What is mechanical neck pain?

Mechanical Neck Pain

Mechanical neck pain is a common musculoskeletal condition characterized by pain associated with facet joints, intervertebral discs, muscles, or fascia in the cervical region, without signs of serious pathology or neurological involvement. 1

Definition and Classification

Mechanical neck pain is distinguished from other types of neck pain by:

• Pain primarily related to mechanical structures (joints, discs, muscles, fascia)
• Absence of serious underlying pathology (infection, malignancy, inflammatory disorders)
• Often associated with mobility deficits
• May present with or without referred pain

The American College of Radiology differentiates mechanical neck pain from cervical radiculopathy and other serious pathologies by categorizing neck pain into four grades 1, 2:

• Grade I: Neck pain with no signs of major pathology and minimal interference with daily activities
• Grade II: Neck pain with no signs of major pathology but significant interference with daily activities
• Grade III: Neck pain with neurological signs of nerve compression
• Grade IV: Neck pain with signs of major pathology

Clinical Presentation

Patients with mechanical neck pain typically present with:

• Local pain in the cervical region
• Pain that may be exacerbated by certain movements or postures
• Limited range of motion
• Muscle tenderness or spasm
• Possible referred pain to shoulders or upper back
• Absence of neurological deficits (distinguishing it from radiculopathy)

Etiology and Risk Factors

Common causes and contributing factors include:

• Poor posture, particularly forward head posture
• Thoracic spine dysfunction and increased kyphosis 3
• Occupational factors (prolonged sitting, computer work)
• Muscle imbalances and weakness
• Previous neck injury
• Stress and psychological factors
• Age-related degenerative changes

Assessment

Assessment should focus on differentiating mechanical neck pain from more serious conditions:

• Red flags requiring immediate attention include 2:

  • History of trauma
  • History of cancer or unexplained weight loss
  • Fever or signs of infection
  • Progressive neurological deficits
  • Bladder/bowel dysfunction
  • Severe unremitting night pain
  • Age >50 with vascular disease risk factors

• Physical examination should assess:

  • Cervical range of motion
  • Palpation for tenderness
  • Muscle strength
  • Neurological examination (sensory, motor, reflexes)
  • Thoracic spine posture and mobility 3

Management

Evidence-based management strategies for mechanical neck pain include:

First-line Approaches

1. Education and self-management 1

   • Reassurance about benign nature
   • Activity modification while maintaining function
   • Advice to stay active (recommended in 99.1% of cases) 4

2. Exercise therapy 1

   • Scapular resistance exercises (used in 89.3% of cases) 4
   • Neck-specific exercises
   • Postural correction exercises
   • General physical activity

3. Manual therapy

   • Cervical mobilization (used in 47.8% of cases) 4
   • Thoracic manipulation (underutilized at only 4.5% despite recommendations) 4

Pharmacological Management

• NSAIDs: Use at lowest effective dose for shortest duration 2
• Muscle relaxants: For short-term use in acute cases with muscle spasm
• Opioids: Should be used with tight restrictions, at lowest dose possible for shortest time 2
• Paracetamol: Not recommended as a single medication for low back pain; similar caution may apply to neck pain 1

Additional Interventions

• Dry needling: Used in 22.8% of cases, may help with pain and quality of life 4, 5
• Kinesiotaping: May improve range of motion and decrease disability 5
• TENS: Used in 12.5% of cases, but evidence is limited 4
• Heat or cold: May provide symptomatic relief

Imaging

For uncomplicated mechanical neck pain (Grade I and II), imaging is generally not indicated. Imaging should be reserved for 1, 2:

• Persistent symptoms despite conservative management
• Presence of red flags
• Suspected neurological involvement
• Planning for interventional procedures

When imaging is indicated, MRI is preferred due to superior soft-tissue resolution and ability to evaluate potential nerve compression 2.

Prognosis

Most episodes of mechanical neck pain resolve within days to weeks with appropriate management. However, approximately 10% of cases may become chronic 6. Factors associated with poorer outcomes include:

• Longer duration of symptoms
• Higher initial pain intensity
• Previous episodes of neck pain
• Psychological factors (anxiety, depression, catastrophizing)

Common Pitfalls in Management

1. Overreliance on passive treatments rather than active self-management strategies
2. Unnecessary imaging for uncomplicated mechanical neck pain
3. Inadequate assessment of thoracic spine despite its relationship to cervical dysfunction 3
4. Underutilization of thoracic manipulation despite evidence supporting its use 4
5. Overuse of opioids for pain management

By understanding the nature of mechanical neck pain and implementing evidence-based management strategies, clinicians can help patients achieve pain relief and improved function while avoiding unnecessary interventions and potential complications.