Acute Neck Pain
Acute neck pain is characterized by sudden onset and usually lasts less than three months. Pain may be localized to the neck or radiate to the head, shoulders and arms¹. According to NICE guidance, the prevalence of condition-specific acute neck pain ranges from 40% to 70%. Various factors, including injury, disease, degenerative changes or altered biomechanics, can place stress on the spine and trigger this type of pain. However, identifying the exact cause of the discomfort is often challenging. Potential contributors include nerve injury, scar tissue, arthritis and the emotional aspects of pain².
Functional anatomy
The cervical spine consists of several structural groups that work together to maintain function and support³ ⁴ ⁵ ⁶:
Muscles: Includes anterior, posterior and lateral muscles, as well as muscles that contribute to movement of the neck.
Ligaments: Includes the anterior and posterior longitudinal ligaments, intertransverse ligaments, ligamentum nuchae, alar ligaments, apical ligament of the dens and ligamenta flava.
Neurological and vascular structures: Includes arteries, nerves, glands and passageways that support communication and circulation.
These structural groups of the cervical spine work together to perform three main functions:
Protect the spinal cord: Provides a robust structure that protects the spinal cord from injury.
Support the head and enable movement: Provides flexibility and stability during head movement.
Provide a safe passage for the vertebral arteries: Allows blood to reach the brain safely through the vertebral arteries.
Mechanism of injury and differential diagnosis
Understanding the mechanisms behind acute neck pain and considering differential diagnoses are central parts of a physiotherapy assessment. Several factors may contribute to acute neck pain:
Cervical muscle injury: A common cause of acute neck pain, often associated with muscular overload. For example, prolonged sitting with a forward-flexed posture may lead to muscle tension and pain.
Muscle imbalance: Asymmetrical muscle training may contribute to pain. For example, excessive strengthening of the upper trapezius without corresponding strengthening of the lower trapezius may overload the upper trapezius and contribute to symptoms.
Concussion: After a concussion, patients may experience head and neck pain. Symptoms may occur immediately or develop over time and can last from a few days to months or years. Symptoms persisting for more than three months may be classified as post-concussion syndrome.
Road traffic accidents (RTA): Symptoms may occur suddenly or within several days after an accident. As with concussion, symptom duration may vary considerably.
Whiplash: This condition may occur after a road traffic accident or another type of trauma, such as a fall. Whiplash involves injury to soft tissues and can result in substantial pain and functional impairment.
These factors should be assessed carefully to rule out other possible causes of neck pain and
develop an appropriate treatment plan.
Risk factors
Identifying and understanding risk factors is important for prevention and early assessment because acute neck pain can progress to persistent or chronic symptoms. Potential contributing risk factors include:
Older age: Increasing age is associated with degenerative changes in cervical structures, which may make the neck more susceptible to pain⁷.
Sex: Women have a higher risk of developing neck pain, potentially related to differences in hormonal factors, muscle strength and biomechanics⁸.
Previous trauma: Previous injuries to the neck, shoulders or pelvis may increase the likelihood of developing neck pain because prior injury can alter tissue function or load tolerance⁹⁸.
Psychological factors: Psychosocial factors such as stress, anxiety and depression are known to influence pain perception and may be important risk factors¹⁰.
Lifestyle: Factors such as inactivity, poor posture and work-related physical demands may contribute to the development and persistence of neck pain¹⁰.
By addressing these risk factors, healthcare professionals may support better prevention and management of acute neck pain.
Classification of neck pain
According to the 2017 updated clinical practice guidelines from the Orthopaedic Section of the American Physical Therapy Association (APTA), neck pain is classified into the following categories:
Neck pain with mobility deficits
Neck pain with movement coordination impairments
Neck pain with headache
Neck pain with radiating pain
Clinical presentation
Acute neck pain can present differently between patients and often involves more than localized pain in the neck. Common associated symptoms include¹¹¹²¹³:
Referred pain: Pain may radiate to the head, shoulders, upper or lower back, and may be accompanied by radiating pain or numbness in the upper extremities. This may reflect referred or widespread pain associated with cervical innervation.
Mobility restriction: Reduced range of motion in the neck.
Coordination impairments: Problems with muscular control and coordination.
Muscle tension and spasm: Tight muscles and involuntary contractions in the cervical musculature.
Dizziness and nausea: Patients with cervical vertigo may experience these symptoms¹⁴.
Fever: May indicate an underlying infection and requires appropriate medical assessment.
Screening for red flags
Red flags are signs and symptoms identified through the patient's history and clinical examination that may indicate potentially serious or life-threatening conditions. Identifying red flags is a critical part of the assessment and should occur before further examination or treatment. If red flags are identified, they determine the need for further action. Potential red flags include:
Symptom patterns: Worsening symptoms; recent bladder or bowel dysfunction; sensory changes; unsteady gait; age over 50 years; previous cancer; unexplained weight loss; severely restricted range of motion (ROM) or severe pain; the signs known as the 5 Ds (dysarthria, diplopia, dysphagia, drop attacks and dizziness) or 3 Ns (nystagmus, numbness and nausea); body temperature above 38°C; blood pressure above 160/95; and resting heart rate above 100 bpm.
Family history: A family history of cardiovascular disease or other relevant pathology.
Cranial nerves: If cranial nerve involvement is suspected, all 12 cranial nerves should be tested.
Mechanism of injury: For example, road traffic accidents or major trauma.
Psychosocial factors: Although these are not classified as red flags, they should be considered, particularly when they interfere with sleep or activity or are associated with extreme pain.
Early identification of red flags enables prompt intervention and referral when necessary and may reduce the risk of serious complications.
Subjective assessment
A subjective assessment involves asking a range of questions to understand the patient's problems and goals. This guides the subsequent objective examination and provides information that supports accurate clinical reasoning. Questions may include:
Onset of symptoms: Is the pain acute, recurrent, sudden or chronic?
Pain characteristics: What type of pain is experienced, for example sharp, aching or burning? How severe is the pain, and when does it occur, such as at particular times of day or in specific situations? What aggravates or relieves the symptoms?
Location of pain: Where is the pain located, and does it radiate to other areas?
Previous medical history: Has the patient had previous injuries, infections or other relevant conditions that may contribute to the pain, in addition to red-flag conditions such as cancer?
Occupational history: Is the patient's work physically demanding or sedentary? This may provide insight into whether occupational factors influence symptoms.
Fever: Are there current signs of fever that may indicate an underlying infection?
Psychological symptoms: Does the patient have symptoms of anxiety or depression that may influence the pain experience?
Yellow flags: Are there factors that increase the risk of persistent symptoms, such as fear of movement, catastrophizing or poor coping strategies?
Objective assessment
The subjective assessment provides the basis for understanding the patient's presentation. The objective assessment builds on this by using specific tests and examinations. The process may include:
Screening for red flags: Before proceeding with examination, it is essential to ensure that no red flags indicate a serious condition requiring urgent intervention.
Canadian C-Spine Rule: In specific trauma cases, consider using the Canadian C-Spine Rule to determine whether imaging is required to rule out cervical fracture.
Oculomotor tests: Assess eye movements for signs of neurological abnormalities that may affect balance and coordination.
Neurological examination: Assess dermatomes, myotomes, reflexes and cranial nerves to identify possible neurological deficits.
Observation: Observe posture, movement patterns and asymmetries. Also look for visible swelling, muscle tension or deformity.
Palpation: Assess muscles, joints and other structures for tenderness, increased tone or other abnormal findings.
Cervical range of motion (ROM): Assess both active and passive range of motion to identify restrictions and pain associated with specific movements.
Muscle strength: Assess the strength of the cervical musculature and related muscle groups to identify weakness or asymmetry.
Special tests: Perform relevant special tests when indicated to support or exclude specific diagnoses, such as Spurling's test for radiculopathy or the alar ligament test for instability.
Neck Disability Index (NDI): Use this outcome measure to assess functional limitations related to neck pain. The NDI provides a quantifiable measure of functional status and can help monitor treatment progress.
Treatment and management
If red flags are identified, the patient should be referred promptly or receive urgent medical assessment. For patients without red flags, NICE guidance and other research support the following approaches to the management of acute neck pain¹⁵ ¹⁶ ¹⁷:
Reassurance: Reassure the patient and explain that the condition is often self-limiting and commonly improves with appropriate management. A positive and supportive approach may reduce anxiety and promote recovery.
Early exercise: Based on findings from the objective assessment, NHS guidance recommends early exercises to improve mobility and reduce pain. This may include range-of-motion exercises that gradually progress to more resistance-based exercise as symptoms improve.
Advice and education: Give practical advice, such as using a supportive pillow and remaining active within tolerable limits. Modified activity is generally encouraged rather than complete rest, as movement can support circulation and recovery.
Manual therapy: Techniques such as joint mobilization, myofascial techniques and soft-tissue massage may be used to reduce muscle tension, improve range of motion and relieve pain when clinically appropriate.
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