If I asked you what you’d work on in order to improve your athlete’s performance, what would your answer be? I hope you thought to yourself: it depends. Yes, indeed. But let’s keep it general, what is foundational?
If you answered clearing the cervical spine, good for you, 10 points for Gryffondor! But let’s be honest, the neck is not quite the first thing that comes to mind when we think about improving performance.
the cervical spine is at the foundation of many movements and has a huge trickle-down effect on other structures
The neck has a strong relationship with the thoracic spine and is the home of the brachial plexus, which innervates the entire upper extremities.
Poor cervical spine rotation is going to limit thoracic rotation, and a stiff or poorly aligned neck could create congestion of the vascular and nervous structures that originate at the cervical spine, impairing motor control and strength.
As you can see, impairment to the cervical spine could definitely limit performance. This is why it is so important to screen for, identify and address cervical spine mobility issues as part of the foundation for performance and prevention.
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Movement Impairments of the Cervical Spine
The common theme in the movement impairments of the cervical spine is that the superficial muscles get dominant over the deep ones, which affects the precision of movement. The most common muscles that create issues are the sternocleidomastoid, the scalenes, and the levator scapulae.
Observing posture and screening active range of motion of the cervical spine in flexion, extension and rotation can highlight several movement impairments:
Cervical extension-rotation: Forward head posture with asymmetry in cervical musculature and scapula alignment. Pain with rotation, ipsilateral side bending and extension.
Cervical extension: Forward head. Pain with extension.
Cervical flexion-rotation: Decreased cervical lordosis and flat thoracic spine. Pain with rotation and ipsilateral flexion.
Cervical flexion: Decreased cervical lordosis and flat thoracic spine. Pain with flexion.
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Cervical spine and thoracic spine
The thoracic spine is going to have an effect on the cervical spine in a bunch of different ways, but we’re going to look at the opposite relationship here.
Limited cervical spine rotation to one side is going to limit thoracic spine rotation to the other side
This concept is accentuated by any athlete who needs to track objects while running, such as football receivers who need to track the ball over their shoulder.
The idea is taken a step further with rotational athletes. A left-handed hockey player winding up for a slap shot is going to need cervical rotation to the right as he loads with thoracic spine rotated to the left. The opposite is going to happen as he lets go of the rubber band and strikes the puck, as depicted in the image below:
For a better understanding of what I mean by letting go of the rubber band, head to our article: Nevermind Your Six-pack: Can You Use Your Obliques?
For throwing athletes, like baseball pitchers, as the head tracks the target on one side, the thoracic spine loads to the opposite side. If the neck can’t rotate properly, the body will self-organize around that, most likely by flying open early. This will impact timing of the throw and performance. Plus, it will likely result in increased stress in other structure, such as the shoulder and elbow.
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Here is an example of an athlete with limited cervical rotation range of motion:
The athlete in this video has a history of elbow pain when throwing early in the season for the past 3 years. He was given exercises to strengthen his elbow joint in the past, but the issue keeps coming back. This could be caused by many factors obviously, including his elbow, but we can’t ignore that his lack of cervical spine rotation could have an effect on that, especially since we also found that his thoracic spine rotation was limited. The plan of action here is to optimize cervical as well as thoracic range of motion, which in turn, will offload the elbow.
It’s an interesting case for which we’ll most certainly have a follow-up article.
Cervical spine and the shoulder girdle
Two large muscles originating at the neck contribute to supporting the weight of the arms: the upper trapezius and the levator scapula. We often see upper crossed syndrome with rounded shoulders resulting in forward head posture. The protective tension in the upper trapezius muscles creates compression at the cervical spine, which can restrict range of motion and cause pain. To maintain the eyes level, cervical extension occurs, and the levator scapula becomes short pulling the scapula in downward rotation.
That’s going to be a painful area for most of these individuals which can be assessed on palpation. But when screening cervical rotation or flexion, we will often also see the scapula move with it.
For overhead athletes, such findings need to be addressed in order to ensure not only optimal rotation, but also optimal shoulder upward rotation. Eric Cressey would tell you that scapular downward rotation is like starting a race 10 meters behind the line.
As you can see, proper shoulder function is linked to proper neck function, and vice versa.
All the more reason to integrate all of those components to our rehab or our training. #rehabistraining!
Cervical spine and the elbow
Here’s a cool little story. One of our guys playing college baseball had medial elbow pain right at the ulnar collateral ligament during his season. Obviously, it hurt to throw and we suspected a sprained UCL.
He went for a consult and an MRI, which came back clear. This came as a surprise, but since he was cleared, it made sense to get him progressively back to throwing. When he started the throwing program, the pain was still there. He consulted a second time and went through further testing. Everything still came back negative. Needless to say, this left us confused at what was actually causing his pain, which continued to be in the region of the UCL.
After a thorough discussion about his pain, a look at his posture, and an assessment of cervical spine and scapulothoracic function, we observed that the shoulder girdle was significantly depressed, and it was taking the clavicle with it. Suddenly, it all became clearer. We were looking at referred pain from a neurogenic thoracic outlet syndrome. The nerves were getting caught up between the first rib, the scalenes, and the clavicle, which was causing referred pain down to the elbow. This also made sense of his self-report of occasional cramps and a burning sensation in the anterior neck region.
All of those expensive tests couldn’t see that though. An understanding of the foundational role of the cervical spine and its relationship with the upper extremities helped us make that link. More importantly, no amount of resting the elbow would have really solved the problem.
A 30-second screen to avoid regrets
Suffice it to say, any assessment should involve clearing of the cervical spine at some point. It’s quick and there is no good reason to skip it. We all need to use our cervical spine a significant amount in our activities of daily living, simply to look over our shoulder or to position ourselves to hear things better. If you’ve ever experienced a torticolis, you’ll know how important cervical spine range of motion is. It’s foundational.
It’s so foundational that even if someone is asymptomatic, it makes a lot of sense to take 30 seconds and clear the cervical spine. As a former athlete, the last thing I would have wanted is to have something limiting my performance that could have easily been found and just as easily fixed, but that I just didn’t know about. I wouldn’t be able to live with myself knowing that I didn’t take care of something and it came right back to bite me in the ass.
Impairment to the cervical spine can significantly limit performance, yet it literally takes 30 seconds to screen. Investing that 30 seconds is well worth the outcomes in terms of both prevention and performance.
1. Sahrmann S, Associates. Movement System Impairment Syndromes of the Extremities, Cervical and Thoracic Spines; Considerations for Acute and Long-Term Management. Elsevier; 2011.
2. Cervico-ocular Reflex Is Increased in People With Nonspecific Neck Pain | Physical Therapy | Oxford Academic. Accessed April 16, 2021. https://academic.oup.com/ptj/article/96/8/1190/2864879
3. Anatomy and clinical relevance of sub occipital soft tissue connections with the dura mater in the upper cervical spine. Accessed April 16, 2021. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7425638/
in collaboration with Mai-Linh Dovan M.SC., CAT(C)
Marc-Antoine has been involved in baseball for many years. He played within Baseball Québec’s structure, at Northeastern Oklahoma A&M College and the University of Pittsburgh. In 2015, he was selected in the MLB Draft by the Oakland Athletics. Since retiring, Marc-Antoine has been transmitting his passion to young prospects as the pitching coach for the Académie Baseball Canada.