As massage therapists quickly learn, pain in the neck and neck injury affects thousands of people each day.

Kneading of the posterior muscles

In 1975, at age 25, I injured my neck in a rugby game and compounded the injury by going bodysurfing the next day.

The neck injury left me with a spasm on the left side of my neck that caused intense pain, limiting my ability to turn my neck, and created a headache that was unlike anything I had ever experienced.

The next week a friend recommended chiropractic treatment, but upon initial examination the chiropractor said that the spasm was too strong for him to safely adjust my neck.

He gave me a cervical collar and recommended a local massage therapist. By that afternoon I had scheduled my first session. Like many Americans, I had never considered going to a massage therapist until soft-tissue pain became a part of my life.

During the intake prior to the session the massage therapist explained that the muscles of my neck were connected to my skull, shoulders, back and chest, and that she needed to treat my full body to get maximum results.

I still remember that massage treatment, because I couldn’t believe how many different places she touched that were sore and tender. She further explained that the muscles of my neck and back needed regular treatment due to their density and generally inflexible nature.

I agreed to weekly sessions, and by the fourth session the pain, stiffness and headache were gone.

I had found my future career.

The Neck

The neck is often used as a metaphor to demonstrate physical characteristics or variables of the human condition. The stubbornness of a “bull neck” or the beauty of a “swan neck” are easily perceived, as the neck is one of the most important and distinguishable regions of the human body.

The neck has multiple responsibilities, including support for the head and face, and coordination of movement between the cranium and thorax.

It houses the cervical portion of the spinal cord, seven delicate vertebras, the esophagus, major arteries and veins, lymphatic vessels, lymph nodes, myriad muscles, and dense, fibrous connective tissue that wraps, envelopes and connects all of its components.

As massage therapists quickly learn, pain in the neck and neck injury affects thousands of people each day. Indeed, neck and back pain are often the two most common complaints by those who suffer soft-tissue injuries and seek massage therapy as a primary treatment.

These pains are commonly caused by automobile accidents, athletic injuries, repetitive use, postural distortions, or degenerative conditions. This article will look at the anatomy of the neck, basic neck injuries, and treatment strategies that are available to the therapist from a broad variety of massage disciplines.

The seven cervical vertebras form the deepest infrastructure of the neck. Housing and protecting the spinal cord in their vertebral foramen, these vertebras also allow movement of the head through the interconnection of atlas, axis and cranium.

The muscles of the neck are divided into two major segments: postvertebral and prevertebral. The postvertebral muscles include the erector spinae group of longissimus and splenius, which are responsible for keeping the neck erect and for rotation.

The spinalis, semispinalis and rectus capitis posterior groups interconnect the cervical vertebras to each other and the vertebras to the base of the skull.

The prevertebral muscles include the three scalenes, the longus capitis, longus colli, and the rectus capitis anterior. These muscles combine to bend the neck and head forward (bilaterally) or tilt the head and neck to the side (unilaterally).

There are also muscles that cover the full length of the neck, but attach only to the cranium and shoulder girdle. The trapezius, levator scapulae and sternocleidomastoid are three of the most important muscles of the head-to-shoulder group to consider when treating common neck injuries.

All of the cervical vertebras and muscles are enveloped, supported, and strengthened by multiple layers of dense, fibrous fascia.

There are three rings of cervical fascia at superficial, intermediate and intrinsic locations within the cervical column. Each muscle is also housed within its own fascial wrapping, or epimysium, which is richly innervated with sensory neurons.

The myofascia of these muscles are often the site for tissue thickening and adhesions following injury.

Side-lying upper trapezius technique

Common Neck Injuries

Neck sprain and strain are the most common neck injury that massage therapists treat. Neck sprain usually refers to ligament damage while neck strain refers to muscle damage.

These injuries are often caused by impact or contact with another person, object or surface.

Neck sprain or strain is most frequently associated with sports accidents, but can easily occur in falls or automobile accidents.

Common symptoms of neck sprain and strain are:

  • Pain in the neck that increases with movement
  • Muscle stiffness and decreased range of motion
  • Delayed pain in neck (24 to 48 hours) following accident
  • Headache associated to neck pain
  • Tingling or numbness in arms or hands

Massage therapy can be safely administered to the client with a neck injury once a physician has evaluated the injury and ruled out more serious damage to the vertebra or to the intervertebral disks.

Whiplash occurs when there is forceful impact from behind, causing the neck and head to violently move forward and back in an abrupt motion.

While many whiplash injuries are caused from rear-end automobile accidents, there are also lateral whiplash injuries that occur from violent side impact. The common symptoms are:

  • Neck pain and stiffness
  • Headaches
  • Pain in the shoulders or upper back
  • Difficulty concentrating
  • Blurred vision or ringing in the ears
  • Irritability and fatigue

Like neck sprain or strain, a physician should evaluate the whiplash injury. Based on the severity of the symptoms, MRI or CAT scans may be useful in determining the severity of the neck injury.

Once structural damage has been ruled out, any massage therapy treatment can be enhanced with the use of ice (for acute stage), or contrasting heat and cold (for chronic stage) therapies.

Overuse and Postural Distortion

Overuse injuries to the neck are often caused by daily activities that are repetitive in nature, or create undue strain for extended periods of time.

These can include carrying heavy backpacks or purses, work-related repetitive motion with the arms and shoulders, or sitting at a desk in a strained position that holds the head and neck forward of the body. The common symptoms are:

  • Neck pain and stiffness
  • Pain that radiates from neck to shoulder
  • Tenderness at the base of the skull
  • Chronic, dull pain throughout the neck and upper back
  • Tension headaches

Massage therapy treatments are even more beneficial if the client can change the repetitive pattern that may have caused the injury. Carrying a lighter backpack or purse in a more balanced position, or changing the workstation to allow for better body mechanics is necessary for an optimal outcome.

While forward-head position is common in the computer age, postural distortions of the neck may also be caused by distortions in the back, pelvis or legs. Chronic tightness of the fascia and muscles of the upper neck is one of the primary causes of tension headaches.

Deeper traction of cervical spine

Degenerative Conditions

Osteoarthritis and degenerative disc disease can be caused by prolonged strain of the spine. As the discs lose pliability, the potential for bone spur formation increases.

Another condition is cervical stenosis, or the narrowing of the spinal canal. In any of these conditions the nerves of the cervical spine can become irritated or pinched. The common symptoms are:

  • Neck, shoulder, arm or head pain
  • Limited movement
  • Postural deformities
  • Numbness or loss of feeling

Many degenerative conditions are moderate, and massage therapy is effective for soft-tissue restoration. However, some conditions will only improve following surgical intervention, especially for advanced cases of cervical stenosis.

Treatment Strategies

Every discipline of massage therapy can have a positive effect on diminishing neck pain. From Swedish to shiatsu, neuromuscular to myofascial, sports massage to structural integration—a treatment plan that incorporates the following criteria should improve the soft tissue dysfunction found in common neck injuries. The criteria are:

  • Treat the whole body. All soft tissue is connected through the multiple layers of fascia that surround and support the body.
  • Spend considerable time warming the soft tissues of the neck before applying deeper pressure.
  • Balance the treatment of the neck by working with posterior, lateral and anterior regions of the neck.
  • Address any corresponding issues in the paraspinal tissues of the thoracic and lumbar regions.
  • Test range of motion of the neck before and after treatment.
  • Teach safe stretches for the neck and back and encourage the client to practice alignment exercises that improve posture.

Massage therapy is most effective when delivered in a progressive series of sessions that gradually works deeper with less sensitivity.

Go slow, improving the parasympathetic reflexes of the autonomic nervous system.

Deep kneading of trapezius

The Neck Routine

This routine utilizes a combination of Swedish massage, myofascial therapy and structural- integration techniques.

From the supine position: Start with gentle range-of-motion techniques, including traction, flexion, hyperextension, lateral flexion and rotation. Ask for feedback about any sensitivity during movements.

Begin long, two-handed gliding strokes that include the lateral and posterior tissues of the neck. Traction and tissue warming are primary goals. Use less lubrication to increase tissue warmth.

Transition to moderate kneading strokes that will include upper trapezius and levator scapula, as well as the full posterior line of the neck. Find areas that feel dense or thick and spend extra time with circular friction.

Apply cross-fiber friction and kneading strokes at the sub-occipital region with one hand, while rotating the head to the opposite side with the other hand.

Apply deeper cross-fiber friction at the scapular attachment of the levator scapula, followed by deeper gliding strokes moving laterally on the spine of the scapula.

With head turned slightly to one side, begin more specific kneading of the sternocleidomastoid (SCM), from belly to either attachment. Hold the SCM at its belly and move the entire muscle.

Use finger pads to apply moderate pressure across the scalene group. Remember that there is a scalene opening between the anterior and medial scalene, closer to the distal end. The brachial plexus and subclavian artery pass through this opening, so be cautious with pressure and speed.

Finish with larger range-of-motion movements.

From the side-lying position: Use palms or finger pads to glide and knead the tissues between the clavicle and spine of the scapula. Pressure can be increased to work through the trapezius as needed.

Use a soft fist to pull posteriorly across the tissues of the SCM, scalenes, and levator scapula. Ask the client to slightly nod up and down while the strokes move across each segment of the neck. Work the suboccipital tissues more specifically.

Stretch the shoulder down while applying opposing pressure on the skull. Have the client fully exhale during each stretch.

From the prone position: Apply broad pressure with the palms or forearms on the upper thoracic paraspinals. Deeper work on the rhomboids should be included.

Knead the tissues of the full posterior neck, including the attachments at the skull, and the tissue between the neck and shoulder. Reach under the trapezius and apply circular friction to the supraspinatus.

Return to the supine position: Apply deeper traction, using the fingertips to lift on either side of the spinous processes. Repeat several times, each time with more pressure.

Lifting the head and neck, use fingertips to apply cross-fiber strokes at each intervertebral joint. The nuchal ligament, which interconnects the spinous processes of the cervical vertebras, may be accessible from this position.

Finally, use the soft fist to apply slow pressure across the tissues of the trapezius region, moving from anterior to posterior with each stroke. Slowly turn the head in the opposite direction with each stroke. Continue this technique on the lateral neck and apply pressure to the posterior muscles as well.

Have the client check range of motion post-session as a comparison to pre-session restrictions.

A Rewarding Experience

Effective treatment of the neck can be one of the most rewarding experiences for client and therapist.

The appreciation and trust that emanates from successful outcomes can create a long-term client-therapist relationship—or perhaps it will inspire the client to change careers and help others.

It did for me.

About the Author

George P. Kousaleos, L.M.T., is the founder and executive director of the CORE Institute School of Massage Therapy and Structural Bodywork, in Tallahassee, Florida. George has practiced and taught myofascial therapy and structural integration since 1979. He was active in the development of the National Certification for Therapeutic Massage and Bodywork examination program and the Massage Therapy Foundation, as well as organizing sports massage teams for the British Olympic Association in 1996 and for the 2004 Athens Olympiad. In the summer of 2011 George was asked to develop a Sports Bodywork Therapy team that would work with the athletes of the Florida State University Football Team.


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