The Main Cause of My Neck Pain – Habitual Slouched Posture
After years of pain, disability, failed treatments, and sporadic searches through books and internet websites, I made a serendipitous discovery that ended my chronic neck pain. Surprisingly, the main cause was not the bad neck strain in my early 20’s, or the accelerated degenerative disc disease that followed, but the decades of habitual slouched posture that had profoundly weakened some muscles (neck flexors, thoracic extensors, shoulder blade stabilizers), while tightening, spasming and inflaming others (neck extensors, shoulder blade suspensor muscles — upper trapezius and levator scapula). At the worst of it, my shoulder blades were so unstable that even the smallest task involving my arms such as loading the dishwasher or pulling on my jeans caused spasms at the sides of my neck. And my neck flexors were so weak I couldn’t even lift my head from the pillow when lying on my back in bed.
And with time, my posture was only getting worse. Poor posture feeds on itself because slouching forward stretches and weakens the back muscles (back extensors) needed to keep the body erect against gravity, while the muscles that curl the upper body inward tighten and strengthen. As we age and lose muscle mass and strength (unless we deliberately keep active and exercise) slouched posture slowly worsens, and may accelerate with illness or chronic pain. The only way to end the vicious cycle is to decisively and mindfully correct poor posture until balanced* posture feels right and slouched does not, and even then constant vigilance is needed.
*Instead of the terms ideal or neutral posture, I like the term, balanced posture, because spine and pelvic extensors and flexors should be in balance. When one muscle of an antagonist pair that operates a joint is too weak, it allows the faulty alignment; while the other relatively stronger muscle creates the faulty alignment. The musculoskeletal system is least stressed during rest and activity when antagonistic pairs of postural muscles are balanced. The same goes for all antagonistic pairs of muscles. Care must be taken in strength training to avoid overworking one member of an antagonistic muscle pair. Only working the biceps to get that great bulge of anterior upper arm muscle, but ignoring the triceps at the back of the arm, predisposes to elbow and shoulder pain. Concentrating on the pectorals to get a great chest, but ignoring back extensors, causes shoulders to round forward, and mid to upper back extensors to elongate causing kephotic posture.
Chronic Pain and Posture
It’s not only poor posture that begets worse posture. But any chronic pain, especially in the core areas of spine, shoulders, chest, and abdomen, seems to protectively tense up the front of the body, curling it into flexion (fetal position). Don’t most of us just want to huddle on the couch or in bed when we are in pain or feeling unwell? So the observation by Professor Jull that neck pain patients when simply rising to a standing position can’t “shape” their lower back/pelvic area into a normal (lordotic) curve, (which requires activation of extensors) and don’t use their deep stability muscles well (such as the spinal multifidus), may apply to all chronic pain patients.
Prior to the worst of my neck pain, I had developed a chronic stomach condition called post-viral gastroparesis (partially paralyzed stomach), which is like bad stomach flu but lasts for 6 months to forever. Soon I looked skeletal and had profound fatigue from the medication as well. I remember how carefully I moved as rounds of nausea, heartburn and stomach cramps knocked me down day after day; how stiff and out of balance I felt, how all I wanted to do was huddle on the couch and watch of all things, reruns of CSI (Crime Scene Investigations). No wonder my posture suffered, and my neck pain, spasm and weakness ramped up worse than ever. A total nightmare. Eventually I wasn’t able to do household chores or drive. How did I let myself get so weak? Avoidance of pain and my depressed mood (whether cause or effect?) limited more and more my everyday activities until I could barely do anything. And I didn’t even notice how slouched I’d become, and no one said anything because I was so ill.
An important lesson: When chronic illness and pain limit physical activity, making the effort to use good posture helps keep postural muscles strong and reduces the risk for increased neck, shoulder and back pain.
1. Pain in Neck, Shoulder and Upper Back muscles.
Slouched posture causes Forward Head and Destabilization of Shoulder Blades, both of which, predispose to spasm, pain and inflammation of the neck, upper back and shoulders. These are chronic muscle strain symptoms (not generally nerve compression symptoms) and even though attributed to a previous neck injury and/or existing degenerative disc disease and spinal osteoarthritis, slouched posture may likely be the root cause even though these other disorders are present.(see How Slouched Posture Causes Neck Pain: 1. Forward Head and 2. Destabilized Shoulder Blades…)
2. Slouched Posture Causes Worsening of Radicular Pain Through Neck Muscle Tightness and Spasm
Radicular Pain is pain that radiates down the arm (or leg in the case ofsciatica) in a specific pattern (see sensory dermatome). Radicular pain is often caused by irritation of spinal nerve roots coming off the spinal cord. The nerve roots area off-shoots of the spinal cord that travel through openings (foramina) formed by vertebral facet joints. Those openings can become narrowed, and the nerve tissue irritated by bone spurs and/or bulged–out hardened disc material caused by degenerative disc disease (spinal arthritis) or when the inner shock-absorbing gel of discs herniates from acute injury.
In slouched posture, the excessive kephotic curve of the upper back is balanced by an excessive lordotic curve of the neck/cervical spine (unless the cervical lordotic curve is lost) in an effort to balance the weight of the head without overworking the back neck muscles (neck extensors). Excessive cervical lordosis forces vertebral facet joints closer together, narrowing the foramina, and can irritate the nerve roots all by itself or further irritate nerve tissue already impinged on by bone spurs. Muscle spasms at the back of the neck can also narrow foramina by clamping together the vertebral facet joints. Improving posture takes some of the pressure off nerve roots by straightening the neck and easing muscle spasms. And if nerve roots aren’t already inflamed there may be no symptoms even with severe foraminal narrowing, as long as posture is optimal and muscle spasm is absent. (see my MRI report—In spite of moderate to severe narrowing in several nerve root foramina I now have no radicular pain; also see Johnson).
Very importantly, do not ignore numbness and/or weakness of arms or legs. “Persistent pressure upon a nerve root of three-months duration may not recover when the pressure is relieved.”(Cailliet) This means surgical decompression must be done before damage is permanent.
3. Cervicogenic Headaches
Tight back neck muscles due to Forward Head and Neck can irritate the occipital nerve, which runs through the upper trapezius and another neck extensor, the semispinalis capitis. The nerve may be compressed and irritated by spasms of those muscles high at the back of the neck near the base of the skull.
4. Shoulder Pain: Rotator Cuff Tears and Frozen Shoulder
Slouched posture causes weakening of the muscles supporting the shoulder joint, which predisposes to shoulder problems like torn rotator cuffs and frozen shoulder (adhesive capsulitis). In particular the downwardly tilted scapula can’t create enough space for the topmost tendon of the rotator cuff (which is already slack from lateral drift of scapula) when the arm is lifted overhead, causing it to be pinched and damaged by the bony process of the shoulder blade called the acromion.
5. Thoracic Outlet Syndrome – Numb Fingers, Hands and More.
Several nights a week, I would be awakened from sleep with numb fingers and hands. I would sit up in bed and shake my hands until the feeling came back. This was one of the seemingly unrelated symptoms along with headaches and big toe pain that disappeared when my posture improved.
Night–time numbness and tingling in hands and arms are symptoms of a Thoracic Outlet Compression Syndrome (TOS).
The thoracic outlet is a narrow passageway between collarbone (clavicle) and ribs that the subclavian artery and vein, and the brachial plexus (a network of nerve fibers formed from the lower 4 cervical and first thoracic nerve roots) must travel through to get to the arm. The nerves of the brachial plexus control most arm and hand muscles, and receive sensory input from most of the skin and muscles of the arm.
Slouched posture and downwardly tilted shoulder blades causes tightness in front shoulder muscles, which narrows the thoracic outlet in the shoulder, and may compress the brachial plexus and/or subclavian artery that runs through it. Symptoms include waking from sleep with numbness, tingling, weakness, and coldness of hands and arms. Neck muscles, particularly the upper trapezius, may be painful. Most patients improve with therapy for posture and muscle imbalance. See Medscape article: Thoracic Outlet Syndrome Treatment & Management. Kendall et al, discuss a similar syndrome,Coracoid Pressure Syndrome where the brachial plexus is compressed by the Coracoid Process of the shoulder blade, which is pulled forward and down by a tight pectoralis minor. Symptoms are pain down the arm with slight pressure on the area of the coracoid. Also pain that worsens with weight on the shoulders from a backpack or purse, or when carrying something heavy with that arm. The upper trapezius is often in “protective spasm” from trying to lift the shoulder girdle off the nerve bundles. First line of treatment is to realign posture and shoulder blade position. See Fix the Shoulder Blade Exercise
Sleep position may aggravate TOS caused by slouched posture. Sleeping on the back forces the shoulder blades to tilt backwards so they lie flat against the bed. This pulls on the pectoralis minor, which overlays the brachial nerve bundle. If the pec. minor is already short and tight due to slouched posture then sleeping on the back may worsen the nerve compression.
In Depressed/Droopy Shoulders, the clavicle (collarbone) is horizontal or slopes down to end of shoulder. The acromion process of the shoulder blade is also held too low. There are two areas of possible nerve and blood vessel compression in the thoracic outlet: 1. between clavicle and first rib, and 2. between coracoid/short tight pectoralis minor and the 3rd through 5th rib. The upper trapezius is stretched and weakened, but protectively spasms to lift the clavicle off compromised structures. Weight-bearing by the arms worsens the compression and stress on upper trapezius. (Depressed shoulders may be seen in weight lifters, who let heavy barbells and dumbbells hang off their collarbones, which pulls them lower and overstretches the upper traps. Also some female dancers, actors, and models, intentionally strive for a long swan-like neck, which depresses the shoulders.)
Another possible cause of arm pain originating in the thoracic outlet area may be an “Elevated First Rib” which would predispose to compression under the collarbone. The first rib elevates (within the relatively rigid structure of the ribcage) by action of the anterior and middle scalene muscles.
Scalenus Syndrome (Scalenus Anterior or Anticus syndrome) — The anterior and middle scalenes are also involved in a third possible area of thoracic outlet compression. Between them is a narrow area through which the brachial nerves and subclavian artery (not the subclavian vein) travel before passing under the collarbone. Turning the head, which causes twisting of the neck, narrows the passageway, but rarely causes symptoms from nerve compression unless there are predisposing factors. These include presence of a cervical rib (additional rib-like structure extending from the C-7 vertebra), enlargement of the scalenes due to exercise, and chronic tightness/spasm, which manifests as a rotation of the head toward the spasm, and sometimes a head tilt toward the same side as the spasm but not always. I’ve noticed that scalene spasm may occur on the same side as a shoulder blade that rides abnormally high. I don’t know the reason for that, but perhaps has something to do with crowding and compression-caused irritation at the top of the shoulder.
6. Aggravation of Big Toe Arthritic Pain and Arthritis
For over 25 years I’ve had an enlarged, arthritic first big toe joint on my right foot. This is called Hallux rigidus or rigid big toe, which has caused limited movement of my right big toe and pain while walking. (Try walking without bending your big toe. It’s difficult.) Fifteen years ago I had surgery to remove the bone spurs, but within 6 months much of the excessive bone had grown back, though the worst of the bone spurs didn’t return. But I still had chronic pain and inflammation and used an insert to stiffen the sole of my right shoe to limit bending of the painful big toe.
…But then I improved my posture and somehow my toe pain began to improve. I discovered that poor posture had a lot to do with my toe pain. Apparently I had always been leaning forward from flat back posture and putting too much pressure on my arthritic big toe. With improved posture and awareness that my weight should be distributed evenly between heel and forefoot, my big toe pain improved greatly…even to the point that I don’t need the sole stiffener and can go barefoot.