Cervical Postural / Mechanical Neck Pain

Who: Anyone with a sustained-position load and a life. Students, desk workers, drivers, new parents, tradies who hold one position.
What: Diffuse, dull, bilateral or central ache across neck / upper trapezius / interscapular region. A smear on the body chart, not a spot.
How it behaves: Aggs: sustained positions — screens, driving, study, holding a phone up. Builds through the day. Eases: movement, changing position, stretching, heat. Settles in minutes.

The one thing to take from this page:

The body chart makes this diagnosis. The objective exam only tells you how irritable it is. This is a pattern of exclusion, ruled in on the subjective and confirmed by an exam that finds nothing sinister.

([1], GBD systematic analysis [2], seven pooled inception cohorts, Level I, Australian first author.)

⚠️ No Australian guideline for this presentation; anchored to the JOSPT Neck Pain: Revision 2017 [3]. ACSQHC has a Low Back Pain Clinical Care Standard and a Knee Osteoarthritis Clinical Care Standard. There is no neck equivalent, and RACGP publishes none. And read the anchor honestly: the guideline is 83 pages, paywalled, its PubMed record carries no results abstract, and it was not read in this pass. It is named here. Nothing on this page is quoted from it.

Pattern > Label. "Postural syndrome" names a posture that four measured studies say isn't the problem. A diffuse, position-dependent, movement-easing neck with a clean neurological screen names the pattern.

The 70/30 applies harder here than anywhere. By the time you've finished the five stages you have already ruled every competing pattern in or out. The P/E confirms irritability and hands you asterisk signs. It does not make the call.

Five stages, in your course's order.

MAIN PROBLEM

"My neck's just always tight. It's worse by the end of the day and I feel it across my shoulders."

No incident. No moment. A description of a load over time, not an injury.

BODY CHART

This is where the work happens. Draw it, then read it against the list — the body chart discriminates before you touch anyone.

Record P1 (the diffuse ache) and any P2 separately. Mark φp where it is genuinely pain-free. If you cannot draw a spot, that is a finding, not a failure.

BEHAVIOUR

• Coding: most of these are M or Is — morning stiffness <30 min = M, >30 min = In. A neck that is stiff for two hours every morning is not this pattern, and you go looking for something inflammatory.
• 24-hour pattern: best on waking, worst at 4pm. That trajectory is the pattern. The reverse trajectory isn't.
• Severity: VAS 0–10 at best / at worst / right now.
• Irritability — all three parts. Resting symptoms (usually none) + vigour of the provoking activity (a sustained position, not one movement) + time to settle (minutes, on moving). Low irritability here buys you a full P/E and a loading plan on day one.

HISTORY

Insidious. No trauma, no single mechanism. The change is usually in workload, sleep, training volume or life stress — not in a movement.

Three questions with prospective data behind them, which is more than most of what gets asked:

([4], 396 of 457 pain-free adults followed 12 months [5], six prospective cohorts, low-to-moderate certainty. Very-low-certainty support for the activity question across 20,350 participants in [6]; take the direction, not an effect size.)

What not to spend the subjective on: how they sit at their desk, their pillow, their monitor height, how much they're on their phone. Measured cervical flexion angle during phone use did not raise the odds of developing neck pain — standing OR 1.0 (95% CI 0.97–1.04), sitting OR 1.01 (0.98–1.04) (Correia et al. 2025) — and did not associate with prevalence (OR 1.00, 0.98–1.02, p=0.66), frequency or intensity in 582 adults [7].

Ask about it if it's their belief. Then treat it as a belief, not as a cause.

SPECIAL / SCREENING QUESTIONS

Clear, all of them, or this isn't the pattern:

• 5 D's and 3 N's — dizziness, diplopia, dysarthria, dysphagia, drop attacks; nausea, nystagmus, numbness.
• UMN symptoms — clumsy hands, dropping things, gait change, bladder change.
• Dermatomal or myotomal symptoms below the shoulder.
• Systemically unwell, unexplained weight loss, night pain that wakes and won't settle with position.
• Trauma of any kind → §4, and the Canadian C-Spine Rule.

Top three, one discriminating feature each. Rule the dangerous ones out first (§4), then discriminate on the body chart.

And the headache branch, because students get this one backwards.

• Cervicogenic headache — headache reproduced by cervical movement or palpation, with restricted upper cervical rotation. The cervical flexion-rotation test is the discriminator: Se 83.0% (95% CI 70–92), Sp 83.0% (71–91), +LR 5.0 (2.6–9.5), −LR 0.2 (0.1–0.4), moderate certainty, 4 studies / 182 participants [9]. Every other history item and clinical finding in that review: accuracy remains unclear.
• Migraine with neck pain — throbbing, 4–72 hours, unilateral, ± aura, nausea, photophobia.

Read this number twice. Neck pain is present in 77.0% (95% CI 69.0–86.4) of migraine patients versus 23.2% (18.6–28.5) of non-headache controls — 87.0% (77.0–93.0) in chronic migraine [10]. A stiff, tender neck in a headache patient tells you close to nothing, because three quarters of migraineurs have one. Finding it does not make the headache cervical.

The two that aren't a neck problem at all live in §4: cervical arterial dysfunction (CAD page) and cervical myelopathy (myelopathy page).