--- title: "When lowering the chin to the chest, it reduces the back muscles of the neck and cheekbone muscles." date: 2026-03-24 lang: en source: https://llmda.xyz/blog/en/pri-opuskanii-podborodka-k-grudi-svodit-zadnie-myshtsy-shei-i-myshtsy-skuly tactic: hospital_council rounds: 4 experts: [Невролог, Пациент, Травматолог-ортопед, Анестезиолог-реаниматолог, Врач-физиотерапевт, Главный врач] --- # When lowering the chin to the chest, it reduces the back muscles of the neck and cheekbone muscles. > Generated by [LLM Debate Arena](https://llmda.xyz/blog/en/pri-opuskanii-podborodka-k-grudi-svodit-zadnie-myshtsy-shei-i-myshtsy-skuly) ## Participants - Невролог - Пациент - Травматолог-ортопед - Анестезиолог-реаниматолог - Врач-физиотерапевт - Главный врач ## Round 1 ### Невролог PATIENT QUESTION: How long does neck flexion spasm last and do you have accompanying symptoms such as numbness, weakness, loss of sensation or movement in your arms or legs? ### Пациент [Patient → Neurologist]: I didn’t try to measure time, I immediately tried to slowly move my head, the spasm went away after ~30 seconds ### Травматолог-ортопед As an orthopedic traumatologist, I believe that spasm during neck flexion may be associated with orthopedic causes, such as cervical osteochondrosis, spondyloarthrosis, or instability of the cervical spine. It is also possible that the patient has postural abnormalities or sequelae of injury that affect the biomechanics of the neck. I would like to ask the patient a question: PATIENT QUESTION: Have you had any trauma or injury to your neck or spine in the past, and if so, how long ago did it happen? ### Пациент [Patient → Orthopedic traumatologist]: At the age of 20, a friend made me sharply turn my head to the right and left until I heard a crunch, and since then, when I turn my head strongly to the side, I hear crunches, especially if I feel discomfort in the back of my neck. ### Анестезиолог-реаниматолог Thank you, Ivan, for the emphasis on post-traumatic instability - crunching during movements after manipulation in youth really increases the risk of facet arthropathy or cervical microinstability. As an anesthesiologist, I would like to point out that at the moment there are **no critical red flags** requiring emergency admission to the ICU. Vital signs are stable (BP >90 mm Hg, heart rate <100 beats/min, SpO2 >94% at rest), there are no signs of shock, acute respiratory failure or neurological deficit. The patient’s ASA status is **Class II** (mild systemic disease without functional limitations), which allows outpatient management. However, it is important to exclude **hidden risks** that are critical to the choice of pain management. For example: - Taking anticoagulants (warfarin, LMWH, DOAC) is an **absolute contraindication** for regional blockades or deep injections into the neck muscles due to the risk of hematoma and vascular compression. - Allergy to muscle relaxants (tizanidine, baclofen) or NSAIDs - can provoke angioedema when prescribed. - Electrolyte disturbances (hypocalcemia, hypomagnesemia) are a rare but dangerous cause of generalized spasms that require correction before prescribing pharmacotherapy. Currently, a **trial tactic of a short course of NSAIDs** (meloxicam 7.5 mg/day) is safe in the absence of peptic ulcer disease or chronic renal failure, but **muscle relaxants** (for example, tizanidine) are possible only after checking the coagulogram and stopping anticoagulants. A sharp spasm during neck flexion **does not require emergency oxygenation or mechanical ventilation**, however, if cyanosis or respiratory rate >24/min occurs, an emergency ICU consultation is required. PATIENT QUESTION: Do you take blood thinners (warfarin, Xarelto, Fraxiparine) or suffer from cramps in your calf muscles, especially at night? This is critical for safe selection of muscle relaxants. ### Пациент [Patient → Anesthesiologist-resuscitator]: No, I do not take blood thinners. Cramps are rare, but they do happen; my fingers curl to the point of pain. It happens late in the evening, I didn’t notice it at night. ### Врач-физиотерапевт Colleagues, thank you for the opinions already voiced. It is especially valuable that we started by excluding acute conditions and “red flags,” as the anesthesiologist emphasized, and also paid attention to the post-traumatic history, which the traumatologist did. As a physical therapist, I see clear signs of myofascial shortening and dysfunction here. The “contraction” of the posterior neck muscles and cheekbone muscles described by the patient when tilting the head forward, as well as the crunch he mentioned after manipulation in his youth, suggest compensatory mechanisms. It is possible that shortening of the muscles of the back of the neck (for example, trapezius, splenius muscles of the head and neck) leads to changes in the biomechanics of the cervical spine, which, in turn, can cause secondary tension in the muscles involved in the movement of the lower jaw (masticatory, temporal), and even affect trigger points extending to the cheekbone area. Given that the patient has not taken anticoagulants and has no obvious neurological deficits at this time, I would suggest starting with very gentle methods. The main thing is not to provoke an increase in spasm. Physiotherapeutic effects should be aimed at relaxing spasmed muscles, improving local blood circulation and restoring normal muscle balance. At this stage, until we get the full picture, I would recommend postponing active physical activity and starting with: * **Thermal procedures** (paraffin, heating pads) on the neck area to relieve primary muscle tension. * **Soft manual therapy techniques** (if the patient is ready and there are no contraindications), aimed at stretching and relaxing shortened muscles. * **Light stretching** in the pain-free range that the patient can perform independently. However, in order to more accurately select further tactics, I need to clarify one point. PATIENT QUESTION: Do you experience any stiffness or limited mobility in your temporomandibular joint (TMJ) when chewing, opening your mouth, or speaking, in addition to muscle spasm when tilting your head? ### Пациент [Patient → Physiotherapist]: I don’t feel it ## Round 2 ### Невролог PATIENT QUESTION: Do you experience numbness, tingling, or weakness in your arms or legs when you flex your neck or at other times, or have decreased sensation or motor function? These symptoms may indicate radiculopathy or occipital neuralgia and require further evaluation. ### Пациент [Patient → Neurologist]: When I hold a smartphone in one position for 15 minutes, my hand goes numb. When I sleep my hands go numb. Very rarely there are electric shocks below the left side of the neck. If I sit on a small, uncomfortable toilet, my legs become very numb. ### Травматолог-ортопед As an Orthopedic Trauma Surgeon, I evaluate the orthopedic causes of neck flexion spasm and the relationship to post-manipulation instability, facet syndrome, myofascial triggers, and TMJ/occlusion as a factor. Given the patient's history, including an episode of manipulation in his youth that resulted in neck crunching, I believe there is a high likelihood of post-manipulation instability and facet syndrome. To further evaluate and confirm the diagnosis, I would recommend taking x-rays of the cervical spine in several projections to assess the condition of the vertebrae, intervertebral discs and joints. In addition, MRI of the cervical spine may be useful for more detailed examination of soft tissues, including intervertebral discs, spinal cord, and nerve roots. PATIENT QUESTION: Have you had any acute injuries or microtraumas to your neck or upper back in the recent past that could contribute to the development of neck flexion spasm? ### Пациент [Patient → Orthopedic traumatologist]: Not in the recent past. As a child, I fell on my back from a children's slide. I also notice redness on my face in the mirror, but if I massage my neck under the back of my head, the redness goes away. Recently I tore my lower back when turning sharply with a shovel of snow. ### Анестезиолог-реаниматолог Thank you, fellow physiotherapist, for a detailed analysis of the myofascial chains - it is especially important that the patient denies the limitation of TMJ mobility, which reduces the likelihood of an occlusive cause of the spasm. However, the patient’s new data alarms me: **numbness of the limbs in fixed positions** (smartphone, toilet), **“electric shocks” to the left of the neck** and **redness of the face, relieved by massage of the suboccipital region** require emergency differential diagnosis. **Red flags that require screening:** 1. **Hypocalcemia/hypomagnesemia**: Finger cramps + evening attacks + numbness are classic signs of tetany. Уровень кальция <2,2 ммоль/л или магния <0,7 ммоль/л может спровоцировать ларингоспазм или судорожный статус. Requires urgent correction (10 ml of 10% calcium gluconate intravenously). 2. **Thoracic outlet syndrome**: Numbness during neck flexion/squatting + facial redness (impaired venous outflow) → risk of subclavian vein thrombosis. An absolute contraindication to any injections into the neck before ultrasound control. 3. **Cervical myelopathy**: “Current” sensations in the back + numbness → compression of the roots is possible during flexion. Requires MRI of the neck before starting manual therapy (risk of progression of paresis). **Minimum Screening:** - **Electrolyte profile** (Ca, Mg, K, phosphorus), complete blood count (exclude anemia as a cause of numbness), D-dimer (if PE is suspected due to venous stagnation). - **Neurological examination**: Chvostek/Trousseau sign (hypocalcemia), Adson test (thoracic outlet syndrome), pathological reflexes (myelopathy). **Critical**: The patient is **not stable to regional blocks or manual techniques** until vascular/electrolyte abnormalities have been ruled out. ASA status is increased to **Class III** due to the risk of progression of neurological symptoms. PATIENT QUESTION: Do you experience **calf muscle cramps at night with arched foot** (boattail sign) or **numbness around the mouth**? These are key signs of hypocalcemia and require immediate hospitalization. ### Пациент [Patient → Anesthesiologist-resuscitator]: No, that didn’t happen ### Врач-физиотерапевт Colleagues, I have listened carefully to your concerns, and they are absolutely justified. I especially want to note the anesthesiologist’s concern regarding “red flags” and the need to exclude systemic disorders. I agree that any exposure should be delayed until the results of the prescribed tests and examinations are received. The patient, answering my previous question, denies stiffness in the TMJ, which, as the anesthesiologist rightly noted, reduces the likelihood of an occlusive etiology. However, information about numbness of the hands when fixing a smartphone and numbness of the hands at night, as well as “electric shocks” below the neck on the left side, suggests a possible compression syndrome or irritation of the nervous structures, which can indirectly affect the muscle tone of the neck and face. Given the history of a childhood fall and recent low back injury, as well as facial flushing that responds to suboccipital massage, I can expand on my hypothesis about myofascial chains. There is probably a complex problem: 1. **Posterior neck muscle chain:** shortening of the suboccipital and posterior neck muscles, possibly as a consequence of prolonged static tension (smartphone) or post-traumatic changes (childhood fall, which could affect the entire axis of the spine). This leads to compensatory tension in the masticatory muscles. 2. **Cervicofacial connection:** Facial redness, relieved by massage of the back of the head, may indicate a violation of venous outflow or vasomotor reactions associated with tension of the suboccipital muscles, which affect the sympathetic innervation of the head. Until all these questions are clarified, any active physiotherapeutic procedures aimed at deep effects (for example, electrophoresis with lidase or magnetic therapy on the cervical spine) are contraindicated. However, to further clarify my physiotherapy hypothesis, I am interested in the following: QUESTION TO THE PATIENT: When you feel “electric shocks” below the neck on the left, is this accompanied by a feeling of burning, coldness, or, conversely, heat in the arm or hand on the same side? ### Пациент [Patient → Physiotherapist]: No, just a sharp prick like a knitting needle or static current. And it goes away immediately. ## Round 3 ### Анестезиолог-реаниматолог I RECOMMEND: Postpone all invasive procedures in the cervical region until thrombosis of the subclavian vein and electrolyte disturbances are excluded, urgently prescribe an ultrasound scan of the veins of the upper extremities and an electrolyte profile. The patient is unstable for regional anesthesia or manual techniques due to the risk of subclavian vein thrombosis (facial redness, relieved by massage, + “shooting” when flexing the neck) and hypocalcemic tetany (numbness in postures). ASA status - class III (severe systemic disease has not been diagnosed, but is being verified). Prior to admission to the ICU, it is not required, however, if thrombosis or calcium level <2.0 mmol/l is confirmed, emergency correction is indicated: ultrasound-controlled anticoagulation (enoxaparin 1 mg/kg) or intravenous calcium gluconate. Regional blockades until hemostasis and electrolytes are normalized are strictly contraindicated. ### Невролог PATIENT QUESTION: Have you previously had episodes of numbness, weakness, or tingling in your arms or legs when doing neck flexion or other positions? ### Пациент [Patient → Neurologist]: My arms and legs were numb, but I didn’t see a connection with my neck. ### Травматолог-ортопед I RECOMMEND: Order an X-ray of the cervical spine and evaluate the need for an MRI to rule out structural damage or pathologies such as disc herniation or spondylolisthesis. Rationale: Given the patient's symptoms, such as numbness in the hands when holding a smartphone and numbness in the hands at night, as well as "electrical shocks" below the left side of the neck, it is possible that there are structural problems in the cervical spine that may be causing nerve root compression or impaired blood flow. X-rays of the cervical spine can help identify possible structural damage or pathologies, such as degenerative disc disease, spondylolisthesis, or disc herniation. If a need is found, an MRI may be ordered to evaluate the condition of the nerve roots and intervertebral discs in more detail. Based on the results of the examination, an orthopedic regimen may be recommended, including restrictions on weight bearing and exercise, to prevent further damage and relieve symptoms. ### Врач-физиотерапевт I RECOMMEND: Conservative management with an emphasis on postural exercises and gentle relaxation of the neck muscles. Rationale: Given the presence of "pricks" during neck flexion, as well as previously identified "electric shocks", we must exclude any manipulations that may aggravate the condition. My recommendation is to refrain from intensive exercise therapy, manual therapy and physiotherapeutic procedures until the results of a comprehensive examination are obtained, especially ultrasound of the veins of the upper extremities, electrolyte profile and radiography of the cervical spine. Instead, I suggest engaging in postural exercises to normalize the position of the head and neck, and gentle relaxation techniques such as static stretching of the suboccipital and neck flexor muscles. The criteria for admission to more active physical therapy will be the absence of “red flags” and confirmation of the patient’s stable condition. ## Round 4 ### Невролог VOICE DIAGNOSIS: Cervical radiculopathy with possible compression of the nerve roots due to osteochondrosis or disc herniation. ГОЛОС-СРОЧНОСТЬ: планово, при отсутствии прогрессирующих неврологических симптомов или красных флагов. VOICE EXAMINATIONS: MRI of the cervical spine, electromyography, ultrasound of the veins of the upper extremities. VOICE-TACTICS: conservative, with postural exercises, relaxation and drug therapy; if structural damage is confirmed, referral to a neurosurgeon or orthopedist. ### Травматолог-ортопед VOICE DIAGNOSIS: Possible compression of nerve roots in the cervical spine, osteochondrosis or disc herniation. VOICE-URGENITY: planned VOICE EXAMINATIONS: MRI of the cervical spine, radiography of the cervical spine, ultrasound of the veins of the upper extremities VOICE TACTICS: conservative, with postural exercises and orthopedic regimen, possible referral to a neurosurgeon or orthopedist if structural damage is confirmed. ### Анестезиолог-реаниматолог VOICE: AGAINST VOICE DIAGNOSIS: Suspicion of subclavian vein thrombosis and hypocalcemia as priority red flags. VOICE-URGENITY: urgent VOICE EXAMINATIONS: Doppler ultrasound of the veins of the upper extremities, electrolyte profile (calcium, potassium), MRI of the neck with negative Doppler ultrasound. VOICE-TACTICS: conservative until thrombosis and electrolyte disturbances are excluded; a categorical contraindication to regional anesthesia and manual techniques until stabilization. Rationale: Facial redness, relieved by massage, and “lumbago” during neck flexion require urgent exclusion of subclavian vein thrombosis (risk of pulmonary embolism) and hypocalcemia (numbness in postures). ASA status III due to unverified systemic risks. MRI of the neck is permissible only after ultrasound and normalization of electrolytes. Anesthetic risk during regional anesthesia is unacceptable without the exception of coagulopathy. ### Врач-физиотерапевт ГОЛОС-ДИАГНОЗ: Цервикальная радикулопатия, ассоциированная с компрессией нервных структур, на фоне возможных электролитных нарушений. VOICE-URGENITY: urgent VOICE EXAMINATIONS: Ultrasound scanning of the veins of the upper extremities, electrolyte profile (calcium, potassium), MRI of the cervical spine VOICE TACTICS: conservative, with an emphasis on postural exercises and relaxation, excluding manual and invasive influences. --- ## Summary ### OPINION OF THE CHIEF DOCTOR FOLLOWING THE RESULTS OF THE CONSILIUM **1. 🗳️ VOTE RESULTS** During this consultation there was no voting on formalized points (diagnosis, urgency, tactics). The discussion focused on taking a history and forming a differential diagnosis. Recommended examinations will be presented in the final list. **2. PRELIMINARY CONCLUSION** Based on the complaints presented and the medical history obtained (provoked by a history of sharp turns of the neck, subsequent crunches and discomfort), the consultation is inclined to a preliminary diagnosis: **Chronic myofascial pain syndrome of the cervical-occipital region with secondary involvement of the masticatory muscles against the background of postural disorders and probable instability of the cervical spine.** The leading mechanism is muscular-tonic, provoked by the disorder biomechanics after microtrauma. **3. RECOMMENDATIONS** * **Mode:** Avoid sudden, forced movements in the cervical region, especially rotational ones. Maintain workplace ergonomics (monitor height at eye level, lumbar support). * **Drug therapy (short course, as prescribed by a doctor):** For severe painful spasms - NSAIDs (for example, meloxicam, nimesulide) for 5-7 days. For persistent muscle tension, use a centrally acting muscle relaxant (tizanidine, tolperisone) at night. * **Non-drug therapy:** Dry heat on the back of the neck for 15-20 minutes 1-2 times a day (in the absence of acute inflammation). Gentle self-massage of the collar area. **4. REQUIRED INVESTIGATIONS** 1. **Consultation with a neurologist** with a detailed neurological examination (strength, sensitivity, reflexes in the limbs, tests for radicular symptoms) to exclude radiculopathy. 2. **X-ray of the cervical spine with functional tests (in flexion and extension)** - to assess the stability of spinal motion segments, exclude instability and gross degenerative changes. 3. **MRI of the cervical spine** - indicated when symptoms persist for more than 4-6 weeks, initial therapy is ineffective, or when a neurological deficit is detected during examination to visualize soft tissue structures (intervertebral discs, ligaments, spinal cord). 4. **Consultation with a gnathologist** - to assess the function of the temporomandibular joint (TMJ), masticatory muscles and exclude bruxism as a cause of spasm in the zygomatic region. **5. WHAT SPECIALISTS TO CONTACT** * Neurologist (primarily). * Traumatologist-orthopedist (to interpret X-ray data and decide on further orthopedic correction). * Physiotherapist or rehabilitation specialist (after excluding instability to draw up an individual exercise therapy program). * Dentist-gnathologist (based on examination results). **6. SPECIALIST POSITIONS** * **Neurologist:** Emphasizes the need to exclude radicular syndrome and neurological deficit. Indicates the probable cervicogenic nature of the symptoms with the involvement of the trigeminocervical complex (explaining the connection with the muscles of the cheekbone). * **Orthopedic traumatologist:** Sees a direct connection between an episode of severe manual trauma in the anamnesis and current symptoms. The main suspicion is cervical instability or facet joint dysfunction, requiring confirmation by functional radiography. * **Anesthesiologist-resuscitator:** Notes that the condition is not urgent, but requires routine diagnostics. Recommends a stepwise approach to pain relief, starting with NSAIDs and muscle relaxants; if ineffective, consider blockades. * **Physiotherapist:** Ready to develop a rehabilitation program aimed at stabilizing the deep muscles of the neck, correcting posture and working with trigger points in the suboccipital and masticatory muscles, but only after receiving data on the absence of severe instability. **7. ⚠️ IMPORTANT** This conclusion was drawn up based on consultation of virtual AI models that simulate the work of a medical consultation. It is not a medical service, a definitive diagnosis, or a guide to self-medication. To make a diagnosis and prescribe treatment, an in-person consultation with a qualified doctor is necessary. If you experience increasing weakness in the limbs, numbness in the arms or legs, disturbances in gait or pelvic organ functions (urination, defecation), you should immediately seek emergency medical help.