The Scapula is the Butt of the Neck

Originally published in 2017. Updated in 2026 with additional information about cervical centralization and Mechanical Diagnosis & Therapy.

A surprising number of people, including physicians, are unaware of the way the spine can refer pain to other parts of the body. It is much more common to see an understanding of lumbar spine referral patterns, or to hear people refer to pain traveling into the leg as “sciatica,” while cervical spine referral patterns can be less obvious.

Many people understand that their “pain in the butt” may actually be coming from their low back. Pain that originates from the lumbar spine can be felt in the buttock and, in some cases, farther down the leg. A very similar process can occur in the cervical spine, producing that hard-to-localize pain around the scapula, or shoulder blade, that many of us feel, especially after sitting at a computer or holding one position for a long time.

Take a look at the illustrations below.

Cervical spine referred pain patterns showing symptoms spreading from the neck and shoulder blade into the shoulder and arm.

Lumbar spine referred pain patterns showing symptoms spreading from the low back into the buttock and down the leg.

Notice that in both instances, symptoms can begin centrally, in the low back or neck, and then spread farther away from the spine. In the low back, they may move into the butt and down the leg. In the neck, they may move into the shoulder blade, shoulder, and arm. That’s why I like to say that the scapula is the butt of the neck. In McKenzie Mechanical Diagnosis & Therapy (MDT), movement of symptoms farther away from the spine is called peripheralization.

But the pattern can also happen in reverse.

What is cervical centralization?

Centralization occurs when symptoms that have spread away from the spine begin to retreat back toward it in response to particular movements or positions. With a neck problem, for example, pain or tingling in the hand or arm might retreat toward the shoulder, then the shoulder blade, and eventually become more localized around the neck.

This is important because simply asking whether pain is “better” or “worse” can miss useful information. Imagine that your neck pain temporarily feels a little stronger, but the pain that had been traveling down your arm has disappeared and is now confined to the neck. In MDT, that change in location can be more meaningful than the intensity of the pain alone.

The opposite can also happen. If repeated movement causes symptoms that were around the neck or shoulder blade to spread progressively farther into the arm or hand, that is peripheralization. That response may be a sign that the movement or direction being tested is not the right one for that particular problem.

This process of testing movement and watching how symptoms respond is one of the central ideas behind the McKenzie Method, more formally known as Mechanical Diagnosis & Therapy (MDT). I’m certified in MDT and have used this approach to evaluate and treat neck and back pain for more than a decade.

That pain in the neck can be a real pain in the butt... am I right, or am I right?

PAIN GUIDES

Want to test what your symptoms respond to?

The NeuroActive Pain Guides walk you through a response-based process for testing movements, tracking meaningful symptom changes, and knowing when self-care is not appropriate.

LOW BACK PAIN → NECK PAIN →

Listen to Dr. Bruene on Sports Medicine Weekly

Dr. Bruene appeared on ESPN 1000's Sports Medicine Weekly program on November 5 to discuss the NeuroActive approach and how it fits into sports and athletic performance.  He had a great time and would like to thank Dr. Brian Cole, Steve Kashul, and Theresann Seeger for having him on and for a great discussion.  You can listen here it is the first segment of the show.  

Predilection For Injury in Athletes

Predilection For Injury in Athletes

Last month the cover of Sports Illustrated featured Tiger Woods and asked "What Happened? It Remains The Most Vexing Question In Sports."  Of course there were the well covered personal struggles, but no doubt his injury history is a big part of "what happened."  When we see athletes with numerous non-contact injuries we will also hear the talking heads try to make sense of it.  Some athletes will earn the title "injury prone" which can hurt their stock amongst front offices and fans alike.

When a player is injury prone (most especially from non-contact injuries i.e. Derrick Rose) it is an indication that he or she is not neurologically stable.  Sports, by definition, involve repetition of certain movements.  If those movements are not performed properly, joints and tissues are subject to unfavorable loads and more likely to break down.

It isn't novel to point out that "form" matters in exercise.  We all understand that if you squat or deadlift with poor form, you're likely to hurt yourself.  Inversely, with proper form these movements can be performed without injury at extremely heavy loads.  Nearly any movement involved in sport has an equivalent in development.  It is remarkable, for example, how similar throwing movements are to the baby turning from face up to face down.

The closer we are able to get to the ideal movement pattern, the less likely the movement is to result in injury.  Being neurologically stable means that the ideal patterns are automatic.  The muscles involved in the movements will be recruited in the appropriate order and the form happens subconsciously.

So Woods and Rose take hits for their injury history, who is on the other side of the coin?  Two examples are Jaromír Jágr, a man still playing professional hockey at the age of 44, and Roger Federer, a man who has been at the top of his sport for so long that it surprises a fan who woke from an 11 year coma that he is still a top tennis player.

Neurological stabilization training is beginning to be used more and more in the training rooms around the pro sports world.  NeuroActive Fitness is the first of its kind in offering these techniques to everyone from regular folks on up to pro athletes in a group fitness setting.  You can get what the pros get in an affordable way.  

***It should be noted:  A large component that should not be ignored is recovery.  One who deadlifts with proper form still needs to take the time to recover before deadlifting again to avoid injury.  The trick with pro athletes is allowing for recovery before stressing the joints or tissues again when there's another game potentially the next day.