Sports Medicine for the Orthopedic Resident

Julie A Neumann, Donald T Kirkendall;Claude T Moorman, III;;

• Publisher: WSPC
• Year: 2016
• ISBN:
  9789814635554
• Topic: Medicine
• Subtopic: Anatomy

This should read: "Sports medicine including care of the athlete can be an exciting and unique aspect of orthopedic residency training and beyond. Many of us develop a lifelong passion for helping athletes get back to competition, but, at times, the challenge of mastering sports medicine can be daunting. This book is written by health care providers specifically to help residents prepare to effectively manage conditions seen in athletes both on the field and in clinical situations."

Chapter 1

The Cervical Spine

Melissa Erickson, MD

Athletic injury accounts for approximately 10% of the annual occurrence of cervical spine injuries in the United States.¹ Cervical spine injury has been reported in football, soccer, wrestling, basketball, trampoline, sledding, baseball, hockey, water sports, diving, and rugby, with the majority occurring in collision sports.^2,3 Injuries range from temporary Burners syndrome, commonly known as stingers, to permanent catastrophic spinal cord injury.

Incidence

Because football is associated with the highest number of catastrophic injury in sport, much of the data regarding cervical spine injury comes from football studies. Yet, the incidence per 100,000 participants is higher in gymnastics and hockey. Historically, catastrophic injuries have decreased dramatically in football due to better equipment, medical care, rule changes, and coaching. The National Collegiate Athletic Association banned the intentional striking of an opponent with the crown of the helmet, also known as spear tackling, in 1976. In 1978, the National Operating Committee of Safety of Athletic Equipment (NOCSAE) football helmet standard was set at the collegiate level and followed two years later at the high-school level. In 1976, the rate of quadriplegia was 2.24/100,000 players in high school and 10.66/100,000 in college.⁴ From 1989 to 2002, the overall incidence of quadriplegia dropped to 0.82/100,000 at the college level and 0.5/100,000 at the high-school level. The higher incidence of quadriplegia in collegiate athletes is thought to be due to higher collision forces between bigger, faster, and stronger players. Spear tackling continues to be the most common cause of quadriplegia. Players on the defense and special teams are considered be at the greatest risk.⁵

Anatomy and Mechanics

The cervical spine consists of seven cervical vertebrae. The occiput, atlas, and axis are referred to as the upper cervical spine. The atlantooccipital articulation accounts for 50% of cervical flexion-extension motion. The atlanto-axial articulation accounts for 50% of cervical rotation motion. The lower cervical spine includes C3 through C7. Progressing down the spinal column, the diameter of the bony canal gradually narrows as the diameter of the spinal cord widens, thus reducing the space available for the cord in the lower cervical spine. Cervical stenosis is defined as a canal diameter that is less than 13 mm or if the Pavlov ratio (cervical canal diameter/vertebral body width) is less than 0.8 on a lateral radiograph.² When the neck is neutral, the overall alignment of the cervical spine displays lordosis. When engaging in collision sports, most of the forces are dissipated by the paravertebral musculature. If the neck is flexed, however, the lordosis is reduced and the cervical vertebra alignment becomes straight. If a tackle is made in this position (spear tackling), the axial load is absorbed by the spine causing compression of the cervical spine, which can result in catastrophic spine injury.⁶

Special consideration should be given to the pediatric cervical spine. Children have more horizontally oriented facets, increased capsular and ligamentous laxity, and their paracervical musculature is not fully developed all of which leads to a relative hypermobility. However, children tend to recover faster and sustain less disabling injuries than adults.⁷

Physical Exam

When examining an awake and alert patient with neck pain after an injury, begin with palpation of the spinous processes and paracervical musculature. The active range of motion is recorded in flexion, extension, lateral flexion (both directions), and rotation. A complete sensorimotor evaluation of the extremities is performed being careful to note any sensory deficits that occur in a dermatomal distribution. Biceps, brachioradialis, and triceps deep tendon reflexes are also tested. Perform Spurling’s maneuver by having the patient turn their head toward the symptomatic arm and then apply an axial load. If this maneuver reproduces radicular pain, it is considered positive. Controlled separation of the head and shoulder can be used to reproduce symptoms of a traction injury to the brachial plexus.

Cervical Spine Injuries

Cervical strain

The most common cervical spine injuries in athletes involve soft tissues resulting in a strain of muscles or sprain of ligaments. Direct blows or rapid eccentric muscle contraction can cause strains of the muscle. Forced flexion of the head and neck can cause ligamentous sprains or capsular injures of the facets. Patients will present with localized pain without radiation or neurologic deficit and range of motion may be limited secondary to pain. If an athlete presents acutely with pain after a contact event, a cervical collar should be placed and further work up is warranted. Anteroposterior, lateral, and odontoid radiographs should be obtained. If these are negative, obtain lateral radiographs in flexion and extension to assess for instability. The mainstay of treatment are immobilization and anti-inflammatories until pain is resolved. The collar can be discontinued and the patient can return to play once a full, painless range of motion is demonstrated.

Burners syndrome (“stinger”)

Burners syndrome is a temporary burning and weakness in a single upper extremity. Most commonly, this occurs in the C5 and C6 distribution. In younger athletes, this is thought to be a traction injury to the brachial plexus. In older athletes, Burners syndrome is caused by compression of the upper cervical roots. The cervical foramina are narrowed transiently when the cervical spine is forced into hyperextension alone or in combination with lateral flexion or shoulder elevation to the affected side resulting in transient radiculopathy. Athletes complain of a transient paralysis with a burning sensation that radiates from the shoulder to the fingertips. Full recovery normally returns within 10 minutes. The athlete can be allowed to return to play once they are asymptomatic and have a normal cervical spine and upper extremity sensorimotor exam. It is important that athletes regain full limb strength needed to protect themselves before returning to play. Athletes are restricted from play, however, if they have had more than three episodes, cervical stiffness and tenderness, persistent weakness, or if both upper extremities are involved. More seriously injured patients should be queried. Once these restrictions are ruled out, the athlete should undergo a period of rest and upper extremity strength rehabilitation.⁷

Intervertebral disc herniation

Acute disc herniation results from an axial load that increases intradiscal pressure. The nucleus pulposus is extruded through the annulus fibrosus into the spinal canal compromising the space available for the spinal cord. The resulting cord injury can be either transient or permanent. The athlete may present with paralysis of all four extremities, loss of pain and temperature sensation, posterior neck pain, and paraspinal spasm.² Patients may also present with anterior cord syndrome. An MRI (magnetic resonance image) is typically used to detect a herniated disc.

Transient quadriplegia

Neurapraxia of the cervical cord can result in transient quadriplegia. Hyperextension can cause infolding of the ligamentum flavum, creating a dynamic narrowing of the canal. Hyperflexion can cause a pincer effect between the lamina of the cranial vertebra and the endplate of the caudal vertebra. Brief compression of the cord creates a “post-concussive” effect on the cord.² Athletes with cervical stenosis may be predisposed to transient quadriplegia. A Pavlov/Torg ratio of less than 0.8 was found in 93% of football players with transient quadriplegia. The recurrence rate in football players has been reported as high as 56%.⁸

Athletes complain of pain, burning, and tingling bilaterally that is thought to be due to local compression or contusion of the cord. This can be in the upper extremities, lower extremities, or both with variable amounts of motor deficits. The symptoms are temporary with complete recovery occurring within 15 minutes, but in some recovery may take up to 48 hours.

Congenital anomalies and Down syndrome

Congenital anomalies change the structural integrity of the cervical spine, predisposing an athlete to catastrophic injury. Klippel–Feil syndrome is a failure of segmentation characterized by fusion of two or more vertebrae. With an increasing number of fused segments, fewer motion segments can dissipate applied loads increasing risk of injury at the remaining mobile segments. Odontoid hypoplasia can result in atlantoaxial instability placing the athlete at risk of spinal cord injury.

Athletes with Down syndrome have hypermobile occipitocervical and atlantoaxial articul...