"My neck hurts when I look up" Why, even though the range of motion is normal? The "hidden dysfunction" of the thoracic spine that causes cervical hyperextension and 3 immediate interventions

Cases where cervical extension range of motion is maintained but pain does not disappear. The cause may be a problem of "relative flexibility," where the cervical spine is moving too much to compensate for the thoracic spine that does not move. This article explains the often-overlooked mechanism of thoracic-derived neck pain, as well as differential assessment and exercise therapy that you can use starting tomorrow.

Hello, I am Akabane, a physical therapist.

A complaint I often encounter in clinical practice is "my neck (dorsal side) hurts when I look up." First, we check the ROM, right?

According to textbooks, cervical extension is about 50° to 60°. When I actually measure it, the range of motion is decent. The end-feel is also more soft-tissue-like than bony. However, the patient complains, "It hurts right there."

Even in imaging findings, there are no obvious neurological symptoms due to hernia or spinal canal stenosis.

"Why does it hurt even though it moves?"

If you hit a wall here, you tend to end up with symptomatic treatments like "let's loosen the trapezius muscle for now."

This time, I will delve into this "phenomenon of having range of motion but still feeling pain" from the perspective of 【Excessive movement (Hyper-mobility) of the cervical spine due to thoracic spine dysfunction】**, and share specific assessments and approaches that you can use starting tomorrow.

1. Why does it hurt even though it "moves"? The trap of relative flexibility

In conclusion, it is a state where "the cervical spine is being moved 'excessively' because the thoracic spine is stiff."

Movement occurs at the joint with the least resistance (the easiest to move) (relative flexibility). Originally, the action of looking up (total spinal extension) is the following coordinated movement.

• Upper cervical spine: Guidance of gaze

• Lower cervical spine: Provision of extension range of motion

• Thoracic spine: Posterior tilt of the base through extension

• Thoracic cage/ribs: Expansion

If the thoracic spine is in a "stiff" state, the brain will excessively move the **lower cervical spine (around C5-C7)**, which is the easiest to move, to compensate in order to achieve the goal of "looking up."

In other words, **the ROM appearing normal is the result of the cervical spine working overtime to cover for the thoracic spine's slacking off.** If you perform massage or stretching on the cervical spine (improving movement even further) in this state, it may actually promote instability and even worsen the pain.

2. Clinical mechanism: Concentration of stress on the lower cervical spine

I will organize anatomically why it hurts when the thoracic spine does not move.

• Zygapophyseal joint impingement: When looking up forcibly while the thoracic spine is in a state of excessive kyphosis (hunchback), the lower cervical zygapophyseal joints make contact prematurely, causing compressive stress (impingement).

• Muscle dysfunction: If thoracic extension does not occur, the center of gravity of the head cannot move backward smoothly. As a result, the cervical extensor muscle groups (such as the splenius and semispinalis muscles) are forced into continuous eccentric contraction to support the weight of the head, leading to muscle spasms.

It is important to interpret this not as "it hurts because the muscles are stiff," but as "the muscles are becoming stiff to stop uncontrollable movement."

3. [Practice] "Differential evaluation" to determine if the thoracic spine is the culprit

So, how do you determine if the pain of the patient in front of you is derived from the thoracic spine? Here are evaluation methods that produce immediate changes.

① Thoracic extension assist test (symptom reduction test) This is the simplest and most powerful one.

1. Have the patient perform the movement that causes pain (active cervical extension) and confirm the intensity of the pain (NRS, etc.).

2. The therapist stands behind the patient, uses their palms to grasp the thoracic spine (around T1-T6) and passively guide and fix it in the direction of extension.

3. While giving the cue to "puff out your chest," have them look up again.

Judgment: If the cervical pain is reduced or disappears with this, it is highly likely that the cause is not the cervical spine itself but "insufficient thoracic extension" (Positive).

② Wall standing check (modified Wall Angel test)

1. Stand with your back against a wall.

2. Have them look up in that state.

3. At this time, if the shoulders or back move significantly away from the wall, it is evidence that thoracic extension is not occurring and they are looking up by compensating with the entire trunk.

4. [Intervention] 3 approaches you can use starting tomorrow

If the evaluation suggests a thoracic spine problem, intervene using the following steps.

Step 1: Improve thoracic mobility (manual/self)

First, move the thoracic spine that is physically not moving.

• Manual therapy: Thoracic PA (Postero-anterior) mobilization in the prone or seated position. Not only the mid-thoracic spine but also the mobility of the cervicothoracic junction (C7-T1) is important.

• Self-exercise (foam roller): Place the roller under the thoracic spine, support your head with your hands, exhale, and arch your chest.

  • Point: To prevent the lower back from arching, perform this with your knees bent and your buttocks kept on the floor.

Step 2: Thoracic expansion (coordination with breathing)

The thoracic spine and ribs are a set. If the costovertebral joints are stiff, the thoracic spine will not extend.

• Cat & Dog (quadruped position): Perform this with the intention of "moving the spine one vertebra at a time." Especially during extension, focus on "showing the sternum forward" rather than "dropping the navel."

Step 3: Motor control (rewriting movement patterns)

This is the most important part. Even if the range of motion increases, if the brain does not forget the "habit of looking up using only the neck," the pain will recur.

• Cueing (gaze guidance): When looking up, saying "lift your chin" induces cervical hyperextension. Change the instruction to "shine the light on your chest toward the ceiling"or"look up from your solar plexus."

• Upper cervical spine control: Practice extending from the thoracic spine while maintaining a slight chin tuck. By extending while engaging deep flexor muscles such as the longus colli, you can prevent impingement of the facet joints.

5. Summary

"Neck pain when looking up" does not always mean "neck treatment."

• Even if cervical ROM is normal, there may be pain due to hypermobility.

• In the background, thoracic hypomobility is often hidden.

• If assisting the thoracic spine during evaluation reduces pain, the target is the thoracic spine.

• The key to a fundamental solution is not just "improving range of motion" but also "relearning movement patterns."

The moment a patient is surprised, saying "My neck pain is gone even though you didn't touch my neck!" is one of the highlights of being a therapist. Please try focusing on thoracic spine movement in your clinical practice tomorrow.

References

• Yang J, et al. Effectiveness and safety of thoracic manipulation in the treatment of neck pain. Technol Health Care. 2024.

• Tsegay GS, et al. Effectiveness of Thoracic Spine Manipulation on the Management of Neck Pain. J Pain Res. 2023.

• Sahrmann SA. Diagnosis and Treatment of Movement Impairment Syndromes.

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