What is usually going on
Neck pain comes from a small number of structures, and they can be told apart.
Muscular pain and trigger points. Tight, tender bands in the trapezius, levator scapulae and the deep neck muscles, referring pain in patterns that are consistent enough to be recognised — into the shoulder blade, up behind the ear, across the top of the head.
Facet joint irritation. The small paired joints at each level of the cervical spine. Pain is typically one-sided, worse turning or looking up, and refers into the shoulder and upper back rather than down the arm.
Cervical radiculopathy. A nerve root compressed by a disc or by degenerative narrowing. This is the one that sends sharp, electric pain past the shoulder and down into the arm and hand, often with numbness in a specific band.
Cervicogenic headache. Neck structures referring pain into the head, frequently mistaken for migraine and treated as such for years.
The assessment
Where the pain sits, where it travels, what position brings it on, how long it has been there, what you do all day. Then the examination: range of movement in each direction, palpation of the joints and the muscle groups, reflexes, power and sensation in the arms, and how the shoulder girdle and upper back are contributing.
Imaging is ordered when the examination raises a question it can answer — not routinely. Degenerative changes on a cervical MRI are near-universal after a certain age and, on their own, explain very little.
Treatment
Trigger point injections where a muscle is locked in spasm and manual treatment has not released it. These are quick, done with a fine needle, and frequently give the window in which rehabilitation can finally work.
Joint injections where a facet joint is the pain generator — both treating the inflammation and, because the response is informative, confirming the diagnosis.
A rehabilitation plan for the mechanics. The deep neck flexors and the muscles holding the shoulder blade are almost always part of the picture, and they are the part that determines whether the pain stays away.
Dr. D’Alessio is board-certified in Physical Medicine & Rehabilitation and does not perform surgery. Where an examination suggests you need a surgical opinion, you will be told and referred.