If you’ve ever had aches and pains in your neck and shoulders, you have probably been told that you need to get a massage. When that doesn’t seem to provide long-term relief for you or you get tired of constantly getting a massage, you may be referred to a specialist in myofascial release or a Rolfer to get really “deep” work. But is this always the answer? Is more pressure or more bodywork always the answer to chronic pain?
A MAN WITH STUBBORN NECK PAIN
I recently started working with a guy who had seen four other Rolfers already. He had neck pain that would only start in the middle of the night after lying in bed for 2 to 4 hours. It would almost never bother him the daytime. It would only bother him at night and into the morning. The Rolfers he had seen had worked a lot around his shoulders and neck, apparently trying to loosen up what they thought was bound up fascia in his neck and shoulders.
The treatments didn’t help, and this gentleman was hoping that I would be able to help him — SOMEHOW! — loosen up the aching that kicked in at night.
I started to palpate the neck and shoulders to see if there were any of the telltale signs of dense, fibrotic tissue around his neck and shoulders. Not surprisingly, I found nothing. The musculature around his neck was soft and thin and relatively pliable. Almost too thin and too pliable in fact. The myofascial tissue on the right actually felt thinner than on the left, and this seemed to make sense given the pain on the left side. Often the side with the more dense tissue will be the side that is more symptomatic and painful as it’s the side that’s overworking.
However, as will become apparent, this isn’t always the case.
This was not the first time I had seen somebody who had pain that would start only after long periods of rest. Often times, people will feel discomfort start in their hips when they’ve been at rest for a long period. Their feet might hurt, their back might hurt, their shoulders might hurt, etc. You can see any of a number of videos of mine about the hips to see how obsessed I am with this.
In cases where pain sets in during rest, it is essentially never about the body being too tight. It is about the body being too weak to maintain enough activation and stability for the body part (and the person) to feel comfortable. Muscles get too slack and allow the joint mechanics and joint position to get too far out of whack, and the brain perceives this as a problem – rightfully so!
So I had him do an exercise called a face pull to see how his muscles were working. This exercise requires excellent shoulder blade stability, and the ability to laterally rotate the shoulder joint while in abduction. This forces the upper trap, the levator scapulae, the supraspinatus, the deltoids, and the lateral rotators of the rotator cuff to work in concert (some other muscles as well but how long do you really want this list?). I wanted to see what happened to the muscles along the top of the scapula that insert into the neck. What I saw was pretty illuminating.
When you do any exercise, there is muscle activity. When you do a bicep curl, your bicep will bulge a bit as it contracts. The more you do it, the more it bulges. When you do shoulder exercises, you can often spot asymmetry very easily by looking at what the muscles that attach up into the neck are doing. The muscles around this gentleman’s shoulders were doing VERY different things. The “web” looking structure of the upper trap on his right side was visibly less developed and less active in the motion.
As he approached the sixth rep, he was already starting to feel like his right shoulder – at the upper traps and supraspinatus – was tiring out far more quickly than on the other side.
I had him do some lateral raises, and the result, as you can see in the video below, was the same. Left side working; right side looking like a deflated balloon!
When we switched to doing lateral rotation one arm at a time, the asymmetry between the two sides became even more pronounced. His left side could do the exercise with no problem through 10 repetitions, while the right side started to get tired after only four repetitions and stayed fatigued for a full minute after the set.
When I see asymmetry this pronounced, this is where I start. Minor asymmetries are one thing, but yawning gaps in strength and development are never good. I sent him home to do a few exercises like this throughout the day and definitely before going to bed. A few sets of 10 throughout the day would be enough to start kicking in the musculature of the right side to even out the issue.
PAIN FROM INACTIVITY
The way I look at pain that starts from inactivity is this. Whatever part of your body is affected requires a certain level of muscle activation in order for things to feel right. The muscles around the joint (if it is a joint were talking about) need to be balanced from side to side and front to back. When we’re healthy the base level of activation is good enough to keep his comfortable. When you have neck pain like this gentleman, the base level of activation is good when you’re awake but not sufficient once you are in full relaxation mode and/or lying in bed.
When you start to strengthen the weaker muscles you are giving them a higher maximum output. As the maximum output goes up, the baseline activation also goes up. The higher the baseline activation goes, the further you are away from the threshold of pain.
To make this a little more concrete: pretend that you need 20 N (NOTE: THIS IS A COMPLETELY MADE UP, NONSCIENTIFIC NUMBER USED FOR THE SAKE OF THIS ILLUSTRATION ONLY!) of force from muscle A on the left and muscle B on the right in order to feel comfortable. If you fall below 20 N, your neck will hurt. If the difference between the force generated by the two muscles exceeds 8 N, you will hurt.
When you’re awake, muscle A is at 21 N and muscle B is at 27 N. Great. When you fall asleep your muscle A drops to 15 N and muscle B drops to 21 N. Oops. Now you’re in pain.
Or let’s say you’re a bit stronger. Muscle A puts out 35N and Muscle B puts out 28N. As you sleep through the night, muscle B drops to 24N. Oops. You violated the 8N difference limit. Now you’re in pain.
So what do you do?! You train muscle A and muscle B to both get much stronger. You train them to put out a maximum range of 55N and a baseline output of 35 N. You make it so that muscle A and muscle B are never far apart enough in terms of force production to cause you pain! And because your baseline output is up at 35N, the muscles are never so slackened that your neck passes that 20N threshold.
THE TAKEAWAY WITH NECK PAIN
So what was the result for our gentleman with neck pain? After about a week of doing the exercises he had noticed marked improvements in neck pain. He had only a one night when his neck seemed to be sore, but all the other nights were great. This was in comparison to having consistent pain at night that would wake him up every single day.
If you’re getting constant bodywork and massage done for something that feels tight all the time, and it doesn’t get any less tight, then you need to look at it from a different angle. if you’re suffering with neck pain similar to what was described here, then you may want to try listed exercises and see how it affects you over the course of a week.
For bodywork and massage professionals there is a clear bias towards manual intervention (for obvious reasons). Just remember the old saying: if all you have is a hammer, everything looks like a nail. For bodywork and massage professionals (and health professionals of many stripes) this happens all the time. As the person with neck pain, it’s up to you to recognize when you need to change course. Manual therapy does make sense for some kinds of neck pain, but if you’ve already had the hammer and your neck pain stays the same, it’s time to look for something else!