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  • Writer's pictureTyler Riley

Deep Cervical Flexors and Their Role in Neck Pain

The neck moves in four ways: flexion, extension, lateral flexion and rotation. Deep cervical flexors (DCFs) and superficial cervical flexors (SCFs) work together to help perform these movements. The primary DCFs include the longus colli and longus capitis. These muscles play a key role in stabilizing the cervical spine during movement.

Neck pain is a common complaint among pilots, with over 80% reporting neck pain at some point during their lifetime (Murray). Pilots experience sustained G-forces along the Gz-plane, which place a strenuous load on the cervical spine. When head gear such as helmets and night-vision goggles are factored into the equation, necks are placed in a compromised position where DCFs can be strained (Murray, Pousette). Pilots report the “check six” position (rotation + extension) as a common contributor to their neck pain (Kikukawa).

Among pilots who report neck pain, Electromyography (EMG) studies show there is higher activation of SCFs such as the sternocleidomastoid and anterior scalene muscles compared to DCFs (Jull). Alternatively, there is decreased activation among the longus colli and longus capitis, suggesting that the increased activation of SCFs may be an over-compensatory response (Jull). Similarly, the evidence supports that increased endurance and strength of the deep cervical flexors is associated with decreased levels of neck pain.

SCFs such as the sternocleidomastoid muscle tend to overcompensate for poor activation of the deep cervical flexors. Coupled with the reduced endurance of DCFs among pilots with neck pain, this poses a significant risk to fighter pilots by leaving them more vulnerable to acute spinal injury or inability to fly (Murray). Pilots may benefit from retraining their DCFs within the context of a motor relearning program. Additionally, a warm-up targeting both the DCFs and SCFs may benefit pilots during a pre-flight warm-up (Bobos). This would incorporate isometric and range-of-motion exercises.

For specific exercise protocols, please contact our team at


Bobos, P., Billis, E., Papanikolaou, D. T., Koutsojannis, C., & MacDermid, J. C. (2016). Does Deep Cervical Flexor Muscle Training Affect Pain Pressure Thresholds of Myofascial Trigger Points in Patients with Chronic Neck Pain? A Prospective Randomized Controlled Trial. Rehabilitation research and practice, 2016, 6480826.

Jull GA, Falla D, Vicenzino B, Hodges PW. The effect of therapeutic exercise on activation of the deep cervical flexor muscles in people with chronic neck pain. Man Ther. 2009 Dec;14(6):696-701. doi: 10.1016/j.math.2009.05.004. Epub 2009 Jul 25. PMID: 19632880.

Kikukawa A, Tachibana S, Yagura S. (1995, March) G-related musculoskeletal spine symptoms in Japan Air Self Defense Force F-15 pilots. Aviat Space Environ Med. 1995 Mar;66(3):269-72. PMID: 7661840.

Murray, M., Lange, B., Nørnberg, B.R. et al. (2015, August 19) Specific exercise training for reducing neck and shoulder pain among military helicopter pilots and crew members: a randomized controlled trial protocol. BMC Musculoskelet Disord 16, 198

Pousette MW, Lo Martire R, Linder J, Kristoffersson M, Äng BO. (2016, November 1) Neck Muscle Strain in Air Force Pilots Wearing Night Vision Goggles. Aerosp Med Hum Perform. 2016;87(11):928-932. doi: 10.3357/AMHP.4579.2016. PMID: 27779951.

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