Sue Falsone: Problems at the Head, Neck, Shoulders and Torso

Do your clients complain of tension headaches or sub-occipital headaches?
Do you, personally, have headaches?

Let’s look at the structure in that area that can lead to problems. We have so many muscles in the top part of the neck and that can become an issue. We can’t just think, “That’s neck pain,” because the pain can be coming from anywhere. It’s a complicated area that also has a ton of muscles attached onto it. We also have to look at shoulder function, cervical function, thoracic and rib function—the whole picture.

How many of your clients have pain in the cervical spine area? That’s where people hold their tension, whether it’s emotional stress or stress from a job, money, family or other stresses in life. Many people have issues in this region and that can be caused by many different things.

The c-spine was built for mobility, but it also has an element of stability to it. We also need rotation all the way down to T4. Then we’ve got the thoracic spine, which can have issues at the vertebrae or in the discs or joints. The thoracic spine is attached to the ribs, and the ribs need mobility to breathe well and give us proper posture.

In terms of functional significance, the lower c-spine needs mobility, but the upper t-spine needs rigidity. The second, third and fourth ribs are stiff so we can have optimal shoulder mobility.

The cervical thoracic junction has the scapula sitting on top of it. Even though the only bony connection of the scapula to this area is at the AC joint, there’s massive muscular connection from the shoulder blade to the cervical thoracic junction.

The diaphragm is used as both a respirator and as a stabilizer. The body will always choose breath over stability, but the diaphragm really needs to act in both capacities. That comes into play again at the lumbar spine—the diaphragm connects all the way down to L3. The lumbar spine is connected to the thoracic spine; we’re looking at one big cogwheel after another.

Spinal Anatomy and Function
When we break down the anatomy of the cervical spine, there are a lot of different things going on. Cervical lordosis is supposed to be there, just as lumbar lordosis is supposed to exist in the lumbar region. We’re not supposed to have a “flat back.” We’re supposed to have curves in the spine, which are there to help dissipate force.

Picture slamming a slinky into the ground. The slinky absorbs force. It’s the same in the spine. As we’re walking, it absorbs a little bit of the force and it dissipates it.

This all fits together. If a person’s head is jutted forward, that puts a lot of pressure on the neck muscles. If it’s too far back, it starts to put a lot of stress on the low back. Everybody’s neutral spine is a little bit different, but the curves are supposed to be there.

The discs in the neck are tiny, and the discs in the thoracic spine are a little bigger but aren’t quite as thick as those in the lumbar spine. In the cervical spine, we have a really tiny vertebral body compared to the really large lumbar vertebral body that has to accept and take a lot of weight.

These facet joints move more in the transverse plane. Then, as we look lower, they start to move a little more in the sagittal and frontal planes.

Rotation belongs in the transverse plane. In the thoracic spine, we start to get more into the frontal plane—side to side motion. Then lower in the lumbar spine, we get into the sagittal plane, where we find flexion and extension. We don’t want to get a lot of lumbar rotation. If we try to rotate at those joints, they’re going to bump into each other and cause some degeneration. Whereas in the cervical spine, we have a lot of rotation; anatomically, we are set up for these motions. You can see how the vertebrae are built for certain movements.

The thoracic spine is really good for side bending, but the ribs gets in the way. We have a limited amount of side bending because of the ribs. You can see that we have to think about how the anatomy and structure affects function.

There are five lumbar vertebrae, with two degrees of rotation at each one. That’s about 10 degrees of rotation at the lumbar spine. It’s not that we don’t want rotation—there will be a little bit of rotation, but we don’t want to exaggerate it. It’s not built for it.

At the thoracic spine, there’s a little bit more than two degrees of rotation, but there are 12 of them, so there’s 24 degrees of rotation at the thoracic spine. At the hips, from a book standpoint, external and internal rotation is 45 degrees, so we have 90 degrees of rotation at the hip. At the lumbar spine, we have about 10 and at the thoracic spine, 24—two times the amount of at the lumbar spine, and at the hip there’s nine times the amount of rotation than a lumbar spine.

Where do we want to get most of the rotation in total body movement? The hips are number one and the thoracic spine is number two. The lumbar spine is the last place we want to get rotation from. Pay attention to how this anatomy can affect function and use that knowledge in your exercise selection.


Neck and Shoulder Function
When we talk about the shoulder, what’s going on at the mid back? What’s going on at the neck? The lower cervical spine needs mobility and the upper thoracic spine needs some rigidity, relative to each other.

You’ve heard the phrase, “You need proximal stability for distal mobility.” We need a stable torso in order to move the distal segment. The shoulder blade is only attached to the body by a muscle, with the exception of the AC joint. We need really good scapular control and muscular control at the shoulder blade in order to have proper shoulder and arm function. The upper back has to have some rigidity to it so those muscles can pull from something.

When we look at the neck, there are at least 10 muscles on each side of the collarbone, so at least 20 muscles. That’s a lot of muscles in one area. We have 10 muscles at the base of the head, just between the base of the head and first vertebrae. That’s important because there are a lot of proprioceptors in muscle and in all those little ligaments. Proprioceptors are what tell us where the body is in space. We have the greatest number of proprioceptors in the head and neck, in the low back and in the feet.

How many of your clients have neck, low back or foot dysfunction? Every person who walks through your door, probably. Right out of the gate, they are walking in with an unawareness of where they are in space. Then they step off a curb and sprain an ankle. Maybe they run into a door because they don’t know where they are in space. We need to be able to correct that. We need help get those proprioceptors activating and working. Fundamentally, that’s the number one thing for them to learn and do.

Many tiny little muscles are really close to joints. That means it doesn’t require big movements to activate them. In fact, they need small, tiny movements.

There’s a time and a place for mobility work. There’s a time and place for stability work. If you need to work on power with your athletes, this might not be the thing you need to work on.

But if your athlete or client comes to you in pain, movement will never be normal in the presence of pain. Unfortunately, people are walking into your facilities in pain. You’ve got to deal with it. Sometimes a little bit of the prehab or a little bit of the proprioceptive work at the beginning of the workouts can help set them up for success.

Then we have the muscles that stick out near the neck—the sternocleidomastoid, the traps . . . all big muscles you’re familiar with. These are all about general movement.

This is a big area for tension. People will say, “I get tension headaches,” or “I just feel tight here.” We foam roll, we massage stick, we trigger point it—there’s just tension there. No matter how much we stretch, no matter how much we massage, that tension never goes away. Or it feels better for 30 minutes and then that tension always seems to come back.

Tension is just a misinterpretation of movement. Tension is when a body starts to feel like it’s going to move, but then no movement is created—that’s tension.

Think about starting to stand up. What would you do? You’d get your feet underneath you; you would start to create a little tension, but you wouldn’t lift yourself off the chair. That’s tension; the same thing happens in the neck and shoulders area. We have created tension; the body is trying to create stability in an area where it doesn’t have any.

That’s the beauty of the body. It will figure out how to get something done. That’s why great athletes are great athletes. They are great compensators; they’re going to figure out how to do something. It’s the same with the body.

If you think of the digestive tube—we have one long tube that goes from the mouth into the esophagus, stomach, intestines . . . all the way down into our colon and rectum. If there is no tension in one section, tension will be created at the other end because we need proximal stability for distal mobility.

If you are neurologically intact, you need to have distal mobility so you can have proximal stability.

How many of your clients don’t have good lumbar stability? A lot. If they don’t have stability at the lumbar, they’re going to create stability above or below. We need a stability point in order to walk and that’s now going to be at the shoulders—they’re using the shoulders to stabilize so they can walk. That’s ridiculous, but that is what happens. The body tries to create tension.

So, not only do we need to soft tissue work, trigger point and other therapy in the neck and shoulders, we also have to do trunk stability work.

Pillar strength is so important. We have to have proper stability at the torso. If we don’t, we are going to see issues rise up everywhere. It all comes back to the center, to the core. Start with trunk stability on top of the mobility and soft tissue work you give them at the cervical region.

Above all, teach them how to breathe.

Postural Alignment
When we look at ideal postural alignment, we see everything well aligned—the whole package . . . shoulder, hip, knee, ankle . . .  a nice coactivation of extensors and flexors, abductors and adductors, external and internal rotators.

But then the person juts the head forward and all of the muscles that were resting but stable suddenly go into panic mode: “The head’s gonna fall off! Fire! Don’t let it drop! Fire! Fire! Her head’s falling off!”

We expect a massage stick to make that feel better. No! The body’s afraid the head is going fall off. That’s why we see all this tension. We’re not going to get rid of that with some soft tissue work. We’ve got to work on restoring natural alignment.

That natural alignment is when everything is working together.

Ideal alignment of upright posture

  • Co-activation of flexors and extensors
  • Co-activation of adductors and abductors
  • Co-activation of internal and external rotators

This is a little different for everybody. We have end-range flexion, end-range extension . . . somewhere in the middle is the neutral spine; that’s all neutral spine is—it’s somewhere in the middle.

Pavel Kolar talks about “the old system” in developmental kinesiology. Everything takes us back to the old system. When babies are born, they come out in a ball. That’s the old system—curled up into flexion. Then they kind of extend and flatten out as they hear and see things in their environment. They fall over and roll over to try to see or get to them. That’s how a baby develops the extensors.

When they come out, they’re one big ball; they are in a big kyphosis. Our kyphosis, as in the mid back, is a primary curve. The kyphosis in our sacrum is a primary curve. The lordosis in our neck and in our lumbar spine are secondary curves; they develop secondarily.

The first thing that happens is, we come out in a ball—primary curves. Lordosis develops after we start to fire our extensors—they’re secondary.

When balance is disturbed in the body, the “old system” takes over. This occurs with injury, central nervous dysfunction, fatigue and even fear. Everything about us takes us back to our old system; that’s what we’re programmed to do.

When we’re in pain . . .
When we’re tired . . .
If we’ve had a stroke . . .
If we have cerebral palsy . . .
If we are afraid . . .
Everything brings us back to that primary system, into that old system. Everything takes us into flexion, adduction and internal rotation.

Whether it’s neurological, orthopedic, emotion, or fatigue and energy levels—everything takes us to that old system of flexion, internal rotation and adduction.

That’s why so much of our workout or rehab programming focuses on the new system. We look to reprogramming the extensors, the external rotators and the abductors because primitively, we instinctively want to go back to flexion, internal rotation and adduction. Our programming needs to focus on the opposite.

Now look again at the digestive tube that goes all the way down the torso. If it’s flaccid in the lower region, for stability, we’re going to create tension higher up. We’re connected mechanically.

That’s what Brueger is talking about when he discusses the “cogwheels.” It’s all about joint centration. If you have a client with tension and pain in the cervical thoracic area and you don’t address things posturally by doing some pillar strength and core work, of course you can expect continued pain. Sometimes all you do is fix what’s happening at the pelvis and lumbar spine, and you can significantly reduce the tension and pain at the neck. It’s how it all works together.

My thought becomes my strategy. My strategy becomes a habit.

Your habit starts to become your posture. Your posture becomes structure. You do it long enough, you will ossify that way. If you get to a point of structural impairment, it’s going to be really hard to change.

If you work with elderly people who are bent somewhat parallel to the ground, there’s nothing you can do for them at that point. There’s just nothing you can do. We have to prevent that from happening in the first place.

The bottom line is to teach the opposite of what people naturally want to do.We want to restore thoracic mobility, especially extension and rotation, because those are part of that newer system.

Lumbar stability and hip mobility work are necessary in a comprehensive program, just as Gray Cook and Michael Boyle talk about in the “joint by joint approach.”We want hip mobility, lumbar stability and thoracic mobility to truly get a comprehensive program we’re all looking for.

 If you have any questions, please feel free to follow and tag me with your questions on Twitter, @suefalsone. My new book, Bridging the Gap from Rehab to Performance, dives deeper into these topics and will help you understand these issues more fully.


Sue Falsone Bridging the Gap from Rehab to Performance

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In Bridging the Gap from Rehab to Performance, physical therapist Sue Falsone walks the reader through the thought process and physical practice of guiding an injured athlete from injury through rehab and back to the field of play. To both health care professionals and strength and conditioning experts alike, she describes the path as her athletes move through pain and healing toward optimal function and advanced performance.

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Sue Falsone The Cervical Thoracic Junction Video

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The cervical thoracic junction is an easily overlooked area that can cause significant problems in the surrounding areas, including shoulder tension and neck pain. Sue Falsone takes her experience working with high caliber athletes and demonstrates practical exercises and strategies you can use to alleviate problems in this area of the body.

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Sue Falsone Thoracic Spine Lecture

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Sue Falsone is known among her peers as the go-to gal for T-spine knowledge, and in this lecture, The Thoracic Spine -- The Missing Link to Core Stability, we learn how she got that reputation.

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