Head, Jaw & Cervical

Postural / Tension Pattern

“Client presents with tight neck and shoulders, usually worse after sitting at a desk or looking at screens.”

Safety first

Before applying any manual techniques, ensure there is no indication of structural damage or contraindication. A history of whiplash, trauma, or unexplained neurological symptoms warrants caution.

Perform vertebral artery screening (as per Scenario 2: Headaches) before treating the upper cervical region. If in doubt, do not treat — refer for further investigation first.

Posture is a response, not a cause The instinct is to call this a posture problem and tell clients to sit up straighter. But forward head position, rounded shoulders, and persistent tension through the neck and upper back are the body’s best available solution to something it’s been dealing with for a while. Correcting the position without addressing what’s driving it is the wrong order of operations. Better posture follows better treatment, rarely the other way around.

This is the most common presentation you’ll see. The desk worker, the student, the driver, the phone scroller. They don’t come in with a specific injury or diagnosis — they come in because their neck and shoulders feel tight, achy, and stiff. And often they’ve felt this way for months or years and accepted it as normal.

The underlying pattern typically includes forward head posture (FHP), rounded shoulders, and upper crossed syndrome (UCS). These postural changes alter the length-tension relationships of cervical and shoulder girdle muscles: some become short and overactive (upper trapezius, levator scapulae, SCM, pectorals, sub-occipitals), while others become lengthened and underactive (deep neck flexors, lower trapezius, serratus anterior).

The result is a self-reinforcing cycle: poor posture → muscle imbalance → discomfort → guarding → more tension → worse posture. Your role is to break the cycle by identifying which muscles are contributing and addressing them — while helping the client understand the postural and lifestyle factors that perpetuate it.

Clients typically report some or all of the following:

Neck stiffness and tightness — often bilateral, worse at the end of the day
Shoulder tension — “carrying tension in my shoulders”
Aching between the shoulder blades
Headaches — often tension-type, may overlap with Scenario 2
Reduced neck mobility, especially rotation and lateral flexion
Discomfort with prolonged postures — sitting, driving, reading
Temporary relief with movement or heat

Contributing factors Prolonged sitting (desk work, driving, studying) · Screen use, especially looking down · Forward head position · Rounded shoulders · Stress and anxiety (muscle guarding, shallow breathing, jaw clenching) · Poor workstation ergonomics · Lack of movement · Sleep position · Breathing dysfunction (upper chest breathing activates accessory muscles)

Trigger point referral areas:

Upper Trapezius	Posterolateral neck, behind the ear, temple
Levator Scapulae	Angle of the neck (where neck meets shoulder), medial scapula border
SCM	Forehead, around the eye, top of head, behind the ear, cheek
Scalenes	Down the arm, into the chest, between shoulder blades
Sub-occipitals	Base of skull, wrapping to forehead and behind the eye

Muscle overlap with Scenario 2 SCM, Scalenes, and Sub-occipitals are also covered in Scenario 2: Headaches. This is intentional — postural dysfunction is a major contributor to headaches, and the same muscles are involved in both presentations.

Muscles involved

Upper Trapezius Levator Scapulae SCM Scalenes Sub-occipitals

Muscle reference pages for this scenario are coming soon.

Subjective — case history:

Where is the tension or discomfort? Neck? Shoulders? Between the shoulder blades?
How long have they had this? Weeks? Months? Years?
What makes it worse? Sitting? Driving? Screen time? Stress?
What makes it better? Movement? Heat? Massage? Sleep?
What does their typical day look like? Desk work? Driving?
Any headaches? (If yes, explore as per Scenario 2)
Any arm symptoms — pain, numbness, tingling? (If yes, consider radiculopathy)
Stress levels? Sleep quality?
Any history of trauma, whiplash, or neck injury?

Observation:

Head position — is the head forward of the shoulders?
Shoulder position — rounded forward? Scapulae protracted?
Cervical curve — excessive lordosis or flattening?
Thoracic curve — increased kyphosis?
Asymmetry — head tilt? One shoulder higher?
Breathing pattern — upper chest or diaphragmatic?

Range of motion — cervical:

Flexion / Extension	Note range, discomfort, and where restriction occurs.
Rotation	Compare sides. Restriction is common, often bilateral but may be asymmetric.
Lateral flexion	Compare sides. Often restricted on both sides in postural patterns.

In postural/tension presentations, ROM may be relatively full but uncomfortable at end range. The issue is often tissue quality and tolerance rather than structural restriction.

Range of motion — shoulder:

Flexion	Can the client raise arms fully overhead? Note restriction or compensation.
Abduction	Compare sides. Note any scapular winging or hiking.
External rotation	Often restricted in rounded shoulder postures.

Shoulder mobility directly affects cervical posture and muscle loading — don’t skip this.

Passive ROM Movement that is limited actively but full passively suggests the restriction is muscular rather than structural. In postural presentations, end feel is often normal but the range is uncomfortable — this reflects tissue quality and sensitivity rather than joint pathology.

Special tests:

Vertebral artery screening: Perform as described in Scenario 2 if you plan to treat the upper cervical region.

Spurling’s test: If the client reports arm symptoms (pain, numbness, tingling), perform Spurling’s to assess for cervical radiculopathy. Extend the cervical spine, laterally flex and rotate toward the painful side, then apply gentle axial compression. Reproduction of arm symptoms suggests radiculopathy.

Palpation:

Upper Trapezius	Client prone. From the occiput along the superior nuchal line to the acromion. Note tone, tenderness, trigger points. Often hypertonic bilaterally with multiple tender points.
Levator Scapulae	Client prone. From the superior angle of the scapula toward the transverse processes of C1–C4. Often exquisitely tender at the superior scapular angle.
SCM	Client supine. From mastoid process to sternum/clavicle. Have client turn head slightly away and lift to engage. Note tone, trigger points, referral.
Scalenes	Client supine. Lateral neck between SCM and upper trapezius. Ask client to breathe and hold — scalenes engage. Note tenderness and referral.
Sub-occipitals	Client supine. Support the head, palpate just below the occiput. Often involved in postural patterns due to compensatory extension at C0–C1.

There’s no fixed order. Let your findings guide you. Upper trapezius and levator scapulae are often the dominant findings — but don’t neglect the cervical muscles that are frequently involved.

Hypertonic, restricted tissue	FMT — passive first, then active if tolerated
Localised tender spots with referral	TPT — sustained pressure, respect tissue response
Muscle won’t relax, guarding	MET — contract-relax to reset tone
Adhesions at attachments	Frictions — use at scapular attachments where indicated

Neurodynamic exercises In some postural presentations, neural tension contributes to symptoms — particularly when the client reports arm symptoms, numbness, or tingling without clear radiculopathy.

Neural sliders (glides): Alternating movements at adjacent joints that slide the nerve through surrounding tissues without sustained stretch. Gentler and suitable for more acute or irritable presentations.

Neural tensioners: Sustained elongation of the nerve tract by positioning multiple joints simultaneously. More effective for chronic neural tension, but introduce gradually.

Neural mobilisation is particularly relevant when soft tissue treatment alone doesn’t fully resolve symptoms, or when there is a clear neural component to the presentation.

Reassess after treatment Has range of motion improved? Has tenderness reduced? Does the client feel less tight or more mobile? Encourage them to notice how long the improvement lasts — this helps identify what perpetuates the pattern.

Cautions:

Red flags for referral: sudden onset of neck pain with neurological symptoms, neck pain after trauma, unexplained weight loss, fever, or night pain that wakes the client.
Radicular symptoms: if the client reports arm pain, numbness, or tingling, assess for cervical radiculopathy.
Hypermobility: some clients with postural dysfunction are hypermobile rather than stiff — their muscles are working overtime to stabilise unstable joints. Aggressive stretching is counterproductive. Focus on stability and strengthening: deep neck flexors, serratus anterior, lower trapezius. Use controlled movement rather than end-range stretching.
Thoracic outlet syndrome (TOS): scalene and pectoralis minor involvement can compress neurovascular structures. Neurogenic TOS (over 90% of cases) often responds well to manual therapy. Venous TOS (arm swelling, bluish discolouration) and Arterial TOS (pallor, coldness, diminished pulses) are vascular — refer immediately.

Evidence: A Cochrane review found manual therapy combined with exercise is more effective than either alone for chronic neck pain (Gross et al., 2015). Trigger point therapy reduces pain and improves function in myofascial pain involving the upper trapezius (Cagnie et al., 2015). Thoracic spine hypomobility contributes to cervical pain — adding thoracic mobility exercises improves outcomes beyond cervical-focused treatment alone (Suvarnnato et al., 2013).

Research also confirms that weakness or inhibition of the serratus anterior is associated with neck pain and perpetuates forward head posture. Addressing serratus anterior activation alongside manual therapy may improve outcomes (Neumann & Camargo, 2019).

Serratus anterior activation (reach and rotate):

This exercise is more complex than it looks. It should be demonstrated by the therapist before being attempted at home. If something doesn’t feel right, stop and ask for clarification at the next treatment.

Set up: Stand in front of a large mirror. Work one arm at a time.
Abduct the arm to 90°: Raise one arm out to the side until parallel to the floor. Keep the spine straight.
Reach out: Extend the arm away from your body as if reaching for something just out of reach. Feel the scapula glide around the ribcage.
External rotation: While maintaining the reach, slowly rotate the shoulder externally and supinate the forearm (palm faces up). Serratus should be fully engaged.
The challenge: While still reaching out and keeping the scapula in position, slowly rotate the shoulder internally and pronate the forearm (palm faces down). Maintain the reach and scapular position. This is the difficult part — the tendency is for the scapula to wing or drop. Resist this.

At the beginning, one repetition per arm may be all that’s achievable. Progress is slow but real.

Thoracic mobility:

Thoracic rotation: Sit on a chair, feet flat. Cross arms over chest. Rotate the trunk to one side, keeping hips facing forward. Hold 2–3 seconds. Repeat 10 times each side.

Thread the needle: Start on hands and knees (wrists under shoulders, knees under hips, spine neutral). Reach one hand under the body and rotate the thoracic spine. Follow the hand with your eyes. Return and reach the same hand up toward the ceiling, rotating the other way. Repeat 10 times each side.

Foam roller extension: Lie on a foam roller positioned horizontally across the mid-back. Support the head with your hands. Gently extend over the roller. Roll slightly up and down to mobilise different segments. 1–2 minutes.

Stretching:

Upper trapezius: Sit tall, hold the seat with one hand. Tilt the head away from the anchored side. Hold 20–30 seconds. Repeat each side.

Levator scapulae: Sit tall, hold the seat. Rotate the head toward the opposite side, then flex the neck (look down toward the armpit). Hold 20–30 seconds. Repeat each side.

Doorway pectoral stretch: Stand in a doorway, forearm on the door frame, elbow at shoulder height. Step forward to stretch the chest. Hold 20–30 seconds. Repeat each side.

Clinical connections

Headaches	Forward head position and upper cervical muscle tension are major contributors to both cervicogenic and tension-type headaches. See Scenario 2: Headaches.
TMD	Jaw clenching often accompanies neck tension. If the client reports jaw symptoms, assess accordingly. See Scenario 1: TMD.
Deep cervical stabilisers	Forward head position is associated with inhibition of the deep cervical extensors (multifidus, semispinalis cervicis), reducing segmental control and forcing the superficial extensors to overwork. When surface treatment is not giving lasting results, consider whether the deep stabiliser layer is contributing.

TMD Headaches Cervical Radiculopathy

Session 2 — Shoulder & Thoracic Spine

Upper trapezius and levator scapulae connect directly to the shoulder girdle and the thoracic spine — addressed in Session 2. Thoracic stiffness and scapular dysfunction perpetuate the postural patterns you treat here. The patterns continue.