Tight Hip Flexors . . . A Pain In the Neck?

Last week a patient came to me with an acute episode of neck pain and discomfort.  She reported having this problem before, and episodes have become more frequent.  The pain always occurred on the right side of her neck.  Her aggravating factors were; sitting at a computer and walking for long distances.  Her past medical history including chronic groin pain on the right side for 5 years for which she has received intermittent episodes of treatment.  Another patient was an airline maintenance worker who spent many hours in a long sitting position, had chronic neck pain.  He reported most significant relief when therapists would perform manual therapy on the hips as opposed to the neck.

With regard to physical therapy interventions of the neck, there are many approaches and techniques that are widely used.  Joint mobilization (Maitland/Mulligan/Paris), trigger point therapy (Travell/Simons), correction of postural dysfunction (McKenzie) etc, are used extensively in PT clinics.  While these techniques often provide good relief in terms of pain and functional improvement, some patients continue to develop recurrent issues.

When it occurs unilaterally and certain movements aggravate it, of course one must consider underlying biomechanical factors.  The idea of assessing the psoas as a possible underlying factor in the development of chronic neck pain is not new.  Various authors have described postural dysfunction, for example upper and lower crossed syndrome (Janda/Levitt) which describe how certain muscles are prone to developing tightness/overactivity, and certain muscles are prone to developing weakness/inhibition.  The idea of postural evaluation is standard in all schools of PT.  As therapists though, we can sometimes be too “zoned in” on the problem area, and not fully appreciate the contribution of other body parts to a dysfunction.  Tightness in the psoas and overlying fascia can pull the thorax forward, and create forward head posture, resulting in increased tension in the posterior neck muscles, as they attempt to compensate for forward head posture.

I have noticed over the years that the psoas, plays a large role in mechanical dysfunction, and affects lower back pain, knee pain and other dysfunction.  I began to collect data (therapist blinded) in patients that were office workers, looking at unilateral neck pain, and side to side difference in Thomas test.  28 of 30 subjects (93.3%) had a more positive Thomas test on the side of neck pain.  The other 2 subjects had no difference side to side.  While there appears to be a clinically significant correlation between neck pain and a positive Thomas Test, more research is needed with good clinical RCT’s to demonstrate a correlation.  Hopefully this post will help to stimulate a more global approach when dealing with chronic pain.  Clinically if a patient is hypersensitive to touch in the cervical spine, trigger point release of the psoas can provide a reduction in sensitivity.  I encourage therapists to s tart performing Thomas tests on your patients who describe unilateral neck pain, especially if they have a history of a hip injury, and see what you find.