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Cervical Pain in the Athlete: Common Conditions and Treatment
Prim Care Clin Office Pract 32 (2005) 231–243
Cervical Pain in the Athlete: Common Conditions and Treatment Gary W. Dorshimer, MD, FACPa,b,c,*, Michael Kelly, DOa a
Internal Medicine/Sports Medicine, University of Pennsylvania Health System—Pennsylvania Hospital, 727 Delancy St, Philadelphia, PA b Head Team Physician, Philadelphia Flyers and Philadelphia Phantoms c Team Internist, Philadelphia Eagles and Philadelphia KIXX
It is important for primary care providers who take care of an athletic population to be familiar with the basic management of cervical pain and emergencies. This is especially true of those physicians who are involved with organized athletic events or who serve as team physicians. In addition, neck pain is a fairly common complaint in general practice, and a basic understanding of the evaluation and management of common neck injuries is an asset for most primary care physicians. Often, the patient who has cervical pain is not a well-conditioned athlete, but rather a ‘‘weekend warrior’’ who has sustained an injury during a recreational athletic event. Furthermore, it is not uncommon for primary care physicians to find themselves in the position of the unofficial team doctor at local athletic events, especially when their children are participating. Cervical emergencies When dealing with a possible cervical emergency during an athletic event, basic cardiopulmonary resuscitation and trauma management guidelines should be followed. It is imperative to keep the injured athlete immobile until cervical spinal injury is ruled out. Unconscious athletes are always assumed to have a cervical spinal injury until proven otherwise. When an injury is witnessed by the physician, the most worrisome mechanism of injury involves axial loading with the neck flexed or hyperextended, because
* Corresponding author. Delancey Medical Associates, 727 Delancey Street, Philadelphia, PA 19106. E-mail address: [email protected] (G.W. Dorshimer). 0095-4543/05/$ - see front matter Ó 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.pop.2004.11.005 primarycare.theclinics.com
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this can cause pinching of the spinal cord, resulting in spinal cord neuropraxia. Another worrisome mechanism of injury involves spear tackling (using the helmet as the point of impact when tackling), because the normal protective effect of cervical lordosis is lost upon impact, which can result in severe neurological injury acutely and bony abnormalities of the cervical spine chronically. This should raise clinical suspicion for the potential of a serious cervical injury even before the athlete is evaluated. Shoulder pads and helmets in football and hockey players should be left on, and the athlete’s neck should be stabilized. The face mask or shield can be cut off to facilitate airway management. The athlete’s airway should be cleared with a jaw thrust maneuver only. Head repositioning and neck extension are never used in an unconscious athlete who has suspected cervical injury. The only time the helmet should be removed is when the athlete’s airway cannot be maintained and the risk of asphyxiation is greater than the risk of cervical injury, or when the helmet prevents cervical immobilization. Any athlete who remains unconscious should be log-rolled onto a spinal back board and transported to the nearest hospital, with the most experienced person stabilizing the neck until it is secured with sand bags. Physicians dealing with motor sports need to familiarize themselves with the individual protocols involving the removal of different types of helmets for a suspected cervical spine injury. In contact sports such as boxing or martial arts, headgear removal may also increase the risk of cervical injury in the unconscious athlete. If an airway can be maintained and the cervical spine is immobilized, headgear removal can be deferred until cervical injury is safely ruled out. Approaching the conscious athlete who has cervical injury is simplified by the fact that the patient can answer questions and cooperate with a neurological examination. Any focal neurological findings suggest spinal injury and should be treated as above. Other red flags include severe neck pain, rigid cervical spasm, persistent athlete apprehension, severe cervical tenderness, and pain with active range of motion or gentle isometrics [1]. Patients who have cervical injury should never have passive range-ofmotion testing. Although the American College of Surgeons recommends in its Advanced Trauma Life Support guidelines that all patients who have trauma above the clavicle have cervical radiographic studies, it is possible to clear the cervical spine without radiographs if certain conditions are met. The National Emergency X-Ray Use Study (Nexus) [2] found that patients who had no midline cervical tenderness, no focal neurological deficits, normal alertness, no intoxication, and no painful distracting injuries had a low probability of cervical spine injury. Thus, fully conscious athletes who have cervical trauma can be cleared without radiographic studies provided the above-mentioned criteria are met. Another prospective study performed in Canada [3] established the Canadian C-Spine Rule for Radiography in Alert and Stable Trauma
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Patients. In this study, patients were found to have a low risk of cervical spine injury if they had no limitation of cervical rotation 45 in either direction, none of three risk factors that mandated radiographic studies (age [65, dangerous mechanism of injury, or upper extremity parasthesias), and one of the following: simple rear-end motor vehicle collision, sitting position in emergency department, ambulatory at any time, delayed onset of neck pain, or absence of midline tenderness. In a comparison study of both criteria [4], the Canadian C-Spine Rule was found to have superior sensitivity and specificity; however, one should keep in mind that both studies focused on developing a set of criteria for use in an emergency department, not on an athletic field. Although the sports physician can rule out serious injury using the above criteria, it is important to remember that this does not necessarily mean that the athlete can be returned to competition. Even after minor injuries, the athlete must demonstrate a full pain-free range of motion and at least 90% strength before return to play can be advised. Thus the approach to the athlete who has a cervical emergency should include assessment of airway, breathing, circulation, consciousness, and level of apprehension. One should then evaluate the athlete for midline cervical tenderness, severe cervical pain at rest or with active range-of-motion testing, neurological deficits, or severe cervical rigidity. If there is any indication of serious cervical injury, the athlete’s neck should be immobilized, and the athlete should be transported to the nearest emergency room for further evaluation. In all cases, the focus should be on protecting the athlete.
Spear tackling Axial loading of the spine has been found to be a common mechanism of severe spinal cord injury during athletics [5]. When the normal cervical lordosis is lost, an impact to the top of the head can transmit extreme axial forces that can result in severe bony and neurologic injury. Spear tackling is a method of tackling in football that involves using the head as the initial point of contact. Athletes who use this technique repeatedly can develop radiographic changes, including cervical stenosis, straightening of the normal cervical lordotic curve, and post-traumatic bony changes [5]. These changes further increase an athlete’s risk of permanent neurological injury from axial loading, and thus are deemed a contraindication to contact and collision sports participation. In 1975, football rules were changed to ban spear-tackling techniques, and subsequent epidemiological studies have shown that the incidence of serious cervical injuries has decreased dramatically [6]; however, it is still important that coaches, trainers, strength coaches, athletes, and parents of young athletes continue to receive education about the dangers of spear tackling to help prevent neurologic catastrophes.
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Stingers Brachial plexus injuries, which are commonly referred to as ‘‘stingers’’ or ‘‘burners’’ by coaches and athletes, are a common occurrence in athletics, especially in football. These injuries can be caused by either traction on the brachial plexus or compression of the dorsal nerve roots. When the neck is flexed laterally and the contralateral shoulder is depressed, a traction force is created on the brachial plexus. Conversely, extreme lateral flexion of the neck can cause cervical nerve root compression by narrowing the neural foramen [7]. Both types of stingers usually result in a transient neuropraxia, manifested in the injured athlete as burning down the affected arm and weakness of the deltoid, supraspinatus, infraspinatus, biceps, brachioradialis, pronator teres, or wrist extensors [6]. The athlete is usually seen coming off the field or mat shaking his arm, which may be hanging limply at the side, and leaning toward the side of injury. Usually, a stinger is a self-limited injury that does not require anything more than keeping the athlete out of the game until the neurological symptoms have resolved. The athlete should not return to play if there is any cervical pain, limited cervical range of motion, bilateral limb involvement, or persistent neurological deficits. It should be noted that some athletes can have residual weakness for several weeks after resolution of sensory symptoms. Although an experienced sports medicine physician may feel comfortable diagnosing a stinger on the sideline, the primary care physician who has little experience with stingers and neck injuries might consider consulting a spine specialist if the athlete has limited motion, bilateral involvement, or persistent motor weakness. Although players who sustain multiple stingers have an increased risk for future stingers, they do not have an increased risk of serious cervical injury [6,8]. Football players who have recurrent stingers may benefit from neck rolls or ‘‘cowboy collars,’’ which limit the amount of lateral neck flexion. Proper fitting is important to limit neck motion. Because there are no studies regarding the efficacy of collars in the prevention of stingers, their use remains controversial. Athletes who sustain a stinger are restricted from participation until all neurological symptoms have resolved and they regain full strength in the affected extremity. This usually takes only a few minutes, but the length of time for symptom resolution can vary from minutes to weeks. The one caveat is that the athlete who has persistent cervical pain, limited cervical range of motion, bilateral limb involvement, or persistent neurological deficits should be considered to have a cervical spinal injury and evaluated appropriately. Cervical cord neuropraxia Cervical cord neuropraxia is a transient neurological event that can cause neurological symptoms in both arms, both legs, all extremities, or the ipsilateral arm and leg [8]. Both the sensory and motor nerves can be
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involved, and symptoms can include nerve pain, parasthesias, and paresis [8]. The most disturbing manifestation involves all four extremities and is called transient qaudriparesis. This has been found to occur in football, boxing, hockey, basketball, and wrestling [9]. Resolution of symptoms occurs anywhere from 10 minutes to 48 hours [9]. The usual mechanism of injury involves axial loading of the cervical spine while flexed or hyperextended. This is presumed to cause a ‘‘pincher’’ mechanism, which occurs when the cervical canal is narrowed by the movement of one vertebra on top of another during extreme flexion or hyperextension [8]. Infolding of the ligamentum flavum during hyperextension can decrease the diameter of the spinal canal by up to 30% [10]. The transient nature of the episode has led to the term ‘‘spinal cord concussion’’ [9]. The mechanism may involve mechanical deformation of the spinal cord, resulting in a transient rise in intracellular calcium concentration [8].
Spinal stenosis Interestingly, a correlation between cervical spinal stenosis and cervical cord neuropraxia has been found; however, the question of spinal stenosis predisposing an athlete to increased risk for permanent neurologic injury or transient qaudriparesis during contact or collision sports remains controversial [9]. A normal spinal canal is considered to be at least 15 mm in sagittal diameter. A canal with a sagittal diameter less than 13 mm is considered to be stenotic. Torg and Pavlov designed a ratio based on lateral cervical radiographs comparing the sagittal diameter of the spinal canal to the midbody diameter of the vertebral body at the same level. This ratio is commonly referred to in the literature as the Torg ratio or the Pavlov ratio, and a value of less than 0.8 has been found to be predictive of spinal stenosis [9]. Although this ratio has been criticized for being overly sensitive, it has utility when counseling patients who have had an episode of cervical cord neuropraxia. Athletes who had previous cervical cord neuropraxia and a Torg ratio of less than 0.5 have an estimated 75% risk of sustaining another episode if allowed to return to contact sport; however, Torg ratios are not recommended as a routine screening tool in asymptomatic athletes because they have low predictive value and specificity [8].
Functional stenosis The relatively recent use of MRI to evaluate cervical injuries has led to the concept of functional spinal stenosis, which is defined as a spinal cord contour deformation or obliteration of local cerebrospinal fluid space. Some authors believe that athletes with this finding on MRI have an increased risk
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of severe neurological injury with head or neck trauma, and it has been suggested that athletes who have functional stenosis and an episode of transient qaudriparesis should be prohibited from participation in contact sports [11]. Return-to-sport recommendations Any athlete who has had a cervical cord neuropraxia should initially be treated for a serious spinal cord injury, with spinal immobilization and transport to a local hospital for radiographic and neurologic studies. The injured athlete should have anterior-posterior (AP), lateral, and open-mouth odontoid radiographs in combination with a cervical MRI. The return-to-play criteria in asymptomatic athletes following an episode of neuropraxia with documented cervical spinal stenosis is controversial. Torg concluded that in the absence of cervical spine instability or structural deficits, and with normal radiographic studies, asymptomatic athletes who have a Torg ratio of 0.8 or less have no increased risk for injury resulting in permanent neurologic damage, and no contraindication to participation in contact or collision sports. In contrast, Cantu contends that athletes who have spinal stenosis should not participate in contact or collision sports because they have an increased risk of transient qaudriparesis and permanent neurologic injury [9]. It is interesting to note that although Torg states that he has not seen permanent quadriplegia, Cantu has seen permanent quadriplegia in a patient who have cervical stenosis and who suffered an episode of transient quadriplegia with no fracture or dislocation [9]. Spinal cord neuropraxia return-to-sport recommendations 1) Athletes who have a single episode of uncomplicated cervical cord neuropraxia, normal radiographs, normal MRI with no evidence of functional spinal stenosis, and no cervical laxity are thought by some to be able to return to contact or collision sports, provided that the athlete’s neurologic symptoms have resolved [8,9]. Consultation with a specialist is recommended to confirm the absence of a functional spinal stenosis or other occult neurological disease that might increase the athlete’s risk of permanent neurological injury. 2) Athletes who have uncomplicated cervical cord neuropraxia and Torg ratios of 0.8 or less, degenerative joint disease, or intervertebral disk disease have a relative contraindication to collision sports participation. 3) Athletes who have an episode of cervical cord neuropraxia combined with cervical instability, neurological symptoms for more than 36 hours, evidence of spinal cord edema or defect, or bone abnormalities have an absolute contraindication to collision sports participation [8]. 4) Athletes who have multiple cervical cord neuropraxia episodes have a contraindication to collision sports participation [8].
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Cervical strain/sprain The neck is a relatively complex part of the human body, and subsequently is susceptible to multiple injuries. Athletes can injure the ligaments, muscles, bones, joints, and even the vasculature of the neck. It is important for the physician to differentiate between serious cervical injury and minor soft-tissue injury. All athletes who have cervical injury should first be evaluated for signs of serious injury, including neurological deficits, limited active range of motion, midline tenderness, severe pain or spasm, and persistent apprehension. After serious injury has been ruled out, the athlete can then be assessed for cervical strains, sprains, contusions, and joint dysfunction. A cervical strain involves injury to cervical muscles or tendons, whereas a cervical sprain involves injury to the cervical ligaments. Most cervical strains occur with eccentric contraction of the neck muscles. These injuries occur not only in sport, but also can occur during many activities of daily living. Interestingly, it has been found that muscles with high ratios of fasttwitch fibers have a higher risk for strains [12]. Most muscle strains can be managed with rest, ice, anti-inflammatory medication, neck support as needed, and gentle range-of-motion exercises. Manipulation may be helpful in relieving the associated muscle spasms and joint dysfunctions. Athletes are allowed to return to play when they regain full strength and range of motion. Cervical sprains can range from minor ligament injury to severe ligament disruption with instability and joint dislocation. Coexisting muscle injuries are a common finding with cervical sprains, and one should be careful not to overlook a possible cervical sprain when evaluating cervical strains, because ligament injuries usually take more time to heal. If severe, they can cause cervical laxity, which increases the athlete’s risk of neurological injury. A common mechanism of injury is a ‘‘whiplash’’ or acceleration-deceleration force on the neck. The major concern with a cervical sprain is the amount of ligamentous laxity. Cervical laxity should never be tested passively. One can ask the athlete to move his head or one can test stability with gentle isokinetic testing (ie, have the athlete keep his head neutral and push against the examiner’s hand). At no time should the examiner push the athlete’s head out of the neutral position. If there is any question about cervical stability, immobilization, radiographs, and consultation with a spine specialist are indicated. It is often helpful to have flexion and extension radiographs in addition to the AP, lateral, and odontoid views to access cervical laxity [13]. Greater than 3.5 mm AP displacement on flexion and extension views or 11 of rotation on AP radiographs indicate cervical ligamentous laxity, which is a contraindication to contact or collision sports participation. Ligamentous laxity of less than 3.5 mm AP displacement on flexion and extension views, or less than 11 of rotation degrees of rotation on
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anteroposterior radiographs is a relative contraindication to contact sports participation [8]. Minor sprains are treated similarly to strains with rest, ice, antiinflammatory medication, neck support as needed, and gentle range-ofmotion exercises. Severe sprains or sprains with ligamentous laxity should be managed by a spine specialist. Osteopathic manipulation may be helpful in treating minor cervical injuries, but it is important to avoid manipulation in the following scenarios: focal neurological deficits, severe cervical pain or spasm, point tenderness over bone, advanced age, severe arthrosclerosis, rheumatoid arthritis, osteoporosis, cervical fusion or fracture, and cervical laxity. Although metanalyses and credible studies on cervical manipulation for athletic injuries are lacking, given the popularity of manipulation with trainers, physical therapists, and athletes, it is important for the physician taking care of athletes to know the contraindications to manipulation. In addition, cervical manipulation should be avoided until serious spinal injuries, including fractures, are ruled out. Other modalities in the treatment of cervical pain may include acupuncture, ultrasound, and topical analgesic creams. Although no controlled studies have demonstrated increased efficacy of these modalities, they remain popular with athletes, coaches, and trainers. Discogenic neck pain Although lumbar disc disease is a common cause of low back pain in the general population, cervical disc disease is a relatively uncommon cause of neck pain in athletes. Cervical disc disease usually affects older athletes, and is more frequent in athletes participating in football and wrestling [12]. Discogenic neck pain in athletes can be caused by cervical disc herniation with subsequent nerve root compression, or degenerative disk disease with a loss of disc height and marginal osteophytes. The symptoms of cervical disc disease may include neck pain, radicular arm pain, loss of arm strength, and deep tendon reflexes if the nerve root compression is severe enough. Cervical disc disease can be treated with relative rest, activity modification, anti-inflammatory medications, cervical support, and progressive rehabilitation. During the acute phase of injury, a short course of oral corticosteroids or nonsteroidal anti-inflammatory agents may be useful in the treatment of symptoms, although controlled studies are lacking. Chronic cases may be treated with epidural or selective nerve-root injections [14–17], though their efficacy is controversial. Athletes who have discogenic neck pain are allowed to return to play when they are asymptomatic, have regained full strength, and range of motion has returned to baseline [12]. Patients who fail to respond to conservative therapy and who continue to have focal neurological symptoms (arm weakness and persistent or
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worsening radicular symptoms, and so on) deserve consultation with a spinal specialist and possible surgical intervention. Return-to-play criteria for postsurgical patients depends on the level of surgery and the number of spinal fusions. A stable one-level spinal fusion at C3 or below is not a contraindication for contact or collision sports. Asymptomatic athletes who have normal neurological function and a two- or three-level spinal fusion may be allowed to return to contact sports, but they are usually advised to avoid contact or collision sports, because the stresses at the vertebrae adjacent to the fusion may lead to degenerative changes. Fusions above C3 and those involving more than three spinal levels are an absolute contraindication to contact or collision sports [8]. Special populations Certain subgroups of athletes have an increased risk of severe spinal cord injury during athletics. These subgroups include patients who have Down syndrome, certain forms of dwarfism, and patients who have rheumatoid arthritis. It is important for physicians dealing with neck pain to recognize that these patients have an increased risk of serious neck injury, and have different restrictions on athletic participation. Athletic patients who have Down syndrome are of particular concern, because atlantoaxial instability has been found in up to 30% of these patients. Twelve to sixteen percent of Down patients who have such instability develop neurologic signs and symptoms [18]. There are a number of athletic events for Down syndrome patients, including the Special Olympics. Down syndrome patients often look to their primary care physician for preparticipation physicals. There are a number of important issues to consider when dealing with such patients. The physician needs to be familiar with the athletic restrictions as well as the signs and symptoms that would not only disqualify the patient from athletic participation, but also prompt a full work-up, including radiographic studies. Initially, the Special Olympics and the American Academy of Pediatrics were both in favor of preparticipation lateral neck radiographs, and many authors are still advocates of their utility [18,19]. Preparticipation lateral neck radiographs continue to be required for participation in the Special Olympics, but in 1995, the American Academy of Pediatrics reversed its position based on re-evaluation of the initial data [19]. The controversy arises from the fact that some Down syndrome patients can initially have abnormal radiographs but normal follow-up radiographs. Conversely, some patients have normal radiographs that eventually become abnormal as they age. Thus, although it is difficult to access the utility of screening radiographs and the issue continues to be debated in the literature, the physician responsible for preparticipation screening of these athletes must obtain preparticipation radiographs because they are required for participation in the Special Olympics.
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The neurological manifestations of atlantoaxial instability in Down syndrome patients include neck pain, gait disturbances, decreased cervical mobility, torticollis, incoordination, spasticity, hyperreflexia, clonus, and other focal findings. Down syndrome patients who have any of these neurological symptoms should have a full evaluation, including an MRI and consultation with a specialist, before clearing for sports participation. The Special Olympics sports that patients who have atlantoaxial instability demonstrated on radiographs should be restricted from include gymnastics, diving, pentathlon, the butterfly swimming stroke, high jumps, soccer, and certain warm-ups that include neck stretching, because these activities have an increased risk of neurological injury. In addition, patients who have known atlantoaxial instability are often restricted from contact sports such as football, wrestling, rugby, and so forth. It is recommended that Down syndrome patients who have atlantoaxial instability and stable neurological symptoms have current radiographic studies before participating in any athletic event, including noncontact events. Patients who have rheumatoid arthritis make up another subgroup who have an increased risk of severe spinal cord injury during participation in contact sports, because of the increased incidence of cervical instability in these patients. Cervical subluxation can be found in 15% of rheumatoid arthritis patients within 3 years of diagnosis, and 17% of rheumatoid arthritis patients who have radiographic abnormalities have neurological symptoms. It is not uncommon for a rheumatoid arthritis patient to see a primary care or sports medicine physician with a complaint of neck pain. Such complaints should be taken seriously, and one should inquire about all physical activity. Many older patients may not consider certain activities athletic, but given their age and comorbid conditions, these events may be quite strenuous. For example, an active 72-year-old rheumatoid arthritis patient developed neck pain after feeling a sharp snap in her neck while ballroom dancing. This patient was eventually diagnosed with atlantoaxial instability and cervical myelopathy [20]. Thus it is important to have a high index of suspicion for atlantoaxial instability and possible cervical spine injury in active rheumatoid arthritis patients. Any rheumatoid arthritis patient who has neck pain that occurs suddenly during physical activity should have radiographic studies to rule out atlantoaxial instability, as well as a full neurological examination. Once again, it is important to never passively test cervical range of motion. Vascular injury In many contact sports, it is quite common for participants to sustain blunt neck trauma. Although such impacts usually result in minor contusions, they have the potential to cause a number of serious injuries involving the cervical vascular structures. Blunt trauma to the carotid artery can cause a dissection, thrombus, or emboli, all of which can result in
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a stroke. In addition, there are a number of cases of syncope, delayed neurological symptoms, and even death from carotid artery trauma [21,22]. Kane [23] reported a case involving a football player who sustained blunt trauma to the carotid sinus during a game. The player walked off the field and complained of dizziness while sitting on the bench. A short time later, the athlete suffered a syncopal episode that was attributed to carotid sinus trauma. Meairs et al [24] reported a case involving a martial artist who developed hemiplegia and aphasia while trying to break free from a neck hold. MRI revealed ischemia in the region of the middle cerebral artery. Ultrasound revealed a punched-out defect in the internal carotid artery, indicative of an atherosclerotic plaque rupture and embolic event. The patient was treated with anticoagulation and thrombolytics. Postthrombolysis, the hemiplegia resolved and the aphasia improved. Although such occurrences are relatively rare, it is important for the physician treating athletes who have neck pain to consider possible involvement of the vascular structures. The treatment of cervical vascular injuries varies from anticoagulation and thrombolytic therapy to vascular surgery. The key to treating these patients is early recognition, prompt anticoagulation, and urgent consultation with a vascular surgeon. Other causes of neck pain There are a number of nonmusculoskeletal causes of neck pain, and one should keep in mind the various medical conditions that may present as neck pain in the athlete. The differential diagnosis for neck pain can be quite extensive. Fortunately, a careful history and physical examination often help one to find the correct diagnosis. It is important for one to observe the patient while eliciting the medical history, because the patient may literally point to the diagnosis. When a patient indicates that his neck pain is anterior or lateral in location, one should consider disorders that include pharyngitis; eagle syndrome (calcification of hyoid ligaments); neck mass (benign or neoplastic); lymphadenopathy due to oropharyngeal, sinus, or dental infections; neuropathic pain; gastroesophageal reflux; and ischemic coronary disease. Sterno-clavicular arthritis or sprain can also cause pain at the anterior base of the neck, with radiation cephalad. Rarely, arteritis of the carotid or carotid dissection can cause neck pain. Superior vena cava syndrome can prompt patients to seek medical attention for neck pain and swelling. When a patient points to the trapezius or scapular areas and complains of shoulder pain, cervical disorders should be prominent in the differential diagnosis. When a patient points to the base of the skull and complains of neck pain, disorders such as occipital neuralgia should be considered, especially if the pain radiates to the back of the head. Other causes of anterior neck pain include pneumomediastinum, acute cholecystitis, laryngeal or tracheal trauma, and aortic dissection, but these disorders often have other associated symptoms to help identify the etiology.
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Summary In summary, it is important for physicians dealing with neck pain in an athletic population to understand the differences between serious and mild cervical injuries. This is best facilitated by a thorough understanding of the signs and symptoms of serious cervical injury, familiarity with the basic anatomy of the neck and its structures, and a working knowledge of common causes of neck pain and mechanisms of injury. All unconscious athletes should be assumed to have a serious cervical injury until proven otherwise, and preventive measures should be taken to ensure the safety of the athlete. This includes airway management with a jaw thrust only, neck stabilization, and preventing helmet removal. In the conscious athlete who has neck pain, serious cervical injury can often be ruled out with an accurate history and physical examination. In all cases of neck pain, it is imperative that the athlete be protected. This may involve removing the athlete from competition, or transporting him or her to the local emergency room. Often, this decision falls on the shoulders of the doctor in the stands. Thus, a basic understanding of the evaluation and management of neck pain in athletes is an asset for all physicians who frequent athletic events or see athletes in the office. The physician responsible for patients who have Down syndrome or rheumatoid arthritis needs to consider the increased incidence of cervical instability in these patients when evaluating for athletic participation or neck pain. References [1] Haight RR, Shiple BJ. Sideline evaluation of neck pain: when is it time for transport? Phys Sportsmed 2001;29(3):8–15. [2] Hoffman JR, Mower WR, Wolfson AB, et al. Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. N Engl J Med 2000;343(2):94–9. [3] Stiell IG, Clement CM, McKnight RD, et al. The Canadian C-Spine Rule for Radiography in Alert and Stable Trauma Patients. JAMA 2001;286(15):1841–8. [4] Stiell IG, Clement CM, McKnight RD, et al. The Canadian C-Spine Rule versus the NEXUS Low-Risk Criteria in patients with trauma. N Engl J Med 2003;349(26):2510–8. [5] Torg JS, Sennett B, Pavlov H, et al. Spear tackler’s spine: an entity precluding participation in tackle football and collision activities that expose the cervical spine to axial energy inputs. American Journal of Sports Medicine 1993;21(5):640–9. [6] Garrick JG, Web DR. Sports injuries: diagnosis and management. 2nd edition. Philadelphia: WB Saunders; 1999. p. 202–3. [7] Ghiselli D, Schaadt G, Mcallister DR. On the field evaluation of an athlete with a head or neck injury. Clin Sports Med 2003;22:456. [8] Torg JS, Ramsey-Emrheim JA. Cervical spine and brachial plexus injuries: return to play recommendations, Phys Sportsmed;25(7):3–10. [9] Allen CR, Kang JD. Transient qaudriparesis in the athlete. Clin Sports Med 2001;21(1):16. [10] Moiel RH, Raso E, Waltz TA. Central cord syndrome resulting from congenital narrowness of the cervical spinal canal. J Trauma 1970;10:502–10. [11] Cantu RC. The cervical spinal stenosis controversy. Clin Sports Med 1998;17:121–7.
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[12] Zmurko MG, Tannoury TY, Tannoury CA, et al. Cervical sprains, strains, disc herniations, minor fractures, and other cervical injuries in the athlete. Clin Sports Med 2003;22:514. [13] Eiff MP, Hatch RL, Calmbach WL. Fracture management for primary Care. 2nd edition. Philadelphia: WB Saunders; 1998. p. 211–30. [14] Hession WG, Stanczak JD, Davis KW, et al. Epidural steroid injections. Semin Roentgenol 2004;39(1):7–23. [15] Stav A, Ovadia L, Sternberg A, et al. Cervical epidural steroid injection for cervicobrachialgia. Acta Anaesthesiol Scand 1993;37(6):562–6. [16] Rowlingson JC, Kirschenbaum CP. Epidural analgesic techniques in the management of cervical pain. Anesth Analg 1986;65(9):938–42. [17] Cicala RS, Thoni K, Angel JJ. Long term results of cervical epidural steroid injections. Clin J Pain 1989;5(2):143–5. [18] Winell J, Burke SW. Sports participation of children with Down syndrome. Orthop Clin North Am 2003;34:440. [19] American Academy of Pediatrics. Committee on Sports Medicine. Atlantoaxial instability in Down syndrome: subject review. Pediatrics 1995;96(1):151–4. [20] Casey AT, Crockard HA, Pringle J, et al. Rheumatoid arthritis of the cervical spine: current techniques for management. Orthop Clin North Am 2002;33:291–309. [21] McCarron MO, Patterson J, Duncan R. Stroke without dissection from a neck holding maneuver in martial arts. Br J Sports Med 1997;31(4):346–7. [22] Carr S, Troop B, Hurley J, et al. Blunt trauma carotid artery injury: mild symptoms may disguise serious trouble. Phys Sportsmed 1996;24(2):10–6. [23] Kane JW. Syncope following neck trauma in a football player. Phys Sportsmed 2001;29(9): 1–5. [24] Meairs S, Timpe L, Beyer J, et al. Acute aphasia and hemiplegia during karate training. Lancet 2000;356:40.
Cervical Pain in the Athlete: Common Conditions and Treatment Gary W. Dorshimer, MD, FACPa,b,c,*, Michael Kelly, DOa a
Internal Medicine/Sports Medicine, University of Pennsylvania Health System—Pennsylvania Hospital, 727 Delancy St, Philadelphia, PA b Head Team Physician, Philadelphia Flyers and Philadelphia Phantoms c Team Internist, Philadelphia Eagles and Philadelphia KIXX
It is important for primary care providers who take care of an athletic population to be familiar with the basic management of cervical pain and emergencies. This is especially true of those physicians who are involved with organized athletic events or who serve as team physicians. In addition, neck pain is a fairly common complaint in general practice, and a basic understanding of the evaluation and management of common neck injuries is an asset for most primary care physicians. Often, the patient who has cervical pain is not a well-conditioned athlete, but rather a ‘‘weekend warrior’’ who has sustained an injury during a recreational athletic event. Furthermore, it is not uncommon for primary care physicians to find themselves in the position of the unofficial team doctor at local athletic events, especially when their children are participating. Cervical emergencies When dealing with a possible cervical emergency during an athletic event, basic cardiopulmonary resuscitation and trauma management guidelines should be followed. It is imperative to keep the injured athlete immobile until cervical spinal injury is ruled out. Unconscious athletes are always assumed to have a cervical spinal injury until proven otherwise. When an injury is witnessed by the physician, the most worrisome mechanism of injury involves axial loading with the neck flexed or hyperextended, because
* Corresponding author. Delancey Medical Associates, 727 Delancey Street, Philadelphia, PA 19106. E-mail address: [email protected] (G.W. Dorshimer). 0095-4543/05/$ - see front matter Ó 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.pop.2004.11.005 primarycare.theclinics.com
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this can cause pinching of the spinal cord, resulting in spinal cord neuropraxia. Another worrisome mechanism of injury involves spear tackling (using the helmet as the point of impact when tackling), because the normal protective effect of cervical lordosis is lost upon impact, which can result in severe neurological injury acutely and bony abnormalities of the cervical spine chronically. This should raise clinical suspicion for the potential of a serious cervical injury even before the athlete is evaluated. Shoulder pads and helmets in football and hockey players should be left on, and the athlete’s neck should be stabilized. The face mask or shield can be cut off to facilitate airway management. The athlete’s airway should be cleared with a jaw thrust maneuver only. Head repositioning and neck extension are never used in an unconscious athlete who has suspected cervical injury. The only time the helmet should be removed is when the athlete’s airway cannot be maintained and the risk of asphyxiation is greater than the risk of cervical injury, or when the helmet prevents cervical immobilization. Any athlete who remains unconscious should be log-rolled onto a spinal back board and transported to the nearest hospital, with the most experienced person stabilizing the neck until it is secured with sand bags. Physicians dealing with motor sports need to familiarize themselves with the individual protocols involving the removal of different types of helmets for a suspected cervical spine injury. In contact sports such as boxing or martial arts, headgear removal may also increase the risk of cervical injury in the unconscious athlete. If an airway can be maintained and the cervical spine is immobilized, headgear removal can be deferred until cervical injury is safely ruled out. Approaching the conscious athlete who has cervical injury is simplified by the fact that the patient can answer questions and cooperate with a neurological examination. Any focal neurological findings suggest spinal injury and should be treated as above. Other red flags include severe neck pain, rigid cervical spasm, persistent athlete apprehension, severe cervical tenderness, and pain with active range of motion or gentle isometrics [1]. Patients who have cervical injury should never have passive range-ofmotion testing. Although the American College of Surgeons recommends in its Advanced Trauma Life Support guidelines that all patients who have trauma above the clavicle have cervical radiographic studies, it is possible to clear the cervical spine without radiographs if certain conditions are met. The National Emergency X-Ray Use Study (Nexus) [2] found that patients who had no midline cervical tenderness, no focal neurological deficits, normal alertness, no intoxication, and no painful distracting injuries had a low probability of cervical spine injury. Thus, fully conscious athletes who have cervical trauma can be cleared without radiographic studies provided the above-mentioned criteria are met. Another prospective study performed in Canada [3] established the Canadian C-Spine Rule for Radiography in Alert and Stable Trauma
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Patients. In this study, patients were found to have a low risk of cervical spine injury if they had no limitation of cervical rotation 45 in either direction, none of three risk factors that mandated radiographic studies (age [65, dangerous mechanism of injury, or upper extremity parasthesias), and one of the following: simple rear-end motor vehicle collision, sitting position in emergency department, ambulatory at any time, delayed onset of neck pain, or absence of midline tenderness. In a comparison study of both criteria [4], the Canadian C-Spine Rule was found to have superior sensitivity and specificity; however, one should keep in mind that both studies focused on developing a set of criteria for use in an emergency department, not on an athletic field. Although the sports physician can rule out serious injury using the above criteria, it is important to remember that this does not necessarily mean that the athlete can be returned to competition. Even after minor injuries, the athlete must demonstrate a full pain-free range of motion and at least 90% strength before return to play can be advised. Thus the approach to the athlete who has a cervical emergency should include assessment of airway, breathing, circulation, consciousness, and level of apprehension. One should then evaluate the athlete for midline cervical tenderness, severe cervical pain at rest or with active range-of-motion testing, neurological deficits, or severe cervical rigidity. If there is any indication of serious cervical injury, the athlete’s neck should be immobilized, and the athlete should be transported to the nearest emergency room for further evaluation. In all cases, the focus should be on protecting the athlete.
Spear tackling Axial loading of the spine has been found to be a common mechanism of severe spinal cord injury during athletics [5]. When the normal cervical lordosis is lost, an impact to the top of the head can transmit extreme axial forces that can result in severe bony and neurologic injury. Spear tackling is a method of tackling in football that involves using the head as the initial point of contact. Athletes who use this technique repeatedly can develop radiographic changes, including cervical stenosis, straightening of the normal cervical lordotic curve, and post-traumatic bony changes [5]. These changes further increase an athlete’s risk of permanent neurological injury from axial loading, and thus are deemed a contraindication to contact and collision sports participation. In 1975, football rules were changed to ban spear-tackling techniques, and subsequent epidemiological studies have shown that the incidence of serious cervical injuries has decreased dramatically [6]; however, it is still important that coaches, trainers, strength coaches, athletes, and parents of young athletes continue to receive education about the dangers of spear tackling to help prevent neurologic catastrophes.
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Stingers Brachial plexus injuries, which are commonly referred to as ‘‘stingers’’ or ‘‘burners’’ by coaches and athletes, are a common occurrence in athletics, especially in football. These injuries can be caused by either traction on the brachial plexus or compression of the dorsal nerve roots. When the neck is flexed laterally and the contralateral shoulder is depressed, a traction force is created on the brachial plexus. Conversely, extreme lateral flexion of the neck can cause cervical nerve root compression by narrowing the neural foramen [7]. Both types of stingers usually result in a transient neuropraxia, manifested in the injured athlete as burning down the affected arm and weakness of the deltoid, supraspinatus, infraspinatus, biceps, brachioradialis, pronator teres, or wrist extensors [6]. The athlete is usually seen coming off the field or mat shaking his arm, which may be hanging limply at the side, and leaning toward the side of injury. Usually, a stinger is a self-limited injury that does not require anything more than keeping the athlete out of the game until the neurological symptoms have resolved. The athlete should not return to play if there is any cervical pain, limited cervical range of motion, bilateral limb involvement, or persistent neurological deficits. It should be noted that some athletes can have residual weakness for several weeks after resolution of sensory symptoms. Although an experienced sports medicine physician may feel comfortable diagnosing a stinger on the sideline, the primary care physician who has little experience with stingers and neck injuries might consider consulting a spine specialist if the athlete has limited motion, bilateral involvement, or persistent motor weakness. Although players who sustain multiple stingers have an increased risk for future stingers, they do not have an increased risk of serious cervical injury [6,8]. Football players who have recurrent stingers may benefit from neck rolls or ‘‘cowboy collars,’’ which limit the amount of lateral neck flexion. Proper fitting is important to limit neck motion. Because there are no studies regarding the efficacy of collars in the prevention of stingers, their use remains controversial. Athletes who sustain a stinger are restricted from participation until all neurological symptoms have resolved and they regain full strength in the affected extremity. This usually takes only a few minutes, but the length of time for symptom resolution can vary from minutes to weeks. The one caveat is that the athlete who has persistent cervical pain, limited cervical range of motion, bilateral limb involvement, or persistent neurological deficits should be considered to have a cervical spinal injury and evaluated appropriately. Cervical cord neuropraxia Cervical cord neuropraxia is a transient neurological event that can cause neurological symptoms in both arms, both legs, all extremities, or the ipsilateral arm and leg [8]. Both the sensory and motor nerves can be
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involved, and symptoms can include nerve pain, parasthesias, and paresis [8]. The most disturbing manifestation involves all four extremities and is called transient qaudriparesis. This has been found to occur in football, boxing, hockey, basketball, and wrestling [9]. Resolution of symptoms occurs anywhere from 10 minutes to 48 hours [9]. The usual mechanism of injury involves axial loading of the cervical spine while flexed or hyperextended. This is presumed to cause a ‘‘pincher’’ mechanism, which occurs when the cervical canal is narrowed by the movement of one vertebra on top of another during extreme flexion or hyperextension [8]. Infolding of the ligamentum flavum during hyperextension can decrease the diameter of the spinal canal by up to 30% [10]. The transient nature of the episode has led to the term ‘‘spinal cord concussion’’ [9]. The mechanism may involve mechanical deformation of the spinal cord, resulting in a transient rise in intracellular calcium concentration [8].
Spinal stenosis Interestingly, a correlation between cervical spinal stenosis and cervical cord neuropraxia has been found; however, the question of spinal stenosis predisposing an athlete to increased risk for permanent neurologic injury or transient qaudriparesis during contact or collision sports remains controversial [9]. A normal spinal canal is considered to be at least 15 mm in sagittal diameter. A canal with a sagittal diameter less than 13 mm is considered to be stenotic. Torg and Pavlov designed a ratio based on lateral cervical radiographs comparing the sagittal diameter of the spinal canal to the midbody diameter of the vertebral body at the same level. This ratio is commonly referred to in the literature as the Torg ratio or the Pavlov ratio, and a value of less than 0.8 has been found to be predictive of spinal stenosis [9]. Although this ratio has been criticized for being overly sensitive, it has utility when counseling patients who have had an episode of cervical cord neuropraxia. Athletes who had previous cervical cord neuropraxia and a Torg ratio of less than 0.5 have an estimated 75% risk of sustaining another episode if allowed to return to contact sport; however, Torg ratios are not recommended as a routine screening tool in asymptomatic athletes because they have low predictive value and specificity [8].
Functional stenosis The relatively recent use of MRI to evaluate cervical injuries has led to the concept of functional spinal stenosis, which is defined as a spinal cord contour deformation or obliteration of local cerebrospinal fluid space. Some authors believe that athletes with this finding on MRI have an increased risk
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of severe neurological injury with head or neck trauma, and it has been suggested that athletes who have functional stenosis and an episode of transient qaudriparesis should be prohibited from participation in contact sports [11]. Return-to-sport recommendations Any athlete who has had a cervical cord neuropraxia should initially be treated for a serious spinal cord injury, with spinal immobilization and transport to a local hospital for radiographic and neurologic studies. The injured athlete should have anterior-posterior (AP), lateral, and open-mouth odontoid radiographs in combination with a cervical MRI. The return-to-play criteria in asymptomatic athletes following an episode of neuropraxia with documented cervical spinal stenosis is controversial. Torg concluded that in the absence of cervical spine instability or structural deficits, and with normal radiographic studies, asymptomatic athletes who have a Torg ratio of 0.8 or less have no increased risk for injury resulting in permanent neurologic damage, and no contraindication to participation in contact or collision sports. In contrast, Cantu contends that athletes who have spinal stenosis should not participate in contact or collision sports because they have an increased risk of transient qaudriparesis and permanent neurologic injury [9]. It is interesting to note that although Torg states that he has not seen permanent quadriplegia, Cantu has seen permanent quadriplegia in a patient who have cervical stenosis and who suffered an episode of transient quadriplegia with no fracture or dislocation [9]. Spinal cord neuropraxia return-to-sport recommendations 1) Athletes who have a single episode of uncomplicated cervical cord neuropraxia, normal radiographs, normal MRI with no evidence of functional spinal stenosis, and no cervical laxity are thought by some to be able to return to contact or collision sports, provided that the athlete’s neurologic symptoms have resolved [8,9]. Consultation with a specialist is recommended to confirm the absence of a functional spinal stenosis or other occult neurological disease that might increase the athlete’s risk of permanent neurological injury. 2) Athletes who have uncomplicated cervical cord neuropraxia and Torg ratios of 0.8 or less, degenerative joint disease, or intervertebral disk disease have a relative contraindication to collision sports participation. 3) Athletes who have an episode of cervical cord neuropraxia combined with cervical instability, neurological symptoms for more than 36 hours, evidence of spinal cord edema or defect, or bone abnormalities have an absolute contraindication to collision sports participation [8]. 4) Athletes who have multiple cervical cord neuropraxia episodes have a contraindication to collision sports participation [8].
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Cervical strain/sprain The neck is a relatively complex part of the human body, and subsequently is susceptible to multiple injuries. Athletes can injure the ligaments, muscles, bones, joints, and even the vasculature of the neck. It is important for the physician to differentiate between serious cervical injury and minor soft-tissue injury. All athletes who have cervical injury should first be evaluated for signs of serious injury, including neurological deficits, limited active range of motion, midline tenderness, severe pain or spasm, and persistent apprehension. After serious injury has been ruled out, the athlete can then be assessed for cervical strains, sprains, contusions, and joint dysfunction. A cervical strain involves injury to cervical muscles or tendons, whereas a cervical sprain involves injury to the cervical ligaments. Most cervical strains occur with eccentric contraction of the neck muscles. These injuries occur not only in sport, but also can occur during many activities of daily living. Interestingly, it has been found that muscles with high ratios of fasttwitch fibers have a higher risk for strains [12]. Most muscle strains can be managed with rest, ice, anti-inflammatory medication, neck support as needed, and gentle range-of-motion exercises. Manipulation may be helpful in relieving the associated muscle spasms and joint dysfunctions. Athletes are allowed to return to play when they regain full strength and range of motion. Cervical sprains can range from minor ligament injury to severe ligament disruption with instability and joint dislocation. Coexisting muscle injuries are a common finding with cervical sprains, and one should be careful not to overlook a possible cervical sprain when evaluating cervical strains, because ligament injuries usually take more time to heal. If severe, they can cause cervical laxity, which increases the athlete’s risk of neurological injury. A common mechanism of injury is a ‘‘whiplash’’ or acceleration-deceleration force on the neck. The major concern with a cervical sprain is the amount of ligamentous laxity. Cervical laxity should never be tested passively. One can ask the athlete to move his head or one can test stability with gentle isokinetic testing (ie, have the athlete keep his head neutral and push against the examiner’s hand). At no time should the examiner push the athlete’s head out of the neutral position. If there is any question about cervical stability, immobilization, radiographs, and consultation with a spine specialist are indicated. It is often helpful to have flexion and extension radiographs in addition to the AP, lateral, and odontoid views to access cervical laxity [13]. Greater than 3.5 mm AP displacement on flexion and extension views or 11 of rotation on AP radiographs indicate cervical ligamentous laxity, which is a contraindication to contact or collision sports participation. Ligamentous laxity of less than 3.5 mm AP displacement on flexion and extension views, or less than 11 of rotation degrees of rotation on
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anteroposterior radiographs is a relative contraindication to contact sports participation [8]. Minor sprains are treated similarly to strains with rest, ice, antiinflammatory medication, neck support as needed, and gentle range-ofmotion exercises. Severe sprains or sprains with ligamentous laxity should be managed by a spine specialist. Osteopathic manipulation may be helpful in treating minor cervical injuries, but it is important to avoid manipulation in the following scenarios: focal neurological deficits, severe cervical pain or spasm, point tenderness over bone, advanced age, severe arthrosclerosis, rheumatoid arthritis, osteoporosis, cervical fusion or fracture, and cervical laxity. Although metanalyses and credible studies on cervical manipulation for athletic injuries are lacking, given the popularity of manipulation with trainers, physical therapists, and athletes, it is important for the physician taking care of athletes to know the contraindications to manipulation. In addition, cervical manipulation should be avoided until serious spinal injuries, including fractures, are ruled out. Other modalities in the treatment of cervical pain may include acupuncture, ultrasound, and topical analgesic creams. Although no controlled studies have demonstrated increased efficacy of these modalities, they remain popular with athletes, coaches, and trainers. Discogenic neck pain Although lumbar disc disease is a common cause of low back pain in the general population, cervical disc disease is a relatively uncommon cause of neck pain in athletes. Cervical disc disease usually affects older athletes, and is more frequent in athletes participating in football and wrestling [12]. Discogenic neck pain in athletes can be caused by cervical disc herniation with subsequent nerve root compression, or degenerative disk disease with a loss of disc height and marginal osteophytes. The symptoms of cervical disc disease may include neck pain, radicular arm pain, loss of arm strength, and deep tendon reflexes if the nerve root compression is severe enough. Cervical disc disease can be treated with relative rest, activity modification, anti-inflammatory medications, cervical support, and progressive rehabilitation. During the acute phase of injury, a short course of oral corticosteroids or nonsteroidal anti-inflammatory agents may be useful in the treatment of symptoms, although controlled studies are lacking. Chronic cases may be treated with epidural or selective nerve-root injections [14–17], though their efficacy is controversial. Athletes who have discogenic neck pain are allowed to return to play when they are asymptomatic, have regained full strength, and range of motion has returned to baseline [12]. Patients who fail to respond to conservative therapy and who continue to have focal neurological symptoms (arm weakness and persistent or
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worsening radicular symptoms, and so on) deserve consultation with a spinal specialist and possible surgical intervention. Return-to-play criteria for postsurgical patients depends on the level of surgery and the number of spinal fusions. A stable one-level spinal fusion at C3 or below is not a contraindication for contact or collision sports. Asymptomatic athletes who have normal neurological function and a two- or three-level spinal fusion may be allowed to return to contact sports, but they are usually advised to avoid contact or collision sports, because the stresses at the vertebrae adjacent to the fusion may lead to degenerative changes. Fusions above C3 and those involving more than three spinal levels are an absolute contraindication to contact or collision sports [8]. Special populations Certain subgroups of athletes have an increased risk of severe spinal cord injury during athletics. These subgroups include patients who have Down syndrome, certain forms of dwarfism, and patients who have rheumatoid arthritis. It is important for physicians dealing with neck pain to recognize that these patients have an increased risk of serious neck injury, and have different restrictions on athletic participation. Athletic patients who have Down syndrome are of particular concern, because atlantoaxial instability has been found in up to 30% of these patients. Twelve to sixteen percent of Down patients who have such instability develop neurologic signs and symptoms [18]. There are a number of athletic events for Down syndrome patients, including the Special Olympics. Down syndrome patients often look to their primary care physician for preparticipation physicals. There are a number of important issues to consider when dealing with such patients. The physician needs to be familiar with the athletic restrictions as well as the signs and symptoms that would not only disqualify the patient from athletic participation, but also prompt a full work-up, including radiographic studies. Initially, the Special Olympics and the American Academy of Pediatrics were both in favor of preparticipation lateral neck radiographs, and many authors are still advocates of their utility [18,19]. Preparticipation lateral neck radiographs continue to be required for participation in the Special Olympics, but in 1995, the American Academy of Pediatrics reversed its position based on re-evaluation of the initial data [19]. The controversy arises from the fact that some Down syndrome patients can initially have abnormal radiographs but normal follow-up radiographs. Conversely, some patients have normal radiographs that eventually become abnormal as they age. Thus, although it is difficult to access the utility of screening radiographs and the issue continues to be debated in the literature, the physician responsible for preparticipation screening of these athletes must obtain preparticipation radiographs because they are required for participation in the Special Olympics.
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The neurological manifestations of atlantoaxial instability in Down syndrome patients include neck pain, gait disturbances, decreased cervical mobility, torticollis, incoordination, spasticity, hyperreflexia, clonus, and other focal findings. Down syndrome patients who have any of these neurological symptoms should have a full evaluation, including an MRI and consultation with a specialist, before clearing for sports participation. The Special Olympics sports that patients who have atlantoaxial instability demonstrated on radiographs should be restricted from include gymnastics, diving, pentathlon, the butterfly swimming stroke, high jumps, soccer, and certain warm-ups that include neck stretching, because these activities have an increased risk of neurological injury. In addition, patients who have known atlantoaxial instability are often restricted from contact sports such as football, wrestling, rugby, and so forth. It is recommended that Down syndrome patients who have atlantoaxial instability and stable neurological symptoms have current radiographic studies before participating in any athletic event, including noncontact events. Patients who have rheumatoid arthritis make up another subgroup who have an increased risk of severe spinal cord injury during participation in contact sports, because of the increased incidence of cervical instability in these patients. Cervical subluxation can be found in 15% of rheumatoid arthritis patients within 3 years of diagnosis, and 17% of rheumatoid arthritis patients who have radiographic abnormalities have neurological symptoms. It is not uncommon for a rheumatoid arthritis patient to see a primary care or sports medicine physician with a complaint of neck pain. Such complaints should be taken seriously, and one should inquire about all physical activity. Many older patients may not consider certain activities athletic, but given their age and comorbid conditions, these events may be quite strenuous. For example, an active 72-year-old rheumatoid arthritis patient developed neck pain after feeling a sharp snap in her neck while ballroom dancing. This patient was eventually diagnosed with atlantoaxial instability and cervical myelopathy [20]. Thus it is important to have a high index of suspicion for atlantoaxial instability and possible cervical spine injury in active rheumatoid arthritis patients. Any rheumatoid arthritis patient who has neck pain that occurs suddenly during physical activity should have radiographic studies to rule out atlantoaxial instability, as well as a full neurological examination. Once again, it is important to never passively test cervical range of motion. Vascular injury In many contact sports, it is quite common for participants to sustain blunt neck trauma. Although such impacts usually result in minor contusions, they have the potential to cause a number of serious injuries involving the cervical vascular structures. Blunt trauma to the carotid artery can cause a dissection, thrombus, or emboli, all of which can result in
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a stroke. In addition, there are a number of cases of syncope, delayed neurological symptoms, and even death from carotid artery trauma [21,22]. Kane [23] reported a case involving a football player who sustained blunt trauma to the carotid sinus during a game. The player walked off the field and complained of dizziness while sitting on the bench. A short time later, the athlete suffered a syncopal episode that was attributed to carotid sinus trauma. Meairs et al [24] reported a case involving a martial artist who developed hemiplegia and aphasia while trying to break free from a neck hold. MRI revealed ischemia in the region of the middle cerebral artery. Ultrasound revealed a punched-out defect in the internal carotid artery, indicative of an atherosclerotic plaque rupture and embolic event. The patient was treated with anticoagulation and thrombolytics. Postthrombolysis, the hemiplegia resolved and the aphasia improved. Although such occurrences are relatively rare, it is important for the physician treating athletes who have neck pain to consider possible involvement of the vascular structures. The treatment of cervical vascular injuries varies from anticoagulation and thrombolytic therapy to vascular surgery. The key to treating these patients is early recognition, prompt anticoagulation, and urgent consultation with a vascular surgeon. Other causes of neck pain There are a number of nonmusculoskeletal causes of neck pain, and one should keep in mind the various medical conditions that may present as neck pain in the athlete. The differential diagnosis for neck pain can be quite extensive. Fortunately, a careful history and physical examination often help one to find the correct diagnosis. It is important for one to observe the patient while eliciting the medical history, because the patient may literally point to the diagnosis. When a patient indicates that his neck pain is anterior or lateral in location, one should consider disorders that include pharyngitis; eagle syndrome (calcification of hyoid ligaments); neck mass (benign or neoplastic); lymphadenopathy due to oropharyngeal, sinus, or dental infections; neuropathic pain; gastroesophageal reflux; and ischemic coronary disease. Sterno-clavicular arthritis or sprain can also cause pain at the anterior base of the neck, with radiation cephalad. Rarely, arteritis of the carotid or carotid dissection can cause neck pain. Superior vena cava syndrome can prompt patients to seek medical attention for neck pain and swelling. When a patient points to the trapezius or scapular areas and complains of shoulder pain, cervical disorders should be prominent in the differential diagnosis. When a patient points to the base of the skull and complains of neck pain, disorders such as occipital neuralgia should be considered, especially if the pain radiates to the back of the head. Other causes of anterior neck pain include pneumomediastinum, acute cholecystitis, laryngeal or tracheal trauma, and aortic dissection, but these disorders often have other associated symptoms to help identify the etiology.
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Summary In summary, it is important for physicians dealing with neck pain in an athletic population to understand the differences between serious and mild cervical injuries. This is best facilitated by a thorough understanding of the signs and symptoms of serious cervical injury, familiarity with the basic anatomy of the neck and its structures, and a working knowledge of common causes of neck pain and mechanisms of injury. All unconscious athletes should be assumed to have a serious cervical injury until proven otherwise, and preventive measures should be taken to ensure the safety of the athlete. This includes airway management with a jaw thrust only, neck stabilization, and preventing helmet removal. In the conscious athlete who has neck pain, serious cervical injury can often be ruled out with an accurate history and physical examination. In all cases of neck pain, it is imperative that the athlete be protected. This may involve removing the athlete from competition, or transporting him or her to the local emergency room. Often, this decision falls on the shoulders of the doctor in the stands. Thus, a basic understanding of the evaluation and management of neck pain in athletes is an asset for all physicians who frequent athletic events or see athletes in the office. The physician responsible for patients who have Down syndrome or rheumatoid arthritis needs to consider the increased incidence of cervical instability in these patients when evaluating for athletic participation or neck pain. References [1] Haight RR, Shiple BJ. Sideline evaluation of neck pain: when is it time for transport? Phys Sportsmed 2001;29(3):8–15. [2] Hoffman JR, Mower WR, Wolfson AB, et al. Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. N Engl J Med 2000;343(2):94–9. [3] Stiell IG, Clement CM, McKnight RD, et al. The Canadian C-Spine Rule for Radiography in Alert and Stable Trauma Patients. JAMA 2001;286(15):1841–8. [4] Stiell IG, Clement CM, McKnight RD, et al. The Canadian C-Spine Rule versus the NEXUS Low-Risk Criteria in patients with trauma. N Engl J Med 2003;349(26):2510–8. [5] Torg JS, Sennett B, Pavlov H, et al. Spear tackler’s spine: an entity precluding participation in tackle football and collision activities that expose the cervical spine to axial energy inputs. American Journal of Sports Medicine 1993;21(5):640–9. [6] Garrick JG, Web DR. Sports injuries: diagnosis and management. 2nd edition. Philadelphia: WB Saunders; 1999. p. 202–3. [7] Ghiselli D, Schaadt G, Mcallister DR. On the field evaluation of an athlete with a head or neck injury. Clin Sports Med 2003;22:456. [8] Torg JS, Ramsey-Emrheim JA. Cervical spine and brachial plexus injuries: return to play recommendations, Phys Sportsmed;25(7):3–10. [9] Allen CR, Kang JD. Transient qaudriparesis in the athlete. Clin Sports Med 2001;21(1):16. [10] Moiel RH, Raso E, Waltz TA. Central cord syndrome resulting from congenital narrowness of the cervical spinal canal. J Trauma 1970;10:502–10. [11] Cantu RC. The cervical spinal stenosis controversy. Clin Sports Med 1998;17:121–7.
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[12] Zmurko MG, Tannoury TY, Tannoury CA, et al. Cervical sprains, strains, disc herniations, minor fractures, and other cervical injuries in the athlete. Clin Sports Med 2003;22:514. [13] Eiff MP, Hatch RL, Calmbach WL. Fracture management for primary Care. 2nd edition. Philadelphia: WB Saunders; 1998. p. 211–30. [14] Hession WG, Stanczak JD, Davis KW, et al. Epidural steroid injections. Semin Roentgenol 2004;39(1):7–23. [15] Stav A, Ovadia L, Sternberg A, et al. Cervical epidural steroid injection for cervicobrachialgia. Acta Anaesthesiol Scand 1993;37(6):562–6. [16] Rowlingson JC, Kirschenbaum CP. Epidural analgesic techniques in the management of cervical pain. Anesth Analg 1986;65(9):938–42. [17] Cicala RS, Thoni K, Angel JJ. Long term results of cervical epidural steroid injections. Clin J Pain 1989;5(2):143–5. [18] Winell J, Burke SW. Sports participation of children with Down syndrome. Orthop Clin North Am 2003;34:440. [19] American Academy of Pediatrics. Committee on Sports Medicine. Atlantoaxial instability in Down syndrome: subject review. Pediatrics 1995;96(1):151–4. [20] Casey AT, Crockard HA, Pringle J, et al. Rheumatoid arthritis of the cervical spine: current techniques for management. Orthop Clin North Am 2002;33:291–309. [21] McCarron MO, Patterson J, Duncan R. Stroke without dissection from a neck holding maneuver in martial arts. Br J Sports Med 1997;31(4):346–7. [22] Carr S, Troop B, Hurley J, et al. Blunt trauma carotid artery injury: mild symptoms may disguise serious trouble. Phys Sportsmed 1996;24(2):10–6. [23] Kane JW. Syncope following neck trauma in a football player. Phys Sportsmed 2001;29(9): 1–5. [24] Meairs S, Timpe L, Beyer J, et al. Acute aphasia and hemiplegia during karate training. Lancet 2000;356:40.