Cervical pain in athletes-And the importance of neck strengthening.

The purpose of this case study is to assist our graduates to fully reflect on a client that they have seen throughout the week. This will also form part of information that we can distribute to clients where they can read up on real life cases where we have been able to help clients and allow them to be pain free! Clients are refered to as Mr.X/Ms.X to keep their privacy.


  • Topic of interest/why?
  • Who?
  • How?
  • Common clinical presentation
  • What does the literature say?


Combat athletes, or collision sport athletes (AFL, NRL) are at greater risk of cervical related injuries and concussion as a result of high impact trauma, degeneration and poor S&C of the associated structures (predominantly the neck). As a result, they will come and see us at Primal first and foremost because we deliver above standard care. Cervical pain CAN be a difficult task to overcome in athletes.

The athlete

Cervical pain is a common condition seen in private practice.
Etiology: Idiopathic, postural, stress/tension, poor scap-humeral rhythm, pathology (arthritic changes, AS, Spondylosis) Alteration in Tx biomechanics.
When an athlete has neck pain, it is important to address and reduce their pain.
But what other factors do we need to consider with athletes who compete in collision or combat sports? (discuss)

Differential Diagnoses

  • Facet joint sprain
  • Discogenic pain/ disc pathology
  • Arthritic changes
  • Associative muscle strain/myofascial pain
  • Concussion
  • Whiplash
  • Radiculopathy
  • Torticollis
  • Trigger point referral

Common presentation

  • Pain in Posterior/Lateral neck (Local and referred)
  • Flexion or extension intolerance
  • Acute and or chronic in nature
  • Decrease Cx ROM (Side bending or rotation)
  • Palpation can elicit pain through translation of the Cx facet joints, Traps, upper Cx erectors
  • Radicular referral following dermatome distribution
  • Radiculopathy

Clinical features

  • Occur acutely as a result of injury/trauma or develop gradually.
  • Recurrent episodes are common
  • Impacts athletes’ performance
  • Post-traumatic neck pain onset is generally associated with wider symptoms (TMJ pain, visual and auditory changes, sleeping problems)
  • Important features outside mechanical realm- Anxiety, depression and history of chronic pain may indicate more severe conditions.

Important considerations-Red flags in Athletes

  • Cx fracture
  • Neurological changes (Spinal cord compression)
  • Arterial dissection
  • Ligamentous disruption of the cervical spine (From trauma)
  • Angina
  • Malignancy


  • Somatic pain can be superficial or deep. Superficial somatic pain generally localized, sharp, well defined.
  • By contrast, deep somatic pain is poorly localized and is of dull aching quality.
  • Somatic: Spondylosis, facet joint, discogenic, myofascial


  • Neurogenic pain radiates down a sensory distribution, can be associated with weakness in upper limbs.
  • Irritation of nerve root (compression, inflammation) typically sharp and cutting in nature
  • Neurogenic: Spondylitis myelopathy, cervical radiculopathy

Athletes and mechanical Neck pain

Pathophysiology generally multifaceted in nature.
Inflammatory process following trauma.
Degenerative/spondylotic changes following overuse/trauma
Frequently, cervical radicular pain is caused by disruption of the anulus fibrosis and can lead to prolapse of IVD. Possible radiculopathy due to spinal cord compression
Facet joint degeneration, inflammation, stenosis interlinked within pathophysiology
Cervical and associative muscular atrophy and weakness.

Why is the above important?

Creates a bigger picture and direct your assessment to help develop your management and treatment plan. Keeps athletes playing, and improves ability to return to sport post injury.


Subjective/Case Hx:

Understanding the nature of sport helps immensely. (Wrestling for example) -> Transferrable knowledge to BJJ, NFL


Orthopedic/special testing (provocative)-specific
Tx Rom
Shoulder Rom
Neurological assessment if required

What does the literature say?

  • Evidently, there is an association between neck strengthening exercises/conditioning, and the decreased risk of cervical related injuries and concussion.
  • One study by Taylor et al. (2006) designed a 12-week cervical training program based on isometric and dynamic strength. The study indicated significant improvements in both avenues of strength occurring as early as 4 weeks, with modest increased in neck circumference after 12 weeks. The study was completed on Air force personnel at risk of injury due to their occupation activities (transferrable knowledge to athletes)
  • A retrospective Analysis by Naish et al. (2013) aimed to determine whether a 26-week isometric neck strengthening intervention program (13 week Strengthening, and 13-week maintenance) was effective at reducing the number and severity of cervical spine injuries.
  • Primary outcome variables included
    1.number of days lost from training and competing
    2. Severity of injury
    3. isometric strength in flexion, extension and side bending
  • Result- A significant reduction in the number of injuries was evident during the competitive season.
  • However, there is conjecture… One study by Multanen et al. 2021, completed a prospective 16-year study on the association of neck muscle strength and cervical spine mobility, with future neck pain and disability in patients.
  • This study found no evidence for an association between neck muscle strength or mobility and the occurrence in later life neck pain and disability. Therefore, relatively determining that screening healthy subjects for neck strength may not be recommended for preventative purposes of neck conditions if not competing in combat or collision sports.
  • Reiterating the importance of athlete and sport specificity and targeted approach to injury prevention.

A study by Eckner et al (2014) evaluated the effects of neck muscle strength and cervical muscle activation in response to impulsive loading to the head (impact)

It is evident that greater neck strength and activation of neck muscles to brace impact are able to reduce an athlete’s risk of concussion and cervical related injury during a collision.

It was found that both in male and female athletes across the age spectrum, greater neck strength and anticipatory cervical muscle activation can reduce the magnitude of the head’s response to impact and are modifiable risk factors for concussion and injury.

Interventions aimed at increasing athletes’ neck strength can decrease the risk of concussion.

  • Another study by Rezasoltani et al. 2005 investigated maximal isometric strength of cervical extension (ISCE) and maximimal isometric strength of cervical flexion (ISCF) in 2 groups of elite wrestlers and a group of non-athletic subjects.
  • Non-surprisingly, the ratios of cervical muscle strength to weight were significantly higher in wrestlers than non-athletic subjects.
  • Concluding that such measurements may be useful to test athletes in combat sports and help identify weakness of specific groups of muscles within the neck to aid in diversifying a management/training program.

Male to female considerations-Wrestlers

  • There are rising trends in Westling injuries presenting In emergency departments
  • A study by Hoge et al. 2020 investigate such trends, as wrestling is one of the fastest growing sports among females, especially in the U.S
  • The study compared common injuries among males and females and their presentations. The study found that female wrestlers were significantly less likely to present with fractures or head and neck injuries than males, however, were significantly more likely to present with strains/sprains.
  • RED-S?
  • It is evident that males and females possess distinctly unique physiology and anatomy, and such variances in ligamentous and muscular strength may help to explain these differences. Prompting unique/individualized managements, specific training strategies and prevention to reduce projected increases in injuries as the sport continues to develop.

Is the above relevant?


So how do we train the neck?
AROM-daily/every 2nd day
1. Supine flex and ext 1×20-40 reps
2. Supine side bending 1×20-40 reps
3. Supine rotation 1×20-40

Once the above is relatively easy, and no longer challenging. Progress with weight. – daily/every 2nd day
1. Supine flex and ext1x20-40 reps (5-10kg)
2. Banded rotations (isometric control of flexors as well)
3. Weighted side bending 2.5-5kg (1×20-40 reps)

Sport specificity within wrestling (on wrestling days, 2-3x days a week)
1. neck bridges 1×20
2. Snatch shrugs 3×10


  • Eckner, J. T., Oh, Y. K., Joshi, M. S., Richardson, J. K., & Ashton-Miller, J. A. (2014). Effect of Neck Muscle Strength and Anticipatory Cervical Muscle Activation on the Kinematic Response of the Head to Impulsive Loads. The American Journal of Sports Medicine42(3), 566–576. https://doi.org/10.1177/0363546513517869
  • Hoge, C., Pirruccio, K., Cohen, O., & Kelly, J. (2021). Rising Trends in Wrestling-associated Injuries in Females Presenting to US Emergency Departments. Western Journal of Emergency Medicine22(2). https://doi.org/10.5811/westjem.2020.9.48490
  • Multanen, J., Häkkinen, A., Kautiainen, H., & Ylinen, J. (2021). Associations of neck muscle strength and cervical spine mobility with future neck pain and disability: a prospective 16-year study. BMC Musculoskeletal Disorders22(1). https://doi.org/10.1186/s12891-021-04807-3
  • Naish, R., Burnett, A., Burrows, S., Andrews, W., & Appleby, B. (2013). Can a Specific Neck Strengthening Program Decrease Cervical Spine Injuries in a Men’s Professional Rugby Union Team? A Retrospective Analysis. Journal of Sports Science & Medicine12(3), 542–550. https://pubmed.ncbi.nlm.nih.gov/24149163/
  • Rezasoltani, A. (2005). Cervical muscle strength measurement in two groups of elite Greco-Roman and free style wrestlers and a group of non-athletic subjects * Commentary. British Journal of Sports Medicine39(7), 440–443. https://doi.org/10.1136/bjsm.2004.013961
  • Taylor, M. K., Hodgdon, J. A., Griswold, L., Miller, A., Roberts, D. E., & Escamilla, R. F. (2006). Cervical resistance training: effects on isometric and dynamic strength. Aviation, Space, and Environmental Medicine77(11), 1131–1135. https://pubmed.ncbi.nlm.nih.gov/17086765/