Athletic Medicine and Rehabilitation

October 2002
From the Editor Mike Braid, M.S. E. D. , A.T., C.


It is once again the fall sports season and time to lace up the shoes, strap on a helmet, and play a little ball. Every football season we seem to come across common themes of injuries; ankle and knee sprains, shoulder dislocations/separations, concussions and cervical spine injuries. Of all of the above injuries, concussions and cervical spine injuries can be the most difficult to assess and determine a course of treatment and return to play criteria.

In this issue we focus on the cervical spine. From brachial plexus injuries to vertebral fractures, it is crucial that an accurate diagnosis and subsequent treatment plan be in place to allow for a safe return to play. We hope that the information provided in this issue can help you in this process.

As always, read on and enjoy this fall sports season.

QUOTES:

" Give people more than they expect and do it cheerfully."
--Dalai Lama

"The achievements of an organization are the result of the combined effort of each individual."
-- Vince Lombardi

"Watch your attitude. It's the first thing people notice about you."
-- H. Jackson Brown

"Take care of your reputation. It's your most valuable asset."
-- H. Jackson Brown

Brachial Plexus Injury
Dr. Martin M. Pallante, M.D.


One of the more common cervical spine injuries is a neurological injury referred to as a "stinger" or "burner." This injury is a peripheral injury and not one that involves the spinal cord. It is characterized by a burning dysethesias that usually begins in the shoulder and radiates into the arm and hand. This injury is a unilateral (one side) condition.

Stingers result from one of two mechanisms. These mechanisms can vary depending upon the physical maturity and skill of the athlete. These are either a compression or tensile (stretch) mechanism.

The compressive injury occurs when the neck is forced back and to the side, resulting in symptoms on the same side of the cervical movement. The tensile injury involves the neck being forced in a lateral direction with subsequent symptoms on the opposite side from the forced movement.

These injuries typically produce loss of function and pain for a limited period of time. Weakness, numbness or both are occasionally associated with the C5-6 nerve root distribution. Recovery from a "stinger" usually occurs in minutes, but the signs and symptoms can persist for several days to a few weeks, particularly if it is a recurrent condition.

It is crucial to distinguish a "burner/stinger" from a spinal cord injury to initiate an appropriate treatment relative to the severity of the injury. The key to clinical distinction between the two is that the spinal cord injury results in multiple limb involvement, where the "stinger" always results in unilateral upper extremity impairment. It should also be noted that a differential diagnosis be made between a brachial plexus injury vs. a shoulder subluxation/dislocation as these injuries can create a dead arm syndrome where numbness and weakness occur in the absence of a cervical injury.

There are no simple criteria for determining return to play. It is found that when "burners" occur the player is not allowed to return to competition until full cervical and upper extremity range of motion is present, symptoms have resolved and upper extremity strength is normal. If any of the above does not occur, then the athlete should be held out until further evaluation can be performed. Should symptoms persist, a thorough work-up should occur including cervical radiographs and possibly EMG studies to determine severity of injury to the peripheral nerves.

(Portions of this were taken from the Document of the Inter-Association Task Force for Appropriate Care of the Spine Injured Athlete. Dallas, Texas, National Athletic Trainers' Association, March 2001)

On-the-Field Management and Immediate Care of the Spine-Injured Athlete
Ted Quick, A.T.,C., C.S.C.S.


Injuries to the spine are relatively rare in athletics. However, when they do occur, they must be treated promptly and correctly. The ideal care of a specific athletic incident begins with observation of the event that leads to the possibility of a spinal injury. The Certified Athletic Trainer (A.T.,C.) and medical staff should make every attempt to closely observe all of the plays because knowledge of the mechanism of injury and degree of contact are often helpful.

Initial Assessment:
The initial assessment of an injured player begins by forming a general impression of the athlete's condition, which includes the consideration of basic life support. If any concerns regarding basic life support are present at this time, the emergency medical services (EMS) should be activated immediately. The athlete should not be moved unless it is absolutely essential to maintain the airway, breathing, or circulation. If a helmet is involved, the helmet and chin strap should be left in place unless they do not hold the head securely enough for immobilization. The helmet should only be removed if the airway cannot be maintained or if the face mask cannot be removed. If the helmet is removed, spinal immobilization and alignment must be maintained. The potential or injury during helmet removal can be further complicated by the presence of shoulder pads that elevate the trunk; proper alignment is maintained by removing the shoulder pads simultaneously with the helmet.

Airway:
The evaluation and maintenance of a functional airway are rapidly performed with full consideration for the potential of a spinal injury. Any athlete who is suspected of having a spinal injury should not be moved until the appropriate personnel are present, and he or she should be managed as though a spinal injury exists. If unconscious, the player is presumed to have an unstable fracture until it is proved otherwise. If it is necessary to move the athlete, he or she should be placed in a supine position while the spine is immobilized. However, as in any instance of trauma response, whatever method necessary to achieve an adequate airway must be used.

Breathing:
Next, the presence of sufficient ventilatory exchange is confirmed through either observation of the chest respiratory excursions or listening and feeling for air movement at the upper airway. Ineffective breathing patterns, the use of accessory breathing muscles, or even apnea can be caused by a cervical spinal cord injury. High cervical cord damage may inhibit the output of the phrenic nerve, which controls the diaphragm and arises from the third, fourth, and fifth cervical nerves.

Circulation:
Circulation if evaluated. A circulation abnormality is rare and unlikely to be present in the absence of a primary cardiac event.

Level of Consciousness:
The athlete's level of consciousness is assessed. The athlete should be oriented to person, place, time, and incident. A fully conscious player is questioned regarding the presence of pain, particularly in the spinal region or a limb, altered sensation or strength of any body part, weakness, visual and hearing function. In an unconscious player or one who exhibits any abnormal neurological function, a rapid, objective, and reproducible measure of cerebral function should be used until a more formal neurological examination is carried out.

Neurological Screening:
A screening is performed to assess motor and sensory function in the four extremities. In a cooperative player, an accurate initial examination of the extremities can be achieved and is vital for a full evaluation of the injury. A cranial nerve assessment should be performed as completely as possible while the helmet is left in place.

Transportation:
If the athlete is suspected of having a vertebral column or spinal cord injury, he or she should be transported to an emergency department, where a more formal neurological examination can be conducted and serial assessments can be completed.

Return to Competition After Cervical Injury
Mike Braid, MSEd, ATC


Cervical spine injuries are particularly worrisome to practitioners, patients and patients' families. Due to the wide variety of injuries and associated circumstances, decisions regarding return to competition must be made on an individual basis. These factors must be considered: What is the injury? Has the patient fully recovered? What are the family's wishes? What sports are being considered? What is acceptable risk?

Maroon et al classified C-Spine injuries into three types:

Type I: Permanent Spinal Cord Injury; Usually, documentation of spinal cord injury contraindicates the athlete's return to high speed or contact activities.

Type II: Transient Spinal Cord Injury such as spinal concussion or neurapraxia.

These patients have motor, sensory or combined deficits, which resolve in minutes to hours. Imaging studies are negative and the "neurapaxia" is not well understood on a pathophysiological basis. Available data from Torg and The Head and Neck Injury Registry does NOT suggest that this transient dysfunction predisposes the athlete to subsequent permanent spinal cord injury. Logic dictates, however, that these athletes be cautioned about further participation in contact activities.

Type III: Radiologic Abnormality without Neurologic Deficit:
- Congenital Cervical Stenosis
- Herniated Cervical Disc
- Unstable Fractures or Fracture/Dislocation
- "Stable" Spinal Fractures
- Lamina Fractures
- Spinous Process Fractures
- Some Vertebral Body Fractures
- Ligamentous Injury
- Spear Tackler's Spine

Unstable spinal injuries warrant immobilization and/or surgical stabilization and usually should preclude further contact sports.

Cervical stenosis is more controversial. A canal of <14mm or A Torg ratio of <0.8 is consistent with spinal stenosis. Theoretically, these patients are at increased risk of catastrophic injury, but, again, no data exists to support that notion. Torg has concluded that football players with stenosis (even with a history of transient symptoms) are not necessarily at increased risk for catastrophic injury and these issues must be carefully discussed with the patient.

Herniated cervical discs may require surgical intervention and possibly single level fusion. In such a case, it may be possible for the patient to return to contact sports after 6-12 months of recovery if they have the ability to demonstrate a normal clinical exam and normal stability on flexion/extension radiographs.

Spear tackler's spine refers to a cumulative trauma disorder in some contact athletes and does increase the risk for cervical quadriplegic injury. Typical findings are:
- Developmental Cervical Stenosis
- Loss or Reverse of Normal Cervical Lordosis
- Posttraumatic Radiographic Abnormalities
- History of Spear Tackling Techniques or Cervical Axial Loading

Theses athletes should be withheld from contact sports!

In summary, athletes with C-Spine injuries require adequate work-up to assess their degree and type of injury. They may return to competition when it is clear that there is no serious bony, ligamentous, or neurologic injury and when the athlete is free from neck and arm pain, has full range of motion of the neck without pain or spasm, has normal neck strength in flexion, extension, and lateral bending, and has normal upper and lower extremity strength. If X-rays are necessary, the patient must have normal alignment, no signs of instability, and return of normal cervical lordosis.

The family must be comfortable with the return to competition and must understand that the risk of injury cannot be completely eliminated, especially in contact or high-speed sports.

Terminology
Michelle Zahrt, A.T.,C., C.S.C.S.


"Burner/Stinger": term commonly used to describe burning, pain and/or numbness in shoulder and arm. This is often a result of a stretch or compression of the brachial plexus nerves.

Brachial Plexus: bundle of nerves in neck and shoulders which innervate the upper extremities. These nerves supply both motor and sensory function to much of the upper back, shoulder, and upper arm.

Axial Load: a compression force to the top of the head with the neck in a forward flexed position (chin toward chest).

LOC/Loss of Consciousness: any loss of awareness, regardless of duration or severity of symptoms.

Motor Function: function pertaining to movement and muscle contraction.

Sensory Function: function pertaining to the senses (touch, temperature, pressure, etc.)

Cranial Nerves: 12 nerves in the brain/head which should be monitored with any head/neck injury.

Lateral Flexion: side-bending of the neck, bringing ear to shoulder.

Cervical Spine: the first seven vertebrae, starting at the base of the skull and moving down toward the shoulder blades.

Spinal Concussion: bruising of the spinal cord, often with swelling. Numbness, loss of motor function, and loss of sensation often result, but are usually short in duration.

Neurapraxia: term used to describe a temporary loss of sensation or motor function. This is often the result of a nerve stretch.

Spinal Stenosis: a narrowing of the spinal canal often resulting in constriction of the spinal cord and possible loss of motor and sensory function.

Herniated Disc: (often called "ruptured" or "slipped" disc) condition which often causes pain, numbness, and/or loss of motor function in the extremities.

Catastrophic Injury: injury resulting in permanent disability or even death.

Staff Profile
Brandi Robertson, PT


Brandi joined the Hackley Sports Medicine and Rehabilitation staff this fall. She is a native of Edmore, Michigan and graduated from Montabella High School. Brandi was a three-sport athlete at Montabella, participating in basketball, softball, and track. She earned all-district and all-conference honors in softball. Brandi earned her Bachelor of Science degree from Alma College in Exercise and Health Science in 1999. She participated in both softball and cross-country while at Alma College. Brandi earned her Master of Physical Therapy degree from Grand Valley State University in 2002.

Brandi is married to Muskegon native Matt Robertson. They live in Norton Shores. Her hobbies include running, watching football, and enjoying the outdoors. With her interest and vast experience in sports, health, and fitness, Brandi is a great addition to our Sports Medicine staff.