What is coat hanger pain?

Estimated reading time: 4 minutesCoat hanger pain is a pain in the neck and upper back, specifically the suboccipital and paracervical regions. It has been described as a “charley horse” kind of sensation in the back of the neck and shoulders. This pattern mimics the shape of a coat hanger with the hook in the neck and the body spreading out across the upper trapezius muscles and shoulders.

Similar to headaches, this is such a common type of pain in the EDS / HSD community. There can be several contributing factors to this pain, which we will explore in greater detail. As there are many factors, we need to appreciate how these work together and adopt some strategies to overcome coat hanger pain.

Exploring the causes behind the pain

Orthostatic intolerance and lack of blood low

Coat-hanger pain is very commonly found in people with conditions that affect the autonomic nervous system (dysautonomia), such as orthostatic hypotension (OH), multiple system atrophy (MSA), and potentially POTS (1, 2, 3). 93% of patients with pure autonomic failure report coat-hanger pain (2).

Coat-hanger pain that improves with sitting or lying down is listed as a symptom in a recent article for providers on how to assess autonomic conditions and obtain a comprehensive medical history (4).

One theory is that because the neck muscles are anti-gravity muscles and are always actively supporting the neck, they are continuously using the oxygen that is delivered to them in the blood. If the blood flow falls below what is needed (such as occurs in people with orthostatic intolerance), the waste products of the muscle activity build up, which can lead to pain (4).

In one study of people with OH, 59% reported coat-hanger pain during their daily activities (3). This study also found that there was a high degree in variability in patients in the severity of the pain, the presence of other symptoms, and how long people needed to recover after laying down.

They suggest this points to the complexity of the condition and that it is probably not just a lack of blood flow to the muscles. Stimulation of other structures in the head and neck can produce the same pain pattern. They even mention that many of their patients had a loss of vagal nerve function that could alter the headache threshold (3).

Muscle tension patterns

I often see this pain pattern in my clients who have a particular pattern: tight muscles at the front of the body and long, stringy muscles in the back body. We are out of balance, so muscles fatigue and complain, leaving this nagging daily pain.

Our posture tends to mimic this with a forward slump and rounded shoulders, maybe a winging scapula. Forward head posture and associated neck pain can follow.

Interestingly, you may also find with this type of posture that a neck hump is developing on the back of your neck. People are often concerned about this development. The reason behind this hump on the back of the neck is due to a laying down of fascia. Fascia responds to force and pressure traveling through the connective tissue.

With a forward head posture, the head weight increases significantly, causing shearing on the vertebrae. The body begins to lay down a fat pad with fascia over time to protect the joints. With appropriate treatment, exercise, and posture, I see these fat pads diminish in my clients.

The fascia has an amazing ability to remodel itself. If we change the forces traveling excessively through a couple of joints, we can change the presentation of the fascia.

While the cause of coat-hanger pain is believed to be multi-factorial, both dysautonomia and postural issues could likely contribute to the lack of blood flow to these muscles, leading to pain. The good news is that there are things to try to manage this pain. We will discuss this below.

Identifying symptoms and the diagnostic process

It is always important to see a medical professional like an EDS-aware physical therapist or physiotherapist if you are experiencing new types of neck and shoulder pain.

They can help identify the cause of the pain, and appropriate manual therapy may be useful in relieving some of the pain symptoms so that you can start to exercise and bring balance to the structure. I have a list of providers who have been trained in my Integral Movement Method, many of whom are physical therapists and physiotherapists.

Home management strategies

There are many strategies we can try to alleviate this condition. Some of these include:

• Hydration
  • Maintaining hydration can reduce orthostatic and coat-hanger headaches due to dysautonomia (5).
• Heat
  • Using a heating pad on the upper back may increase blood flow to the area and relax the overworked muscles.
• Movement
  • This can help increase blood flow to the area and hydrate the fascia.
• Counterpressure maneuvers to get the blood pumping back to the head (6)
  • Things like leg-crossing, calf pumps, squatting, etc.
• Address posture and strength
  • We can change the coat hanger so that it does hold us up in alignment rather than feeling the coat is too heavy! Exercise can really target this area.
• Address pain sensitization
  • Addressing nociplastic pain through nervous system regulating strategies
• Breathing
  • Starting with supine breathing exercises can help allow the muscles to relax. The use of gravity to allow the bones to settle can release habitual tension from the upper back tissues. Once we have relaxed those muscles, we can start implementing some appropriate hypermobility/EDS stability and strengthening exercises. Want to try some breathing exercises? Check out this video.
• Ergonomics
  • It can be worth addressing ergonomic desk setup or driving positions to make sure we are not exacerbating a coat hanger position during our daily activities.

Emily Rich, OT recently joined us in The Zebra Club. and gave a fantastic presentation on the non-pharmacological management of POTS. Members can find this in the resource section in the Presentations folder. This will provide additional resources for addressing postural orthostatic challenges that contribute to coat hanger pain.

Seeking professional care

If you find that your coat-hanger pain improves with lying down, it may be especially beneficial to discuss with your doctor; this can be a symptom of many different types of dysautonomia.

Many things can be done to address some of the symptoms of dysautonomia, from medication to lifestyle interventions like salt intake and compression. Dysautonomia International has a provider’s directory that may help.

Want to try some exercises to start to address your coat hanger pain? Here is one video I created to address this.

If you like that one, I have a full-length Coat Hanger Pain class created by popular request. This one has been very popular since I added it to the video library in The Zebra Club.

FAQ

What does a coat hanger pain feel like?

Coat hanger pain can feel like increased tension, cramping pain, aching, burning, or other painful sensations. It occurs along the upper back or traps, out towards the shoulders, and up into the neck in the shape of a coat hanger.

What is the coat hanger effect?

The coat hanger effect refers to the coat hanger-type pain in the neck and upper back that is often associated with conditions that affect the autonomic system.

How to get rid of hanger pain?

Some strategies to lessen coat hanger pain include heat, hydration, laying down, movement, and counterpressure maneuvers. Working on strengthening this may help. If laying down does help significantly, it may be worth talking to your doctor about dysautonomia.

Jeannie Di Bon

Jeannie Di Bon is a movement therapist, educator and author specializing in hypermobility, Ehlers-Danlos Syndrome and chronic pain. She is the founder of The Zebra Club app and the creator of the Integral Movement Method.