Persistent neck pain is not one diagnosis. The upper trapezius, levator scapulae, suboccipital muscles, cervical joints and nervous system can all contribute, and headache needs its own clinical context. Fibrotic and mechanical tissue changes may contribute to chronic neck-pain presentations, but we do not assume them. At Novo Soft Tissue in the Denver Tech Center, the first visit is an examination. It determines which findings are clinically relevant and whether radial shockwave, focused shockwave, manual treatment, rehabilitation, imaging or referral makes sense.
Background
Can Fibrosis Contribute to Neck Pain?
Yes, it can. Chronically painful muscle can show more than nerve irritability. In an older surgical study, symptomatic trapezius muscles had higher internal pressure than pain-free ones, and operations in four patients found dense fibrosis around the muscle and the accessory nerve. More recently, a 109-patient ultrasound study found the upper trapezius measurably stiffer in cervical myofascial pain than in other neck pain.
These studies support examining the muscle and fascia rather than assuming pain comes only from the cervical joints. They do not show that fibrosis explains every case, and neither palpation nor stiffness proves microscopic fibrosis in an individual. Read the trapezius fibrosis research review → For how trigger points and structural change differ, see trigger point or fibrous adhesion?
Examination
What We Examine in Persistent Neck Pain
- Where it hurts, how long, and your headache pattern
- Rotation, side-bending, flexion and extension
- Tenderness and reproducible referred pain in the upper trapezius, levator scapulae and suboccipital muscles
- Tissue resistance where clinically relevant
- Strength, muscular endurance, and shoulder blade contribution
- A neurologic screen when symptoms suggest it
- Previous imaging, treatment, and how you responded
- Anything that calls for referral
Differential diagnosis
Not Every Headache With Neck Pain Is a Tension Headache
Tension-type headache is typically on both sides, pressing or tightening, mild to moderate, and not worsened by routine activity. The ICHD-3 classification recognizes forms with and without pericranial tenderness.
Cervicogenic headache is caused by a disorder of the cervical spine. It requires evidence that the neck is the source, such as headache that worsens with neck movement. A tender neck alone is not enough.
Migraine can also bring neck pain and tenderness. It is more often one-sided, pulsating, worsened by activity, and accompanied by nausea or light and sound sensitivity.
Headache attributed to TMD is felt in the temple and changes with chewing, clenching or jaw movement. It is explained in temporalis muscle pain, headache and jaw dysfunction, and jaw and facial pain are covered on TMJ, jaw and masseter pain.
Tenderness is common across these. A meta-analysis of 1,200 patients found markedly higher pericranial tenderness than in healthy people in chronic tension-type headache (SMD 1.57), and also in migraine (SMD 1.27). That is why the headache pattern is identified before the neck is treated.
Treatment selection
How Treatment Is Selected
Many people improve with exercise, manual care, activity changes or other conservative treatment. When symptoms persist, the next step is to reassess the presentation rather than repeat the same treatment.
Radial shockwave spreads pressure waves across a broad, superficial area, which suits large superficial muscles such as the upper trapezius in appropriate cases. It has randomized evidence for upper-trapezius trigger points.
Focused shockwave concentrates energy at a chosen depth and may be selected for a smaller, localized target. A 2025 randomized trial found it reduced measured upper-trapezius stiffness and pain.
Manual treatment addresses muscle and fascial restriction found on exam, alongside other approaches when the findings support it. It is not a way to dissolve fibrosis at the microscopic level.
Exercise and rehabilitation remain central. A 2025 clinical practice guideline recommends activation, self-management and exercise for chronic neck pain. Shockwave or manual treatment should complement appropriate loading, not replace it.
All four of our tools are compared on the services page.
Imaging & referral
When Neck Pain or Headache Needs Medical Evaluation First
See a physician promptly for a sudden, severe headache, a headache after significant trauma, fever or other signs of illness, new neurologic symptoms, or a major change in your usual headache pattern. Arm numbness or tingling, weakness, clumsy hands, or trouble walking are a different presentation from myofascial neck pain and need a neurologic assessment first. Hand numbness can come from the neck or from the wrist; see carpal tunnel vs cervical radiculopathy.
Evidence
Does Shockwave Help Chronic Neck Pain?
In randomized trials of myofascial neck pain, shockwave has improved pain and tissue sensitivity, but pooled results have not shown a clear improvement in neck disability. It is used for a selected myofascial component, not for every neck problem.
- Fibrosis: dense trapezius fibrosis found at surgery in 4 symptomatic patients (Hagert, 1990).
- Stiffness: higher upper-trapezius stiffness in 51 myofascial pain patients than in 58 with other neck pain (Hao, 2023).
- Shockwave and stiffness: in 64 office workers, focused shockwave lowered trigger-point stiffness by 6.1 kPa, with disability improving in both the real and sham groups (Vasvit, 2025).
- Shockwave and pain: across 11 randomized trials, shockwave improved pain (SMD 0.67) and pressure-pain threshold (SMD 1.19), but not neck disability (Jun, 2021).
The research supports a real myofascial component in many neck-pain presentations, while showing why the diagnosis matters. Read the full shockwave evidence review →
Sources: Hagert & Christenson, Acta Orthop Scand 1990 · Hao et al., Quant Imaging Med Surg 2023 · Vasvit et al., Complement Ther Med 2025 · Jun et al., Am J Phys Med Rehabil 2021 · Castien et al., Pain Physician 2021 · El-Allawy et al., Dtsch Arztebl Int 2025