A painful stiff neck affects one in three people every year, and is most prevalent in the 35-49-year age group. It causes significant disability for all those affected, but is more commonly seen in women (1).

A stiff neck can be a symptom of vascular disease, inflammatory disorders, infection, and malignancy. Therefore, it needs to be evaluated properly before any treatment begins.

In this article, we’ll discuss what causes a painful stiff neck, how to diagnose it, and some common treatments.
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Location of Neck Stiffness

Neck stiffness can occur due to an injury anywhere along the cervical spine. It can occur at the base of the head where the skull and cervical spine articulate. Symptoms are commonly localized in the cervical column, however they can also spread down into the arms, forearms, or even the hands.

A person may also have a stiff neck because any movement of the damaged muscles, tendons, ligaments, or joints in the cervical area can cause neck pain. Neck stiffness is often accompanied by neck pain. Let’s look at the anatomy of the neck and how neck stiffness occurs.

• Bones of the Neck

The seven cervical vertebrae, the hyoid bone, the clavicles, and the manubrium of the sternum are the only bones of the neck. Inflammation can develop around these bones and joints, causing the neck to become stiff. This is a common cause of axial pain that is localized within the neck.

• Ligaments and Muscles

The anterior longitudinal ligament, posterior longitudinal ligament, ligamentum flavum, intertransverse ligament, supraspinous ligaments, interspinous ligaments, nuchal ligaments, alar ligaments, apical ligament, and transverse ligament are some of the ligaments of the cervical spine. Any injury to any of these ligaments can cause neck stiffness and affect the range of motion of the neck.

Partial and complete tears of the anterior neck muscles, superficial back muscles, suboccipital muscles, spinotransversales muscles, erector spinae muscles, and transversospinalis muscles can also cause neck stiffness and prevent normal movement.

• Spinal Cord and Nerves

Malignancy, inflammation, circulatory disorders, and infection can also affect the spinal cord and the existing cervical spinal nerves resulting in neck stiffness and radicular neck pain. Radicular neck pain usually radiates beyond the neck to the shoulders and the arms.

• Intervertebral Discs

Any damage to the intervertebral discs, such as from inflammation, old age, or increased friction, can also lead to neck stiffness and neck pain.

Intervertebral discs sit in between the cervical spinal vertebral bodies and support the anterior (front) spinal column. If an intervertebral disc herniates or bulges out of its protective fibers, it can affect the cervical nerve or spinal cord and lead to neck pain and neck stiffness.

Types Of Neck Pain

It is possible to narrow down what is causing neck stiffness based on the characteristics of pain and other symptoms accompanying it. Here is a list of some common symptoms you might experience with neck stiffness:

• Soreness In The Neck

Soreness in the neck muscles is usually experienced by those with poor posture, those who sit hunched over a computer without cervical spine support, and those with higher stress levels. In all the above instances, the muscles and ligaments can overstretch resulting in muscle cramping and neck stiffness.

During stress, the upper trapezius muscles are activated independent of posture and concentration as well, leading to neck pain.

• Sudden, Powerful Tightening Of Neck Muscles

There are over twenty muscles that support the cervical spine, and these muscles can spasm due to stress, overload, dehydration, and muscle strain. Dehydration decreases blood volume and so with less blood flow to the muscles, activating the muscles lead to cramps and spasms.

This sudden powerful tightening of the neck muscles can cause muscle tightness and prevent the full range of motion of the neck.

• Dull Headache With Neck Stiffness

A headache with a stiff neck is a red flag as it can indicate more serious conditions like meningitis or encephalitis, unless proven otherwise. Neck stiffness with headaches, especially when accompanied by a fever and rash, must be seen immediately by a doctor. If it is an infection, it will be treated with antibiotics or antivirals, depending on the causative organism.

• Deep, Sharp Pain

Deep, sharp neck pain accompanying neck stiffness could be due to osteoarthritis, spinal stenosis, a herniated disc, pinched nerve, or a tumor. This pain can develop gradually. This sharp pain may radiate in some cases along the arm. If it is accompanied by a change in sensorium or loss of consciousness, then you need to see a doctor immediately.

• Severe Pain With Tingling Sensation

Severe pain accompanied by numbness, tingling, and weakness along the neck and arm is commonly seen in radiculopathy of the cervical spine or myelopathy. Here, the nerves exiting the spinal column are affected, which can cause pain or a tingling sensation along the arms.

• Pain With Tenderness

A stiff painful neck with tenderness is seen in osteoarthritis where the cervical facet joints are inflamed. In some cases, overworked muscles also can also cause neck stiffness and muscle tenderness.

Common Causes Of A Stiff Neck

There are many causes of a painful stiff neck. While the list is extensive, we’ve highlighted some of the common ones below:

Poor Posture And Ergonomics

Poor posture can cause neck stiffness and pain if the head is positioned awkwardly or too far forward, such as when sleeping or working at a desk, overloading the ligaments and muscles in the neck.

When the head is positioned just one extra inch forward, it adds an additional pressure of ten pounds on the cervical spine. The cervical spine must then support this additional load, which can lead to soreness and stiffness.

Spinal Injuries

Medical emergencies like an injury to the neck, spine trauma, fractures to the spine, and narrowing of the spinal canal can prevent full range of motion of the neck and cause neck stiffness. The limitation of movement due to spinal injuries is also associated with weakness in the arms and loss of strength or sensation.

Arthritis

Arthritis affects the joints in the body, and is associated with inflammation of the lining of the joints. This can occur in the spinal joints of the neck, where the inflamed synovium prevents smooth movement of the joints, leading to neck stiffness.

This is common in rheumatoid arthritis, psoriatic arthritis, and osteoarthritis. Bone spurs in osteoarthritis also prevent smooth movement of the joints, leading to neck stiffness.

Meningitis

Meningitis is an inflammation of the meninges lining the spinal cord and the brain. This occurs due to an infection by bacteria, viruses, fungi, or mycobacteria. These infectious agents inflame the meninges. Movements of the neck can stretch the meninges and its attached nerves which causes neck pain and stiffness. It is usually diagnosed with a lumbar puncture.

Teeth Grinding

Bruxism is a rare cause of neck stiffness and pain. It is a condition where the person constantly grinds their teeth, and can lead to neck muscle hyperactivity. The increased muscle tension in the cervical region can lead to neck stiffness.

Temporomandibular Joint (TMJ) dysfunction has also been postulated as a cause of neck pain and accompanying neck stiffness, although how this occurs is not exactly known.

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Common Conditions Associated With Stiff Neck

Atlantoaxial Instability (AAI)

Instability simply means that bones move around too much, usually due to damaged ligaments. In the spine, this can cause nerves to get banged into and joints to get damaged. In the craniocervical junction, instability can cause the upper cervical spinal nerves to get irritated, leading to headaches. In addition, the C0-C1 and C1-C2 facet joints can also get damaged. In addition, there are other nerves that exit the skull here that can get irritated, like the vagus nerve, which can cause rapid heart rate. What’s the Difference Between CCI and AAI? CCI refers to instability in any part of the craniocervical junction…

Read More About Atlantoaxial Instability (AAI)

Cervical Medullary Syndrome

Cervical Medullary Syndrome is a clinical condition that occurs as a result of inflammation, deformity, or compression of the lower part of the brain. Symptoms can be extensive with fluctuating severity based upon the extent of the underlying injury. For example, mild irritation of the brainstem may cause only mild, intermittent symptoms. The upper cervical spine and brain are complex with multiple structures.  These structures reside within the skull and protective confines of the cervical spine.  Neither expands to accommodate inflammation, injury, and disease.  Rather the delicate tissues of the brain and spinal cord are irritated or compressed.   The 4 major conditions that cause cervical medullary syndrome are…

Craniocervical Instability

Craniocervical Instability is a medical condition characterized by injury and instability of the ligaments that hold your head onto the neck. Common symptoms of Cranial Cervical Instability include a painful, heavy head, headache, rapid heart rate, brain fog, neck pain, visual problems, dizziness, and chronic fatigue.CCI or neck ligament laxity treatment options depend upon the severity of the instability and clinical symptoms. When appropriate, conservative care should always be the first-line treatment. Craniocervical Instability Surgery is often recommended when conservative care fails. This involves a fusion of the head to the neck which is a major surgery that is associated with significant risks and complications…

Ehlers-Danlos Syndrome (EDS)

Disorders that affect and weaken the connective tissues such as tendons and ligaments. It is a hereditary disorder which means you are born with it.  EDS has many different signs and symptoms which can vary significantly depending upon the type of EDS and its severity.   It most commonly affects the skin, joints, and blood vessels.  Joints are typically hypermobile with excessive joint range of motion because of a defect in collagen formation. In most cases Ehlers-Danlos syndrome is inherited. That is to say that you are born with it. The two main ways EDS is inherited are: autosomal dominant inheritance and autosomal recessive inheritance…

Pinched Nerves in the Back

We talk a lot about leg pain stemming from a pinched or irritated nerve in the lower back. And, indeed, that’s what our physicians are traditionally taught in medical school—a pinched nerve in the lumbar spine typically presents as a symptom in the leg. However, what if you have some butt pain but no pain or other symptoms in the leg? Does this mean it couldn’t be a pinched nerve? Not so fast. Turns out a pinched low back nerve doesn’t always have to be accompanied by leg symptoms. Let’s start by taking a look at how the back is structured.

TMJ

The temporomandibular joint (TMJ) is the joint connection between your jaw and your skull. If you run your fingers along either side of your jaw line toward your ears, you can actually feel where the jaw bone ends and the skull bone begins. If you open and close your mouth, the difference between the two is dramatic as the jaw bone moves, thanks to the TMJ joint, while the skull bone remains stable. The TMJ and any of its surrounding structures can become painful and inflamed, and this can become so bad that it can prevent patients from even being able to move their jaw bone to chew.

Home Remedies You Can Try

You can try home remedies or supportive care when you first experience a painful stiff neck and see if they relieve your symptoms. Some of them include:

• Ice: You can use ice for a painful stiff neck. Ice or cold therapy reduces pain, decreases blood flow, edema, inflammation, spasm of the muscle if any, and metabolic demand of the muscles. However, there is limited evidence from clinical trials when compared to heat therapy (2).
• Heat: Studies show that heat therapy is very effective in relieving neck stiffness (3). Heat therapy increases blood flow, metabolism of the muscles, and elasticity of the connective tissues. These interventions, when completed just twice a day for five days continuously, can alleviate pain associated with a stiff neck. Infrared heat can be better for deep muscle layers.
• Stretching And Exercise: Neck stabilization exercises are a good way to stretch and ease neck stiffness. This includes chin-tuck exercises, trapezius stretches, and shoulder retraction exercises. These exercises gradually stretch and strengthen the muscles, thereby improving flexibility and elasticity of the neck muscles.
• Over-The-Counter Pain Relievers: Over-the-counter pain relievers like acetaminophen and non-steroidal anti-inflammatory drugs (NSAIDs) can help reduce inflammation and pain temporarily. You can use them as directed for pain relief.
• Muscle Relaxants: If the neck stiffness is due to muscle spasms, then muscle relaxants like methocarbomol and cyclobenzaprine can relax these muscles and ease the neck stiffness. This is usually prescribed to people with recurrent symptoms, or when the muscle spasms do not resolve spontaneously.
• Rest: Resting will help prevent exacerbating any neck stiffness. If your stiff neck is due to stress or poor posture, then rest will ease the tension within the muscles of the neck and cervical spine and allow them to repair and recover.
• Massage: Massage therapy, completed consistently across a 10 week period, is effective at improving motion and relieving neck stiffness in the short term (4). There is no evidence of long-term clinical benefits with massage therapy.

How Stress Management Can Relieve Neck Pain

Studies have shown that there is a strong correlation between neck stiffness and stress (5).

In these studies, higher levels of tension of the upper trapezius, levator scapulae, and sternocleidomastoid muscles was strongly associated with neck pain. This was commonly seen in individuals who sat for more than three hours a day and had higher scores on perceived stress scales.

Participants of the study also benefited from stress management techniques in addition to physical therapy. These techniques included physical therapy sessions, stress management sessions like EMG biofeedback, psychotherapy, and cognitive behavioral therapy (CBT) to facilitate muscle relaxation.

When To See Your Doctor

You must see your doctor if your painful stiff neck is accompanied by the following signs and symptoms:

• Neck stiness with severe headache
• Worsening neck pain
• Neck stiffness for over a week
• Neck pain worsened by movement
• Loss of full range of neck motion
• Fever
• Numbness
• Weakness of arms
• Tingling in arms
• Rashes on the body
• Crepitus over the skin of the neck
• Loss of bowel or bladder function
• Seizures
• Fainting spells
• Loss of consciousness
• Altered sensorium

Conventional Medical Advice On Stiff Neck

In the absence of any red flag signs like fever, loss of consciousness, or paresis, treatment of a stiff neck is based on the severity and type of pain. Treatment commonly includes muscle relaxants, pain relievers, and in some cases corticosteroids.

Some people may use these medications alone, others might use massage therapy, cold therapy or heat therapy which are conventional treatment options for neck pain.

Symptomatic therapy like pain medicines for pain and heat therapy may not be enough for those with rapidly progressing symptoms in conditions like radiculopathy or myelopathy.

If the episodes are chronic or recurrent and with worsening symptoms or even in the setting of fever, weight loss, and fatigue then there may be something serious going on that needs to be investigated.

Supportive care will only temporarily alleviate the symptoms. Conventional medicine is not enough for neck stiffness. You have to treat the cause of the neck stiffness.

How To Get A Proper Diagnosis

A painful stiff neck has many different causes. It’s therefore necessary to evaluate any symptoms carefully, especially to rule out concerning conditions like traumatic injuries, infection, malignancy, and vascular emergencies.

First, your doctor will take a detailed subjective history to assess for any falls, accidents, traumatic incidents, history of travel, and other accompanying stiffness along with the stiff neck pain, etc.

Following the history, your doctor will do a thorough physical exam to check for tender areas, muscle strength, nerve function, the presence of rashes, neck mobility, reflexes, etc. If they suspect cervical radiculopathy, then they may do a Spurling test or an upper limb tension test.

Your doctor may request imaging to further investigate your symptoms and obtain clear imaging of the structures in the spinal region, including bone and soft tissue. . This can include an ultrasound, cervical x-rays during flexion/extension, a digital motion x-ray, and a cervical MRI.

Electromyography and nerve conduction studies are only completed if a person has numbness and weakness alongside their neck stiffness. If a doctor suspects a person has an infection, a lumbar puncture might be advised along with imaging of the brain.

What Happens When A Stiff Neck Is Left Untreated

If you ignore your stiff neck for a while and just “live with it,” your symptoms may get progressively worse over time. In some cases, recurrent inflammation may lead to deposition of calcium in the small joints. This further worsens the neck stiffness.

Torn ligaments, muscles, and tendons may take a long time to heal or may not heal without growth factors and nutrients. If the neck stiffness is due to other systemic illnesses, then leaving them untreated can affect the spine and the rest of the body.