Neck disc injuries are a common cause of neck pain with associated arm pain and pain around your shoulder blade. In some cases you may even have pain in your arm and/or around the shoulder blade, but no neck pain. When you have a cervical disc bulge it can cause pressure on pain sensitive structures, like nerves, in the area . This causes a sharp, severe pain in and around your neck.
This condition is also known as a slipped disc in the neck or a cervical disc herniation. The pain from a neck disc injury feels like a constant stiffness or discomfort which can last for days, weeks or even years. Physiotherapy treatment can help you if you have any of these symptoms!
What are cervical discs and what do they do?
Cervical discs have a strong outer “shell” of connective tissue called the annulus fibrosus. This shell is responsible for keeping the soft inner core contained within its borders. The inner core is a jelly-like substance called the nucleus pulposus that reacts to the movements of your neck to distribute forces going through the cervical vertebrae – like a shock absorber. A neck disc injury is when there is damage to these “cushions” between the vertebrae in your neck.
What happens when you injure a disc in your neck?
A neck disc injury or cervical disc herniation happens when there is a tear in the outer shell of the disc, causing the inner core to bulge out. This injury causes swelling and inflammation in the area which irritates the nerves in your neck. In some cases this bulge of the inner core causes pressure on the nerves exiting the spinal cord at that level.
The disc deforms like a squashed water balloon and there are different degrees of severity to the injury.
- Disc bulge – Depending on the position of your neck and pressure on it, the disc pushes outwards like a lump that sticks out of its normal space. The cervical disc is still able to return to its normal position. Fleeting pain that comes and goes is the key sign as this stage.
- Disc herniation – The outer shell that should contain the inner nucleus tears. This allows the disc to push out even further.
- Disc sequestration – This is when the lump gets pinching off and detaches causing a ‘loose fragment’ of the disc next to the spinal nerves or spinal column. At this stage it’s unable to return to it’s original position.
There is always referred pain along the level of the involved cervical nerves, running to the shoulder, arm or upper back (between or underneath the shoulder blades). This is due to swelling and inflammation which irritates the nerve or the herniated disc putting pressure on the nerve.
Causes of a slipped disc
The cervical discs’ outer fibrous layers tear due to looking down repeatedly (cervical flexion movements). These layers are tightly arranged against each other. When this outer layer tears, it allows the nucleus pulposus to push out onto the spinal cord and cervical nerves, like jelly squeezing out of bread.
Neck disc injuries can be either acute (sudden onset) or chronic (develops over time).
- An acute slipped disc in your neck may be caused by sleeping in an awkward position, sudden forceful bending your neck forward like sneezing or hit on the back of your head. This is common in trauma such as whiplash injuries.
- Chronic neck disc injuries are usually due to repetitive strain like keeping the neck bent forwards for long periods of time e.g. reading a book, dentists leaning over their patients, surgeons staring down for hours each day, nail technicians, etc.
How bad is it?
Acute neck disc injuries have a sudden onset e.g. waking up with neck/arm pain, after a car accident etc. Pain is severe and constant. Often people will seek help for the searing arm pain without necessarily experiencing neck pain. You could also feel pins and needles down the arm and means there is nerve irritation at the level of the neck. If this is the case there isn’t necessarily pressure on the nerve, but the swelling and inflammation where the nerve leaves the spinal cord causes symptoms. This swelling and inflammation is caused by cervical disc bulges to the left or right (lateral disc bulge) where the nerves exit the spinal cord.
In the case of pressure on the nerve you will have numbness in the arm and, in worse cases, loss of power. The pressure is caused by a disc sequestration towards the middle (central disc bulge) where the spinal cord is. This means the arm will feel weak and you could notice that you have trouble lifting the arm or that your hands feel clumsy. If you have these symptoms with severe pain in the arm you should call us as soon as possible as it can lead to permanent nerve damage.
What happens if I ignore it?
If you have a herniated disc in your neck, this means it’s 25% or less the size of the main jelly-like nucleus. You will have mild symptoms, but if you don’t attend to the injury it could get worse. When you continue activities that make the neck disc herniation worse, it could progress to a disc bulge. A disc bulge means the “slipped area” is more than 25% the size of the nucleus. You’ll notice that your symptoms are getting worse.
If a disc herniation gets worse you will have a disc sequestration. This means that the part of the nucleus that bulged actually separates from the main part in the disc. The result is a “loose fragment” that puts pressure on nerves, or in more severe cases, the spinal cord. Our physiotherapist can do a physical assessment to determine where and to which extent the neck disc is putting pressure on your nerves.
Diagnosis of a neck disc injury
Physiotherapists are able to accurately determine the severity (how bad) and at which level the disc(C1-T1) is bulging or prolapsed. We assess the neck with specific tests and palpation (pressure on the different levels). If you experience arm pain we will also test the shoulder by stressing the muscles and joint to determine the exact cause of your pain. In doing so we can eliminate your shoulder as a contributing factor and focus on the main cause of the problem.
We’ll do a neurological assessment to establish the extent of the nerve involvement that could be caused by a pinched nerve in your neck. Also, we determine which level of the disc and nerve/s are involved. Physiotherapists are first line practitioners, so we are more than capable of dealing with a slipped disc in your neck, and even refer you if you need further imaging, medication or surgery.
MRI
An MRI is the best way to visualize herniated discs in your neck. This would be the investigation of choice, but before you go off and get an expensive MRI – we urge you to allow us to pin-point the level that must be targeted during the investigation. This will help to zoom in on the problem area.
X-rays
X-rays are not useful with neck disc injuries as only your bones show up on X-rays. It may however give us an indication of disc degeneration or other conditions. In the case of trauma, X-rays will be useful to rule out any fractures.
CT scan
A CT scan may be useful to identify the slipped disc in your neck, but it’s difficult to identify the nerve roots and its close relationship with the disc putting pressure on these nerves. If you suspect a slipped disc in your neck, especially if you’re feeling nerve pain, an MRI will prove to be much more valuable than CT scans.
Our personal experience with slipped discs
Most patients presenting with a cervical disc herniation complains of the referred pain in the arm more than the initial neck pain itself. The patients are more concerned about the pain in their upper back, shoulder and arm. We tend to find that general practitioners refer the patient to us due to “severe neck spasms” or sending them for a sonar of the shoulder (which turns out to be perfectly normal). Only when we start investigating the neck area, we reproduce your shoulder and arm pain. This just shows that the root of the problem is in your neck and not your shoulder or arm.
Treating your arm or shoulder may sometimes give temporary relief, due to overflow to your neck, but without treating your neck – your pain will not subside.
Another problem we see with neck disc injuries is that people either do not seek help at all or they do not complete rehabilitation. If the problem worsens over time they end up having surgery, adding more scarring to an already injured area. The end result is neck stiffness and a longer rehabilitation period.
What about “self-treatment”?
One of the most common problems we encounter that slows the healing process is the time it takes for patients to seek treatment. In many cases patients think that they are experiencing neck muscle spasms, they dose themselves with muscle relaxants and anti-inflammatory medications. Medication will only mask the problem, but when the medication wears off the pain will return.
Some patients buy soft collars at the pharmacy to help with pain relief. These can give you temporary relief by taking load off the muscles, but what we see is that people start to depend on this “support”. The muscles around the neck get weaker the longer you use the collar and the neck will get more stiff because it’s not moving. The neck discs need movement to stay healthy, so prolonged use of a collar will have a negative effect on healing.
The same principle applies to slings for the arm pain. However, an arm sling will not provide much relief, because the pain isn’t caused by the shoulder. A sling will cause the muscles around the shoulder to become weak and it encourages the wrong position of the shoulder.
Physiotherapy treatment for a neck disc injury
At first physiotherapy involves education and techniques for pain relief.
- Soft tissue massage of the muscles around the neck
- Electrotherapy is effective in relieving some of the pain
- Ultrasound is used to accelerate the healing of the cells
- Strapping and taping can redistribute the forces in the neck to minimize the pressure put on the disc
- Cervical joint mobilizations are very effective for pain relief
- Traction is an old-school technique yet still very effective for treating cervical discs
- Dry needling is used to stimulate the healing process within your body and to localize a cellular response
- Neck exercises like Mackenzie mobilizations are used to maintain the disc position
- As soon as pain allows we will start with gentle exercises to strengthen the neck muscles
- We will guide you through this process and ultimately prevent it from reoccurring. If necessary we can refer you for imaging or to a specialist.
Treatment will include identifying contributing factors aggravating the pain or causing recurrence of the injury. This may be sleeping position, workstation setup putting strain on the neck, muscle imbalances which may lead muscle spasm as some muscles work “harder” to compensate or stiffness of the neck which may put even more strain on an already injured disc.
Neck disc herniations do heal, but patients usually have repeated episodes of pain and stiffness over time. We aim to find the cause of the problem and activities that will make the pain come back again. During treatment we will teach you how to take care of your neck to prevent further episodes of pain.
Healing time
The faster we can attend to a herniated disc in the neck, the shorter the healing time. Firstly, we will treat the swelling and inflammation in the area and this process can take between 3 days and 2 weeks. Pain can take 6-8 weeks to go away completely, even though the initial severe pain will gradually subside within the first 2 weeks.
Your intense pain will improve and be replaced by stiffness. As the healing process continues, you will feel more stiffness, rather than pain. However, the torn outer layers of connective tissue may not be fully healed when pain subsides, so it is very important to complete our rehabilitation program.
The disc is especially vulnerable to re-injury during the first 6 weeks. Repeated episodes of injury to the disc leads to disc degeneration as the disc loses some of its height, which in turn could lead to more compression which ends up putting pressure on nerves.
Phases of rehabilitation
1st Phase: Protection & initial Healing – day 1-3
Protect
Avoid activities that aggravate your symptoms like looking down for prolonged periods of time or looking over your shoulder. A soft collar may be useful for 2 or 3 days during this phase.
Rest
Do not train during this phase and also avoid picking up heavy objects. The nervous system is already irritated due to the injury and picking up heavy objects creates more tension in the nerves going down the arm.
Medication
Anti-inflammatory and pain medication will help with pain relief during this phase.
2nd Phase: Regain full range of motion – week 1
The first aim of treatment will be to restore normal, pain free movements of the neck. We use massage, joint mobilisation, neural mobilisation techniques and isometric exercises (without movement) during this phase. Exercises to activate the deep stabilising muscles of the neck are especially important during this phase.
After this phase of rehabilitation you should have a significant decrease in symptoms and be able to complete most daily activities with minimal pain. Once you have full movement of the neck you will progress to the neck phase of rehabilitation.
3rd Phase: Restore muscle strength – week 2-3
After the range of movement of the neck has been restored the next phase of rehabilitation will involve strengthening the muscles around the neck. This part or treatment is important to improve stability of the neck and prevent re-injury. Initial strengthening will be without resistance. As muscle strength and pain improve resistance bands will be added for further strengthening.
At the end of this phase of rehabilitation you should be able to complete daily activities without pain and be able to start light weight-training or jogging. Once you have sufficient muscle strength through the whole range of movement of the neck you will progress to the next phase of rehabilitation.
4th Phase: Restore and improve neurodynamics – week 3
All the nerves in the body are connected to form one big system – from the brain to fingertips and toes. When you have a slipped disc in your neck, the swelling, inflammation and scarring affects the way nerves move in the body (neurodynamics). This causes nerve symptoms in your arm like pins and needles or numbness.
During this phase of rehabilitation we will add specific exercises to restore neurodynamics. You will do specific exercises to restore the normal movement of the nerves and exercises aimed at restoring the nerves’ ability to handle tension.
At the end of this phase you should be able to do stretches through full range of motion without experiencing pins and needles in your arms.
5th Phase: Improving stability through the kinetic chain – week 5+
A kinetic chain is a concept that proposes that different parts of the body are connected via joints, therefore movement or dysfunction in one area affects other connected areas. The neck connects the head to the upper back and shoulders and all these areas function as a unit. Improving muscle strength in the upper back and shoulders can decrease load and stress on the neck. The reverse is also true, if there is weakness in a part of this chain it places extra stress on other areas. Every part of the kinetic chain should play its part in movement to return to optimal functioning.
This phase of rehabilitation will add exercises to strengthen muscles around the shoulder blades while continuing with strength and endurance training of the neck muscles. Kinetic chain exercises i.e. exercises involving the neck, shoulders and upper back, will be added for example throwing, push-ups etc. to prepare you for return to sport. More complex, full body exercises may also be added late in this phase e.g. burpees.
At the end of this phase of rehabilitation you should be able to train and exercise without pain, stiffness or discomfort.
Other medical treatment
Chiropractic treatment claims to be an effective treatment for a slipped neck disc. However, strong techniques and adjustments may aggravate the condition or cause re-injury of the disc.
Pain medication provided by a general practitioner can be a very effective adjunct to therapy. This provides us with a window period in order for us to treat the slipped disc.
Medication may include muscle relaxants and anti-inflammatories. This could be useful in the initial phase of healing along with physiotherapy. The problem with muscle relaxants is that it doesn’t only work on muscle spasm, it also affects the small muscles around the spine responsible for stability. These are precisely the muscles we will start to activate and strengthen during the first phase of rehabilitation.
A cortisone injection will improve the swelling and inflammation, but the injury still needs time to heal. Physiotherapy supports the natural course of healing.
Soft collars/cervical braces may be useful in the first 2-3 days after the injury for pain relief, but prolonged use will result in weakness of the muscles around the neck. These braces often also encourage incorrect posture of the neck.
Biokineticists can help with final stage rehabilitation and return to sport once pain and stiffness are no longer present.
When is surgery necessary?
In some patients multiple levels may be affected with one or more disc bulges or severe degenerative changes in addition to their bulging disc(s). If the nerve symptoms get worse i.e. pins & needles becomes numbness then loss of strength in the arm, surgery may be an option. Worsening nerve symptoms indicate pressure on the nerves and surgery becomes necessary to prevent permanent nerve damage.
Other Causes of Neck Pain
- Joint – Neck Joint Degeneration (Cervical Spondylosis)
- Muscles – Neck muscle spasm,
- Discs – Cervical Disc injury (Slipped neck disc)
- Ligaments – Interspinous ligament sprain
- Nerve- Pinched nerve in the neck
- Bone – Cervical Facet joint sprain
- Neck pain coming form other areas
