Is your patient able to dissociate movements? If not, that may be the source of their pain.

Most individuals with midback pain are unable to perform cervical flexion or rotation independent of the trunk. Instead of full cervical flexion, they will reach an endpoint but continue downward by performing trunk flexion (red arrow indicates area of “cervical” flexion).

The same holds true for cervical rotation. Most patients will demonstrate about 60 degrees of rotation yet their brain interprets it as full range of motion due to the compensatory rotation of the thoracic spine.

In these cases, initial treatment should focus on lengthening the hypertonic fascia (posterior cervico-thoracic for flexion and cervico-pectoral fascia for rotation). Passive movements should then be performed to re-educate the segments to work independently. This should then be progressed to include active cervical motion with dynamic trunk stabilization.