eMedicine Specialties > Sports Medicine > Spine

Cervical Spine Sprain/Strain Injuries

Gerard A Malanga, MD, Founder and Director, New Jersey Sports Medicine Institute; Director of Pain Management, Overlook Hospital; Director of Sports Medicine, Sports Medicine Fellowship Director, Mountainside Hospital; Clinical Chief, Rehabilitation Medicine and Electrodiagnosis, St Michael's Medical Center; Medical Director, Consultant, Horizon Healthcare Worker's Compensation Services, Blue Cross and Blue Shield Worker's Compensation
Michael J Mehnert, MD, Associate Physiatrist, The Rothman Institute; Daniel Kim, MD, Staff Physician, Department of Physical Medicine and Rehabilitation, University of Medicine and Dentistry of New Jersey

Updated: Mar 31, 2008

Introduction

Background

The most frequent cervical injuries in athletes are probably acute strains and sprains of the musculature of the neck, as well as soft-tissue contusions.

A strain refers to an injury to a muscle, occurring when a muscle-tendon unit is stretched or overloaded. Cervical muscles that are commonly strained include the sternocleidomastoid (SCM), the trapezius, the rhomboids, the erector spinae, the scalenes, and the levator scapulae.

A sprain refers to a ligamentous injury, and the diagnosis of cervical sprain implies that the ligamentous and capsular structures connecting the cervical facet joints and vertebrae have been damaged. Practically, a cervical sprain may be difficult to differentiate from a strain, and the 2 injuries often occur simultaneously. Pain referred to the muscle can arise from any source that is modulated by the dorsal rami.

Numerous epidemiologic studies have been completed in the hopes of identifying the injury risk patterns that are associated with specific sports. Many athletes are reluctant to report minor injuries, and because the overwhelming numbers of sports-related spinal injuries are self-limited and resolve before being reported, the accuracy of these studies has been challenged. The mainstay of prevention and treatment of cervical spine injuries is maintaining good strength and flexibility through conditioning.

For excellent patient education resources, visit eMedicine's Back, Ribs, Neck, and Head Center. Also, see eMedicine's patient education articles Neck Strain, Sprains and Strains, Muscle Strain, and Whiplash.

Frequency

United States

Cervical spine injuries occur in an estimated 10-15% of football players, most commonly in defensive ends, linemen, and linebackers.^{[1,2 ]}The reinjury rate in high school football players following all cervical spine injuries is reported at 17.2%. Football players with 2 previous injuries are reported as having an 87% risk of reinjury. Wrestlers with no history of injuries to the neck have a 20% chance of sustaining a neck injury in a given year^{[3 ]}; however, wrestlers who have had a previous neck injury have an approximate 50% chance of recurrence.

Sporting accidents are second only to motor vehicle accidents as the leading cause of emergency department visits involving neck injuries, and as more people participate in athletic activity, the incidence of cervical injuries can be expected to rise as well.^{[4,5 ]}

Functional Anatomy

The spinal cord is protected by the cervical spine, which provides support for the head and allows for a significant amount of range of motion (ROM).^{[6,7 ]}Seven cervical vertebrae, stacked vertically, comprise the skeletal portion of the spine (see Images 1-3 and 6). Each vertebra (except C1 and C2) has a common body anteriorly and a ring of bone formed by the laminae and pedicles posteriorly. This protective ring of bone forms the spinal canal, which surrounds and protects the spinal cord. The tissues that surround the cord and the spinal fluid fill the remaining space. The C1 vertebra, or atlas, is ring-shaped, has large lateral masses, and attaches to the occipital condyles of the skull, providing support (see Images 2-3).

The transverse ligament lies anteriorly between the 2 lateral masses of C1 and just posteriorly to the odontoid process of the C2 vertebra, or axis (see Image 5). Projecting upward from the body of C2, the odontoid process is contained between the anterior arch of C1 and the transverse ligament. Displacement of C1 and C2 may be associated with rupture of this ligament, which may result in a spinal cord injury.

The remaining cervical vertebrae (C3-C7) are similar in function and appearance. The ovoid vertebral bodies are wider than they are tall. The bilateral raised uncinate processes located posterolaterally correspond to similar beveled surfaces on the inferior aspect of the superior vertebral body. These joints of Luschka, also known as uncovertebral joints, are not present in the embryologic development of the cervical spine but arise as a result of the degenerative and adaptive changes of annular tissue to stresses and loads.

The cervical zygapophyseal joints are synovial in nature. Their articular surfaces are covered with hyaline cartilage, and their fibrous capsules are lined with synovium. The orientation of the cervical zygapophyseal joints allows them to play a weight-bearing role and to provide resistance to anterior translation. Because the C2-C3 facet sits between the upper and lower parts of the cervical spine that move differently, it is considered transitional anatomically and biomechanically.^{[7 ]}

The lower cervical spine flexes and extends, and the atlantoaxial joint moves in rotation. During lateral bending, the spinous processes move to the convexity of the curve (spinous processes move to the right during left lateral bending) in the middle and lower cervical regions. Coupled lateral bending occurs in the opposite direction to the applied axial rotation above the C2-C3 level. Lateral bending from C2-C3 distally is always coupled with rotation in the same direction because of the approximate 45° inclination of the cervical zygapophyseal joints. The obliquity of the articular surfaces in the frontal plane determines the relative amount of side bending or rotation that occurs. The more vertical the joint surface, the more side bending is coupled; the more horizontal the joint surface, the more rotation is coupled.

Regressive changes occur in cervical zygapophyseal menisci with age. The meniscus retracts and narrows between childhood and the fourth decade of life. The meniscus helps increase the contact surface area when articular facets come together, thus helping to transmit some of the load.

The many articulations between the cervical vertebrae make the extensive ROM in the cervical spine possible. However, this large ROM comes at the cost of stability. Cervical spine stability is provided by a combination of the zygapophyseal joints and numerous ligaments and muscles. Extension, flexion, lateral bending, and rotation are permitted by the orientation of the zygapophyseal joints and ligaments. Positioning of the head makes combinations of these motions necessary. In a young person, cervical flexion and extension is about 100°. Bilateral rotation is about 80°, with approximately 50% of this range occurring between C1 and C2. The range of lateral bending is about 30-50°. Older individuals usually have reduced end ROMs because cervical mobility usually decreases with age.

Intervertebral discs are located in between each of the cervical vertebrae from C2-C7. These discs consist of a water-containing central portion, the nucleus pulposus, and a tough fibrous outer ring, the annulus fibrosis. The discs are subject to prolonged and repetitive loading from muscle forces acting across them and from the weight of the head. With their viscous central portion, the intervertebral discs are able to transmit these forces between the end plates of adjacent vertebral bodies. These biconvex discs conform to the concavity of the vertebral bodies, and they also contribute to normal cervical lordosis because they are thicker anteriorly. Only the outer one third to one half of the annulus fibrosis in adults receives a vascular supply. The rest of the annulus and the whole nucleus pulposus are avascular.

The annular fibers consist of 10-20 circumferential collagenous lamellae. The fibers within each lamella are oriented 35° from the horizontal, although the direction of inclination alternates with each lamella. As a result, rotation and translation are more likely to damage the annulus because resistance can be offered only by half of the lamellae whose fibers are oriented in the direction of motion.

The functions of a ligament are: (1) to provide stability to the joint, (2) to absorb energy during trauma, and (3) to act as a joint position transducer during physiologic motions. Ligaments, along with the paracervical muscles in the cervical spine, prevent motion between vertebrae that might injure the spinal cord or nerve roots. The cervical spine ligaments have numerous and complex interrelationships (see Images 4-5). Running vertically along the anterior and posterior aspects of the vertebral bodies, the anterior and posterior longitudinal ligaments attach to the discs as well. The tightly attached posterior longitudinal ligament is thick in its central portion, which helps prevent a disc herniation from pressing directly on the cord posteriorly. The interspinous ligaments are also located posteriorly but are not as well developed in the cervical region.

The ligamentum flavum, a yellowish elastic membrane, overlies the space between the laminae of adjacent vertebrae and the neural arches. The posterior location of the ligamentum flavum helps to restrain hyperflexion. The ligamentum flavum becomes shortened and thicker in hyperextension and elongated and thinner in hyperflexion. During hyperextension, it may protrude into the cervical canal as much as 3.5 mm. Impingement on the spinal cord during extension is normally prevented by the elastic properties of the ligament; however, hypertrophy of the ligamentum flavum or loss of elasticity through degeneration may lead to canal narrowing or cord impingement.

The capsular ligaments, oriented approximately orthogonal to the articular facets, provide maximal mechanical efficiency in resisting distraction of the facets but relatively poor resistance to shear. The posterior longitudinal ligament limits flexion and distraction, the tectorial membrane limits flexion and extension, and the supraspinous and interspinous ligaments limit flexion and anterior horizontal displacement.

The main function of the alar ligaments is to restrain rotation. The alar ligaments originate from the posterolateral aspect of the dens of C2 and insert on the medial surfaces of the occipital condyles. When a single alar ligament is cut, axial rotation increases significantly to both sides; thus, both ligaments are required to be intact for restraining motion. Alar ligaments are stretched the most when the head is rotated and flexed together, and the ligaments are relaxed during extension. The anterior aspect of the transverse ligament acts as the pivot about which C1 (ie, the atlas) rotates.

Holding the odontoid process of C2 against the anterior ring of the atlas, the transverse ligament functions as a restraining band on the dens. Flexion and anterior displacement of the atlas is restrained by its orientation. The facet joint capsules are strong fibrous structures that contribute to posterior stability.

A muscle injury or reaction of some degree is associated with almost every cervical injury. The musculature of the neck is vulnerable to the same types of injuries that affect muscles elsewhere in the body. The role of the muscles is to stabilize the spine, carry loads, and produce motion. The action of the intervertebral muscle forces is to restore the intervertebral motions of an injured spine to its intact values.

The capital flexor muscles include the following:

• Longus capitis
• Rectus capitis anterior and lateral
• Suprahyoid and hyoid muscles

The capital extensor muscles include the following:

• Splenius capitis
• Semispinalis capitis
• Longissimus capitis
• Obliquus capitis inferior and superior
• Rectus capitis posterior major and minor

The cervical flexor muscles include the following:

• Anterior scalene
• Middle scalene
• SCM

The cervical extensor muscles include the following:

• Semispinalis cervicis
• Longissimus cervicis
• Splenius cervicis

Because the bulk of the flexor muscle groups are at the C4-C5 level and the main mass of the extensor muscle groups overlies the C6-T1 levels as well as the atlantoaxial area, these muscle groups are likely sites of major stresses. The muscle groups that laterally flex and rotate the cervical spine include the following:

• Rectus capitis lateralis
• Obliquus capitis inferior and superior
• Intertransversarii
• Multifidi
• Iliocostalis cervicis
• Longus colli
• Levator scapulae
• Longissimus capitis
• Splenius cervicis
• Splenius capitis
• SCM
• Scalene muscles

Related eMedicine topics:
Cervical Spine Injuries in Sports
Cervical Sprain and Strain [in the Physical Medicine and Rehabilitation section]
Disk Herniation

Related Medscape topics:
Resource Center Arthritis
Resource Center Spinal Disorders

Sport-Specific Biomechanics

When contact is made with the head or body, deceleration injuries occur, and sudden flexion and extension of the neck can result. This type of injury is likely to occur in contact or collision sports such as football, soccer, rugby, or lacrosse.

The posterior neck muscles may be strained when resisting flexion forces, and/or the anterior neck muscles may be strained when resisting hyperextension. Microtears or strains in these muscles are caused by the sudden muscular contractions that try to decelerate the applied force. Forced twisting, which is common in wrestling, can also cause a cervical strain. The twisting injury usually happens in the wrestler who is pinned on the mat, and a flexion-extension injury is more likely to happen during the takedown. Deceleration and rotational forces can also cause microtears or stretching of the small intertransverse and interspinous ligaments as well as the joint capsules.

In cervical sprains, the immediate soft-tissue trauma occurs in the structures in and around the facet joints. This trauma occurs with varying severity, including multiple tears in ligamentous tissue with focal hematomas and hemorrhages. A fibrous tissue contraction is the net final effect of the repair of these strained capsular and ligamentous tissues so that restriction of motion and stiffening of the neck may eventually result. The short capsular ligaments of the Luschka interbody joints lack the normal laxity of the capsular structures surrounding the facet joints. Because of their anatomic position, the articulating surfaces of these vertebral body joints are particularly susceptible to injury from axial compression when the head is in a laterally tilted or neutral position.

The cervical spine can absorb much of the imparted energy of collisions by dissipation through the normal lordotic curve of the cervical spine, the paravertebral musculature, and the intervertebral discs. However, when the neck is flexed about 30°, the forces applied to the top of the head are directed to a straight-segmented column because the normal lordotic curve is flattened. The cervical spine is then less able to dissipate the exerted forces in this situation, leading to fracture(s) and possible spinal cord injury. This proposed mechanism is supported by biomechanical studies that replicate it. In individuals with straight cervical spines, less energy is needed to fail under an axial load than in those with a normal lordotic curve; this finding underlines the importance of the cervical musculature in maintaining proper lordosis.

Clinical

History

The evaluation of the athlete with a potential neck injury begins with a detailed history. The clinician should obtain the following information from the patient:

• Mechanism of injury; how, when, and where the injury took place, with particular attention regarding the position of the head and neck at the time of the injury
• Location of the pain
• Aggravating and relieving factors (eg, sneezing, coughing, traction)
• Presence, location, and duration of any neurologic symptoms
• The use of a body pain diagram to understand the athlete’s pain distribution may be helpful in directing further evaluation.
• History of a previous neck injury

The clinical picture for cervical spine/strain injuries is similar to all musculotendinous injuries. In cervical strain, pain and stiffness are the main complaints. In acute cervical sprain, the athlete complains of a jammed-neck sensation, with localized pain in the neck. At the time of the injury, the individual experiences pain; however, the pain may subside after a few minutes, allowing the athlete to return to full sport participation. Pain, swelling, and tenderness may become evident as local bleeding occurs into the torn muscle fibers. Neck motion becomes painful and often reaches a peak several hours later or on the following day. Referred pain, especially to the occipital area or the shoulder, is common; however, the patient has no radiation of pain or paresthesia in any of his/her extremities.

Physical

The physical examination consists of the following:

• A complete neurologic examination, including a thorough testing of the upper and lower extremities for weakness, sensory changes in a dermatomal distribution, or reflex changes
• Cervical ROM (active and passive) testing
• Spurling and Adson maneuvers
• Resistive head pressure
• Cervical compression test

Torticollis may be observed on physical examination, but decreased ROM is more commonly noted. The motion that produces stretching of the involved muscles or ligaments is usually the one that is limited. Palpating the injured area commonly reveals tenderness. Pain during rotation, flexion, or extension against resistance indicates inflammation or damage of the respective muscles. Pain in an inflamed facet joint may be elicited by simultaneous neck extension and rotation. When dealing with athletes, as opposed to the rest of the population, it is best to gain the maximal mechanical advantage possible in order to develop the greatest sensitivity in picking up even a minor weakness.

On examination, no neurologic deficits are demonstrable. Evaluation of the athlete’s posture may also be useful, as minor postural inefficiencies may be magnified in the athlete and contribute to muscle strain.

Related eMedicine topics:
Spinal Cord Trauma and Related Diseases
Torticollis

Related Medscape topics:
Resource Center Spinal Disorders
Resource Center Trauma

Causes

Cervical spine strains and sprains frequently occur as a result of a whiplash injury, which often occurs as the result of motor vehicle accidents, falls, sports-related accidents, or other traumatic events that cause a sudden jerk of the head and neck.^{[8,9 ]}The speed of impact in such mechanisms, proportional to the amount of the energy that is transferred and the amount of acceleration and deceleration, correlates with the severity of the injury. However, it has been demonstrated that zygapophyseal joint pain, rather than soft-tissue pain, is the most common basis for chronic neck pain after whiplash.
 
Cervical injuries may develop over a time period as well (eg, prolonged unusual posture, chronic repetitive strains of the neck). It is worth noting that several authors have described delayed or late instability with the development of neurologic symptoms in athletes after cervical flexion injuries. Some have proposed that poor muscle conditioning or repetitive muscle injury contributes to late instability, and these investigators have emphasized the importance of regular conditioning and proper warm-ups before athletes compete.

Related Medscape topics:
Resource Center Exercise and Sports Medicine
Resource Center Spinal Disorders
Resource Center Trauma

Differential Diagnoses

Other Problems to Be Considered

Cervical dislocation
Cervical subluxation
Cervical spine acute bony injuries

Workup

Laboratory Studies

• Laboratory studies are generally not necessary for the diagnosis of cervical spine strain/sprain injuries.

Imaging Studies

• Plain radiographs
  • In cervical spine trauma, routine radiography remains the initial imaging study of choice. Cervical spine radiographs should be obtained unless the history is clearly one of overuse. Of note, the microscopic damage that occurs as a result of a suspected whiplash syndrome or impulse loading due to athletic activity may not be seen on routine imaging studies.
  • A cervical spine series usually includes anteroposterior (AP), lateral, oblique, and odontoid views.^{[10 ]}All 7 vertebrae must be visualized, and the disc spaces should be approximately equal throughout the cervical spine.
  • The lateral view is useful for assessing alignment and soft-tissue swelling. The normal distance between the front of C3-C5 and the tracheal shadow is 5 mm in the adult. An increase in this distance suggests soft-tissue swelling and significant injury. The posterior borders of the vertebral bodies should lie in a relatively straight line that gently curves in a lordotic direction. Lines drawn through the horizontal axis of each spinous process should converge on a point well posterior to the spine when normal cervical lordosis is present. Loss of lordosis implies muscle spasm, whereas loss of convergence implies potential instability. A step-off in the alignment of the vertebral bodies may indicate either a facet subluxation or dislocation or a posterior element fracture.
  • The lateral view is also useful in assessing the stability of C1 on C2. A space greater than 2-3 mm between the anterior border of the odontoid process and the adjacent posterior border of the anterior ring of C1 suggests abnormal mobility of C1, which can be due to an odontoid fracture or transverse ligament rupture. Lateral radiographs that demonstrate more than 11° of rotation from either adjacent vertebra or demonstrate more than 3.5 mm of horizontal displacement between any one vertebra in relationship to another represent an absolute contraindication to further participation in contact activities.
  • The odontoid or open-mouth view demonstrates the odontoid in the AP direction. The distances between the odontoid and the horizontal portions of the ring of C1 on each side should be equal. If these distances are not equal, a rotary subluxation may be present. The oblique view best shows the facet joints and the neural foramina. If the radiographs reveal any evidence of fracture, dislocation, or subluxation, the patient's neck should be immobilized and the patient should be immediately referred to an orthopedist or neurosurgeon. If the initial static radiographs are normal, flexion-extension lateral views should be obtained once the acute symptoms have subsided. Note that in acute trauma cases, flexion-extension radiographs should be avoided, because during flexion-extension maneuvers, iatrogenic neurologic injuries may result. Flexion-extension views are valuable after acute trauma in revealing ligamentous subacute instability.
• Computed tomography (CT) scanning^{[10,11 ]}
  • CT scanning is performed in patients who have abnormal plain radiographs or in whom there is a strong clinical suspicion of a fracture with inconclusive radiographs.
  • Disruptions of the vertebral body or lamina, fractures of the facet joint, and fragments of intracanal bone are better shown by CT scan studies, particularly with reconstructed images. Multiplanar display, with reformation into sagittal or coronal projections, can greatly enhance demonstrations of fractures and other lesions that are not optimally shown in the transaxial plane or that cover relatively long areas.
  • CT scanning remains the imaging study of choice to evaluate traumatic bony lesions of the cervical spine.
• Magnetic resonance imaging (MRI)
  • MRI is usually indicated in athletes with neurologic deficits and when plain radiographic films and CT scans do not provide enough information for definitive management.
  • MRI is useful in the diagnosis of cord and nerve root injury in patients who are neurologically compromised.
  • Advantages of MRI include the ability to detect soft-tissue and spinal cord abnormalities, such as disc herniation, ligamentous disruption, hematoma, cord hemorrhage or edema, and syringomyelia.
  • MRI or bone scintigraphy may be indicated in cases in which patients have continuing limitation of motion, pain, or radicular symptoms.

Related eMedicine topics:
Atlantoaxial Injury and Dysfunction
Fracture, Cervical Spine
Lower Cervical Spine Fractures and Dislocations
Overuse Injury

Related Medscape topics:
Resource Center Spinal Disorders
Resource Center Trauma

Treatment

Acute Phase

Rehabilitation Program

Physical Therapy

The tissue injury and clinical signs and symptoms of cervical spine strain/sprain injuries are treated during the acute phase of rehabilitation.^{[12,13,14,15,16,17 ]}The goals of this phase are the following:

• Decrease pain and control inflammation
• Reestablish nonpainful ROM
• Improve neuromuscular cervical spine postural control
• Prevent the development of any muscular atrophy of the cervical spine muscle groups and postural muscles
• Facilitate primary tissue healing

Therapeutic activities during the acute phase of rehabilitation include the following:

• Relative rest
• Nonsteroidal anti-inflammatory drugs (NSAIDs)
• Physical therapy modalities
• Manual therapy approaches
• Protected ROM and stabilization
• Isometric muscle strengthening
• Conditioning of other areas

If no neurologic history or deficit is present in a patient with a cervical strain and/or sprain, the athlete should use ice packs for 15-20 minutes every 1-2 hours or have an ice massage for 5-10 minutes every 1-2 hours during the early management of the injury. This treatment aids in decreasing muscle spasms, decreasing pain, and promoting vasoconstriction.

Cold has a number of physiologic effects that are therapeutic. Local application of cold causes vasoconstriction, lowers cell metabolism, decreases extensibility of collagen tissue, decreases muscle contractility, decreases nerve conduction velocity, and increases the pain threshold. The spasticity of the muscle is reduced because local cold affects the muscle spindle's responsiveness to stretching. Local cold also has a direct effect on the conduction velocities of the afferent and efferent fibers, which further decreases muscle spasm.

The relatively deep penetration of cryotherapy makes it an ideal form of treatment for tissues lying deep to superficial layers. The cooling agent must be utilized for a sufficient amount of time for effective deep-tissue cooling to occur. Subcutaneous fat is an effective thermal barrier to heat exchange. A duration of 15-30 minutes is a commonly accepted timeframe required for therapeutic results and physiologic changes to take place. Ice is far more penetrating than heat. Because the vasodilation responses of heat therapy increase tissue edema and may extend the injury or delay healing, heat is not recommended in the acute stage.

Starting active ROM (AROM) and isometric strengthening exercises as soon as possible is very important. After at least 24 hours of cryotherapy, most patients are able to start gentle, painless active-assistive range of motion (AAROM) or AROM. To aid in AROM, transcutaneous nerve stimulation (TENS) or cryokinetics (exercising while the musculature is numbed with ice) may also be used.

Isometric exercises are started in neutral positions and then progressed through the full ROM once the patient demonstrates that ROM has improved. Pain should not be exacerbated by these exercises. AROM and strengthening exercises are progressively increased until the athlete achieves full pain-free ROM and normal strength. Stretching exercises should not be instituted acutely because they may cause reactive paraspinal muscle spasm and tightness. Gentle passive stretching may begin after resolution of the acute inflammatory phase (usually within 72 h), which avoids eccentric muscle loads and stays within the painless arc of motion.

The reactive cervical spasm and tightness after an injury can produce a loss of ROM and chronic contractures if not corrected. Chronic contractures greatly increase the potential for reinjury because if a contracture exists, sudden motion at a moment of contact through that restricted ROM is likely to reproduce the injury and severe pain. A program of cervical stretching and ROM exercises can prevent contractures and restore a protective ROM.

While the athlete undergoes progressive rehabilitation for a cervical injury, stationary bicycling provides a way of maintaining aerobic fitness and an athlete's competitive weight. Swimming also offers an acceptable aerobic exercise program in a semi-unweighted environment; however, a mask and snorkel should be used to avoid aggravation of the cervical muscles that is encountered as the neck is rotated during breathing when swimming.

Any aerobic exercise should be modified for the particular injury so that the activity does not exacerbate the patient's symptoms. The repetitive impact encountered during running, in particular, can aggravate a cervical injury and should be avoided early on in the recovery period. Before workouts, light exercise and stretching should be performed to prepare the muscles for activity.

Criteria for advancement to the recovery phase of rehabilitation include the following:

• Resolution of significant cervical pain
• Significant improvement in passive ROM (PROM), AROM, and neuromuscular control
• Decreased muscle spasms
• Improvement in the muscles and other tissue that maintain the postural adaptive changes

Related eMedicine topics:
Superficial Heat and Cold
Transcutaneous Electrical Nerve Stimulation

Related Medscape topics:
Resource Center Exercise and Sports Medicine
Resource Center Pain Management: Pharmacologic Approaches

Medical Issues/Complications

The clinician should always rule out a significant bony or ligamentous injury, as missing such an injury could result in neurologic injury.^{[18,19 ]}

Consultations

Consult a spinal surgeon for any patient with suspected ligamentous spinal instability.

Other Treatment

• Athletes who have limited ROM and severe pain with a history of a collision can be placed in cervical immobilization in order to rest the musculature and assist with pain control. Careful instruction should be given to patients using cervical collars so that dependency does not occur. Patients should spend at least 1 of every 3 hours out of the cervical collar by the third day of use; this time can then be gradually increased. The patients should discontinue collar use by 1 week from their injury unless there is a significant bony/ligamentous injury.
• Manual therapy techniques can also help to decrease pain and improve mobility and function to the point that the patient may begin to exercise in a painless manner. These techniques include soft-tissue massage, manually sustained or rhythmically applied muscle stretching, traction applied in the longitudinal axis of the spine, and passive joint mobilization. To help decrease pain and spasm, a trained therapist may apply grade 1 or grade 2 mobilizations. Repetitive passive joint oscillations carried out at the limit of the joint's available ROM can have a mechanical effect on joint mobility, thus improving a restriction of vertebral motion. Mechanically controlled passive or active movements of joints can improve remodeling of the local connective tissue, the rate of tendon repair, and the gliding function within tendon sheaths during the repair process.
• If the patient's pain is not significantly relieved during the acute phase of rehabilitation, trigger point injections, typically along the medial border of the scapula, may help decrease trigger zones and referred pain and help improve muscular flexibility. These injections may allow rehabilitation to progress more rapidly, but they should be used judiciously when the active rehabilitation has stalled. Repeated injections are not recommended.

Recovery Phase

Rehabilitation Program

Physical Therapy

During the recovery phase of rehabilitation, the tissue overload and functional biomechanical deficit complexes are addressed.^{[12,13,14,15,16,17 ]}The goals of this phase are the following:

• Completely eliminate the patient's pain
• Improve and normalize cervical PROM and AROM
• Improve and normalize cervical strength and neuromuscular control
• Continue to improve posture
• Initiate sport-training progressions

Therapeutic activities during this phase include the following:

• Protected ROM
• Appropriate loading
• Resistive exercise
• Functional exercises

NSAIDs are probably unnecessary in this phase, and these agents should be tapered. The improved ROM permits further normalization of the patient's posture as muscular strength and balance are enhanced to help maintain the improved posture during daily activities as well as athletic training and competition. Strength training using independent single-plane and complex multiplane coordinated motions is performed using varying combinations of concentric and eccentric isotonic exercises. Thera-Band or Sportscord can be used to allow training at home. Criteria for advancement to the maintenance phase of rehabilitation include the following:

• Fully pain-free cervical PROM and AROM
• Significantly improved cervical spine posture
• Normal neuromuscular control
• Significantly improved strength and flexibility of the supporting muscles and joints

Other Treatment (Injection, manipulation, etc.)

• Manual therapy, including soft-tissue and manipulative techniques, still may be needed to help eliminate vertebral motion restrictions and improve the flexibility and motion of the soft tissues so that cervical PROM and AROM are normalized.
• Occasionally, trigger point injections may be used for recalcitrant, taut, hyperirritable muscles. Again, multiple and repeated injections are discouraged.

Maintenance Phase

Rehabilitation Program

Physical Therapy

During the maintenance phase of rehabilitation, the functional biomechanical deficit and subclinical adaptation complexes are addressed.^{[12,13,14,15,16,17 ]}The goals of this final phase of rehabilitation are the following:

• Increase and improve balance, power, and endurance of the cervical muscles as well as other muscles in the kinetic chain
• Normalize posture
• Normalize multiplane-coupled neuromuscular control to eliminate subclinical adaptations
• Enable the patient to return to unrestricted sport-specific activities

Therapeutic activities during this phase include the following:

• Activities emphasizing endurance, strength, flexibility, and balance
• Functional sport-specific progressions

Soft-tissue flexibility and proper balance of flexibility and strength are emphasized to allow the athlete to assume and maintain a biomechanically correct posture. Power and endurance training is focused on maintaining normal multiplane-coupled cervical motion.

Medication

Pain and inflammation can be reduced by the judicious use of NSAIDs. The antiprostaglandin effect of NSAIDs may control the inflammatory response to an injury and may provide pain relief. The duration of the analgesic effect of an NSAID may be different than the duration of its anti-inflammatory effect. Some investigators have expressed concern that NSAIDs may actually interfere with the later stages of tissue repair and remodeling in which prostaglandins still help mediate cleanup of debris. The dosage, timing, and potential side effects of NSAIDs should be evaluated.

Related eMedicine topic:
Toxicity, Nonsteroidal Anti-inflammatory Agents

Related Medscape topics:
Resource Center Pain Management: Advanced Approaches to Chronic Pain Management
Resource Center Pain Management: Pharmacologic Approaches

Nonsteroidal anti-inflammatory drugs

NSAIDs have analgesic, anti-inflammatory, and antipyretic activities. The mechanism of action of these agents is not known, but they may inhibit cyclooxygenase activity and prostaglandin synthesis. Other mechanisms may exist as well, such as inhibition of leukotriene synthesis, lysosomal enzyme release, lipoxygenase activity, neutrophil aggregation, and various cell membrane functions.

Ibuprofen (Motrin, Ibuprin)

DOC for patients with mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.

Dosing

Adult

200-400 mg PO q4-6h while symptoms persist; not to exceed 3.2 g/d

Pediatric

<6 months: Not established
6 months to 12 years: 4-10 mg/kg/dose PO tid/qid
>12 years: Administer as in adults

Interactions

Coadministration with aspirin increases the risk of inducing serious NSAID-related side effects; probenecid may increase the concentrations and, possibly, the toxicity of NSAIDs; may decrease the effect of hydralazine, captopril, and beta-blockers; may decrease the diuretic effects of furosemide and thiazides; may increase PT duration when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase the risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently

Contraindications

Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency; high risk of bleeding

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Caution in patients with congestive heart failure, hypertension, and decreased renal and hepatic function; caution in the presence of anticoagulation abnormalities or during anticoagulant therapy

Naproxen (Naprosyn, Naprelan, Anaprox)

For relief of mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing the activity of cyclooxygenase, which results in the decrease of prostaglandin synthesis.

Dosing

Adult

500 mg PO followed by 250 mg q6-8h; not to exceed 1.25 g/d

Pediatric

<2 years: Not established
>2 years: 2.5 mg/kg/dose PO; not to exceed 10 mg/kg/d

Interactions

Coadministration with aspirin increases the risk of inducing serious NSAID-related side effects; probenecid may increase the concentrations and, possibly, the toxicity of NSAIDs; may decrease the effect of hydralazine, captopril, and beta-blockers; may decrease the diuretic effects of furosemide and thiazides; may increase PT duration when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase the risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently

Contraindications

Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with preexisting renal disease or compromised renal perfusion risk acute renal failure; leukopenia occurs rarely, is transient, and usually returns to normal during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrants further evaluation and may require discontinuation of drug.

Muscle relaxants

Muscle relaxants are thought to work centrally by suppressing conduction in the vestibular cerebellar pathways. These agents may have an inhibitory effect on the parasympathetic nervous system.

Cyclobenzaprine (Flexeril)

Skeletal muscle relaxant that acts centrally and reduces motor activity of tonic somatic origins, influencing both alpha and gamma motor neurons. Structurally related to tricyclic antidepressants and thus carries some of their same liabilities.

Dosing

Adult

20-40 mg/d PO divided bid/qid; not to exceed 60 mg/d

Pediatric

Not established

Interactions

Coadministration with MAO inhibitors and tricyclic antidepressants may increase toxicity; cyclobenzaprine may have an additive effect when used concurrently with anticholinergics; effects of alcohol, CNS depressants, and barbiturates may be enhanced with cyclobenzaprine

Contraindications

Documented hypersensitivity; patients who have taken MAO inhibitors within the last 14 d

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in patients with angle-closure glaucoma and urinary hesitance

Follow-up

Return to Play

Criteria for the patient's return to unrestricted competition include the following^{[20,21 ]}:

• Minimal or no tenderness
• Full AROM
• Neck strength versus resistance without pain is within normal limits (WNL)
• Posture is WNL
• Neurologic examination is WNL
• Absence of neurologic symptoms

The likelihood of a recurring injury is extremely high if the player returns to action before pain, tenderness, and ROM have returned to normal.

Complications

Long-term complications that may develop from cervical injuries include chronic pain, headaches, depression, permanent loss of cervical ROM, and disability. In patients with chronic symptoms that are unresponsive to a progressive rehabilitation approach, diagnostic zygapophyseal joint injections may help to identify a potentially treatable process, which may respond to radiofrequency denervation treatment in a properly selected patient group.

Prevention

For participants in football or wrestling, strengthening of the muscle groups supporting the cervical spine is imperative.^{[1,2,3 ]}To guarantee adequate development of strength, power, and endurance, strengthening routines need to include a variety of isometric and isotonic exercises. Emphasis must be placed on strengthening not only the large cervical flexors and extensors, but also the smaller paravertebral muscle groups because they offer the final resistance to forces that may cause dislocation of the vertebrae. Sport-specific drills with emphasis on cervicothoracic spine stability should be included in the athlete’s exercise regimen.

Athletes are advised to add a minimum of 1 cm to their neck circumference. Warm-up of the neck and the cervical spine should be emphasized, especially in contact sports. By performing several repetitions of cervical flexion, cervical extension, lateral bending, and rotation, the athlete can sufficiently warm up the neck. After workouts, while the muscles are warm, stretching to maintain or increase the AROM should be completed. In all AROM, the cervical muscles should be stretched to their limits and held in the stretched position for 30-60 seconds.

In football, a proper shoulder pad should encompass many of the characteristics of a proper cervicothoracic orthosis. Important characteristics of a proper shoulder pad include a modified A-frame shape that fits the athlete's chest and prevents the shoulder pad from rolling during contact.^{[1,2 ]}Firm, circumferential fixation to the chest is important. Proper fit to the chest is important in evenly distributing the shock to the shoulders over the pad and to the thorax. Better plastics in the outer shell of the pad and improved resistive padding absorb the shock and allow the use of the shoulder in proper blocking and tackling techniques. Improved shoulder protection should allow the player to de-emphasize the use of the head as a blocking and tackling instrument.

After fixing the chest, fix the neck to the chest by the fit of the shoulder pad at the base of the neck. Thick, stiff, comfortable pads at the base of the neck are the key considerations. This lateral support at the base of the neck offers fixation to the cervical spine.

Prognosis

The prognosis for athletic cervical spine sprains and strains is believed to be excellent.

Education

Proper head and neck positioning should be emphasized in all sports. Football players must be taught proper blocking and tackling techniques to avoid the head-first block or tackle, such as spearing, and the use of the head as an offensive weapon, which can increase the potential of severe cervical injury.^{[1,2 ]}Wrestlers should be instructed to avoid the maneuver of bulling the neck into a hyperextended position while attempting or blocking a takedown because this appears to be associated with the greatest number of neck injuries in wrestling.^{[3 ]}

Miscellaneous

Medicolegal Pitfalls

• Precedent exists for legal action against athletic trainers and team physicians who failed to properly treat injured athletes, and those who treated the injured players are legally responsible for their actions. The most difficult athletic injuries to evaluate and manage on the field are those involving the head and cervical spine.^{[22,23 ]}The risks can be high because of the potential involvement of the nervous system, and as a result, the margin of error is low. The more severe injuries are fortunately the least common; however, a thorough neurologic examination and evaluation of the cervical spine and its ROM is necessary because these should rule out the possibility of a more serious injury.
• Following an acute injury, one should immediately immobilize the athlete's head and neck, maintain an open airway, and make sure the athlete is breathing and has a pulse (ABCs). The safest ways of opening the airway in an athlete with a suspected cervical injury is the jaw-thrust and chin-lift maneuver; the head-tilt method is not considered safe. Extremity neurologic symptoms; severe cervical tenderness; or severe cervical pain at rest, against resistance, or with active motion are all criteria for spinal cord injury transport. When in doubt, always transport the patient as if there is a spinal cord injury present. Logroll the athlete directly onto the spine board with the chief priority of maintaining alignment of the head and neck at all times. To ensure that there is no possibility of motion during transportation, the athlete should be secured with straps once he/she is on the spine board.

Related Medscape topic:
Resource Center Medical Malpractice and Legal Issues

Special Concerns

• A process that should not be performed haphazardly or hastily is managing an unconscious athlete or one suspected of having significant injury to the cervical spine. The best way to prevent actions that could convert a reparable injury into a catastrophe is to be prepared to handle the situation. Preventing further injury is the single most important point to remember. An examiner should always consider that spinal cord injury is a possibility when dealing with an unconscious athlete.

Multimedia

Media file 1: Bony framework of head and neck.

Media file 2: Cervical vertebrae, the atlas and the axis.

Media file 3: Cervical vertebrae.

Media file 4: External craniocervical ligaments.

Media file 5: Internal craniocervical ligaments.

Media file 6: Atlantooccipital junction.

Media file 7: Lateral view of the muscles of the neck.

Media file 8: Anterior view of the muscles of the neck.

Media file 9: Infrahyoid and suprahyoid muscles.

Media file 10: Scalene and prevertebral muscles.

References

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3. Wroble RR, Albright JP. Neck and low back injuries in wrestling. Clin Sports Med. Apr 1986;5(2):295-325. [Medline].

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Keywords

cervical strain, cervical sprain, musculotendinous injury, ligamentous injury, flexion-extension injury, deceleration injury, whiplash, neck pain, neck strain, neck sprain

Contributor Information and Disclosures

Author

Gerard A Malanga, MD, Founder and Director, New Jersey Sports Medicine Institute; Director of Pain Management, Overlook Hospital; Director of Sports Medicine, Sports Medicine Fellowship Director, Mountainside Hospital; Clinical Chief, Rehabilitation Medicine and Electrodiagnosis, St Michael's Medical Center; Medical Director, Consultant, Horizon Healthcare Worker's Compensation Services, Blue Cross and Blue Shield Worker's Compensation
Gerard A Malanga, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Physical Medicine and Rehabilitation, American College of Sports Medicine, North American Spine Society, and Physiatric Association of Spine, Sports and Occupational Rehabilitation
Disclosure: Nothing to disclose.

Coauthor(s)

Michael J Mehnert, MD, Associate Physiatrist, The Rothman Institute
Michael J Mehnert, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Medical Association, and Physiatric Association of Spine, Sports and Occupational Rehabilitation
Disclosure: Nothing to disclose.

Daniel Kim, MD, Staff Physician, Department of Physical Medicine and Rehabilitation, University of Medicine and Dentistry of New Jersey
Daniel Kim, MD is a member of the following medical societies: American Medical Association
Disclosure: Nothing to disclose.

Medical Editor

Janos P Ertl, MD, Assistant Professor, Department of Orthopedic Surgery, Indiana University School of Medicine; Chief of Orthopaedic Surgery, Wishard hospital
Janos P Ertl, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Association, Hungarian Medical Association of America, and Sierra Sacramento Valley Medical Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Russell D White, MD, Professor of Medicine, Department of Community and Family Medicine, University of Missouri-Kansas City School of Medicine, Truman Medical Center Lakewood
Disclosure: Nothing to disclose.

CME Editor

Jon B Whitehurst, MD, Clinical Instructor of Surgery, University of Illinois College of Medicine; Partner and Executive Board Member, Rockford Orthopedic Associates; Orthopedic Chairman, Rockford Memorial Hospital
Jon B Whitehurst, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, and Arthroscopy Association of North America
Disclosure: Nothing to disclose.

Chief Editor

Sherwin SW Ho, MD, Associate Professor, Department of Surgery, Section of Orthopedic Surgery and Rehabilitation Medicine, University of Chicago
Sherwin SW Ho, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, and Arthroscopy Association of North America
Disclosure: Nothing to disclose.

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