Cervical Spine Sprain/Strain Injuries

United States statistics

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. Among high school ice hockey players, a study showed that cervical spine injuries occurred at a rate of 2.44 per 100,000 athlete exposure.[4]

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.[5, 6, 7]

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).[8, 9] Seven cervical vertebrae, stacked vertically, comprise the skeletal portion of the spine. 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 the images below.

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 the image below). 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.[9]

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 the images below).

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

The images below illustrate several views of muscles of the neck.

Related Medscape Reference topics include the following:

• Cervical Spine Injuries in Sports

• Cervical Sprain and Strain

• Disk Herniation Imaging

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.

A study by Holsgrove et al subjected porcine spinal specimens to impact conditions based on those measured in vivo to research cervical spine injury mechanisms. The study concluded that lordosis of the spine increases the likelihood of injury and this underlies the importance that posture represents in injury initiation.[10]

 

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.[11, 12, 13, 14]  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.

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

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.

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.

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 Medscape Reference topics include the following:

• Spinal Cord Trauma and Related Diseases

• Pediatric Torticollis Surgery

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

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.[15] 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

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.[15, 16]

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 Medscape Reference topics include the following:

• Atlantoaxial Injury and Dysfunction

• Cervical Spine Fracture in Emergency Medicine

• Lower Cervical Spine Fractures and Dislocations

• Overuse Injury

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.[17, 18, 19, 20, 21, 22] 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.[23]

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 Medscape Reference topics:

• Superficial Heat and Cold

• Transcutaneous Electrical Nerve Stimulation

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.[24, 25]

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.

Rehabilitation Program

Physical Therapy

During the recovery phase of rehabilitation, the tissue overload and functional biomechanical deficit complexes are addressed.[17, 18, 19, 20, 21, 22] 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.

Rehabilitation Program

Physical Therapy

During the maintenance phase of rehabilitation, the functional biomechanical deficit and subclinical adaptation complexes are addressed.[17, 18, 19, 20, 21, 22] 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.

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.

Class Summary

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.

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.

Class Summary

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.

Criteria for the patient's return to unrestricted competition include the following[26, 27] :

• 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.

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.

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]