CERVICAL STRAIN/SPRAINS

What is it?
A strain or sprain is an injury to a muscle or ligament.  There are many parts of the neck that can be injured, such as the muscles, ligaments, bones, discs, and nerves.  A cervical strain or sprain is a neck injury that involves the muscles or ligaments of the neck. This type of injury can happen in any sport when there is a collision between two athletes, a fall, or contact with impact to the head.   In some collisions or falls, the neck may not be directly injured, but the force of the injury may cause a whiplash of the neck and cause a sprain or strain.  This can occur in many sports, but more often in football, ice hockey, lacrosse, wrestling, and soccer. 

Symptoms
The athlete may start to feel symptoms immediately after the injury, or may slowly feel worsening pain over the course of a few days.  He or she may feel soreness or stiffness in the neck muscles.  It may be difficult to move the neck in certain directions.  The athlete may also feel a spasm or tightness in the neck muscles.  This type of neck injury does not typically involve the bones, nerves, or discs of the neck.  The athlete should not have any numbness, tingling, or weakness in the arms from a true cervical strain or sprain.

Sports Medicine Evaluation/Treatment
 A sports medicine physician will perform a thorough physical examination in order to rule out a more serious neck injury, such as an injury to the spinal cord.  If there are any worrisome signs at the time of the injury, the athlete may be referred for evaluation at the emergency department.  The physical examination includes evaluation of neck movement, location of the pain, and evaluation for muscle spasm.  The athlete can expect a neurological exam to make sure there is no injury to a nerve in the neck.  Sometimes, an x-ray will be ordered to rule out a more serious neck injury.

The treatment of this condition depends on the severity of the injury.  The healthcare provider may prescribe medications to help with the pain or spasm, such as anti-inflammatory medications or mild muscle relaxers.  If the pain is mild, the athlete may be able to do exercises at home to regain full range of motion of his or her neck.  If the pain is worse, the provider may have the athlete work with the athletic trainer if available, or refer the athlete to a physical therapist.  If the athlete is not improving with these treatments over time, an MRI might be ordered to look for a disc or nerve injury.

Injury Prevention
In any collision sport such as football, it is important to play with proper form.  This includes keeping the head up for any collisions or tackles, and not leading with the helmet or head.  Athletes should be taught the proper form for tackling at practice by their coaches, and avoid tackling other athletes until proper technique has been demonstrated.

Return to play
For a cervical sprain or strain that does not include any other worrisome signs, the athlete can return to play once the pain is controlled and he/she has regained full range of motion and strength of the neck.

AMSSM Author: Kris Fayock, MD

HERNIATED DISCS

When people say they have a "slipped" or "ruptured" disk in their neck or lower back, what they are actually describing is a herniated disk-a common source of pain in the neck, lower back, arms, or legs.

Anatomy

Discs are soft, rubbery pads found between the hard bones (vertebrae) that make up the spinal column. The spinal canal is a hollow space in the middle of the spinal column that contains the spinal cord and other nerve roots. The discs between the vertebrae allow the back to flex or bend. Discs also act as shock absorbers.

Discs in the lumbar spine (low back) are composed of a thick outer ring of cartilage (annulus) and an inner gel-like substance (nucleus). In the cervical spine (neck), the discs are similar but smaller in size.

Cause

A disc herniates or ruptures when part of the center nucleus pushes through the outer edge of the dick and back toward the spinal canal. This puts pressure on the nerves. Spinal nerves are very sensitive to even slight amounts of pressure, which can result in pain, numbness, or weakness in one or both legs.

Risk Factors/Prevention

In children and young adults, discs have high water content. As people age, the water content in the discs decreases and the disks become less flexible. The discs begin to shrink and the spaces between the vertebrae get narrower. Conditions that can weaken the disc include:

• Improper lifting
• Smoking
• Excessive body weight that places added stress on the disks (in the lower back)
• Sudden pressure (which may be slight)
• Repetitive strenuous activities

Symptoms

Lower Back

Low back pain affects four out of five people. Pain alone is not enough to recognize a herniated disc. See your doctor if back pain results from a fall or a blow to your back. The most common symptom of a herniated disc is sciatica—a sharp, often shooting pain that extends from the buttocks down the back of one leg. It is caused by pressure on the spinal nerve. Other symptoms include:

• Weakness in one leg
• Tingling (a "pins-and-needles" sensation) or numbness in one leg or buttock
• Loss of bladder or bowel control (If you also have significant weakness in both legs, you could have a serious problem and should seek immediate attention.)
• A burning pain centered in the neck

Neck

As with pain in the lower back, neck pain is also common. When pressure is placed on a nerve in the neck, it causes pain in the muscles between your neck and shoulder (trapezius muscles). The pain may shoot down the arm. The pain may also cause headaches in the back of the head. Other symptoms include:

• Weakness in one arm
• Tingling (a "pins-and-needles" sensation) or numbness in one arm
• Loss of bladder or bowel control (If you also have significant weakness in both arms or legs, you could have a serious problem and should seek immediate attention.)
• Burning pain in the shoulders, neck, or arm

Diagnosis

To diagnose a herniated disc, your doctor will ask for your complete medical history. Make sure to tell him or her if you have neck/back pain with gradually increasing arm/leg pain. Tell the doctor if you were injured.

A physical examination will help determine which nerve roots are affected (and how seriously). A simple X-ray may show evidence of disc or degenerative spine changes.

MRI (magnetic resonance imaging) or CT (computed tomography) (imaging tests to confirm which disc is injured) or electromyography (a test that measures nerve impulses to the muscles) may be recommended if the pain continues.

Treatment

Nonsurgical Treatment

Nonsurgical treatment is effective in treating the symptoms of herniated discs in more than 90% of patients. Most neck or back pain will resolve gradually with simple measures.

• Rest and over-the-counter pain relievers may be all that is needed.
• Muscle relaxers, analgesics, and anti-inflammatory medications are also helpful.
• Cold compresses or ice can also be applied several times a day for no more than 20 minutes at a time.
• After any spasms settle, gentle heat applications may be used.

Any physical activity should be slow and controlled, especially bending forward and lifting. It is extremely helpful to partake in physical therapy, as all strengthening movements will be monitored and safe. This can help ensure that symptoms do not return-as can taking short walks and avoiding sitting for long periods. For the lower back, exercises may also be helpful in strengthening the back and abdominal muscles. For the neck, exercises or traction may also be helpful. To help avoid future episodes of pain, it is essential that you learn how to properly stand, sit, and lift.

If these nonsurgical treatment measures fail, epidural injections of a cortisone-like drug may lessen nerve irritation and allow more effective participation in physical therapy. These injections are given on an outpatient basis over a period of weeks.

Surgical Treatment

Surgery may be required if a disc fragment lodges in the spinal canal and presses on a nerve, causing significant loss of function. Surgical options in the lower back include microdiskectomy or laminectomy, depending on the size and position of the disk herniation.

In the neck, an anterior cervical diskectomy and fusion are usually recommended. This involves removing the entire disc to take the pressure off the spinal cord and nerve roots. Bone is placed in the disc space and a metal plate may be used to stabilize the spine.

For some patients, a smaller surgery may be performed on the back of the neck that does not require fusing the bones together.

Each of these surgical procedures is performed with the patient under general anesthesia. They may be performed on an outpatient basis or require an overnight hospital stay. You should be able to return to work in 2 to 6 weeks after surgery.