.com.

 

 

 

 

 

 

References

Ariëns GAM, Bongers PM, Douwes M, et al

Are neck flexion, neck rotation, and sitting at work risk factors for neck pain? Results of a prospective cohort study. Occupational and Environmental Medicine 2001;58:200-207.

Brinjikji, W., Luetmer, P. H., Comstock, B., Bresnahan, B. W., Chen, L. E., Deyo, R. A.,Jarvik, J. G. (2015). Systematic Literature Review of Imaging Features of Spinal Degeneration in Asymptomatic Populations. AJNR. American Journal of Neuroradiology, 36(4), 811–816. http://doi.org/10.3174/ajnr.A4173

Gregory E. P. Pearcey, David J. Bradbury-Squires, Jon-Erik Kawamoto, Eric J. Drinkwater, David G. Behm, and Duane C. Button (2015) Foam Rolling for Delayed-Onset Muscle Soreness and Recovery of Dynamic Performance Measures. Journal of Athletic Training: January 2015, Vol. 50, No. 1, pp. 5-13.

Lucas KR, Polus BI, Rich PS. Latent myofascial trigger points: their effects on muscle activation and movement efficiency. J Bodyw Mov Ther. 2004;8:160-166

Sawka MN, Burke LM, Eichner ER, Maughan RJ, Montain SJ, Stachenfeld NS. American College of Sports Medicine position stand. Exercise and fluid replacement. Med Sci Sports Exerc. 2007;39:377-90.

http://www.webmd.com/osteoarthritis/features/are-nsaids-safe-for-you#3