1. Standard cervical spinal radiographs include anteroposterior, lateral, oblique, and odontoid views. If there is no evidence of fracture or dislocation, a flexion-extension view of the cervical spine is also obtained. Active neck flexion and extension are always performed by the patient alone and should not exceed the patient's reported comfort level. The spinal column is considered unstable when vertebral body subluxation in excess of 3.5 mm or an angular deformity of 11 degrees or more exists.
2. Supplemental radiographs consist of pillar views to evaluate the lateral masses. Computed tomography (CT) can be used to detect subtle fractures and evaluate the spine for rotatory subluxation. Magnetic resonance imaging (MRI) is also very useful in the evaluation of soft-tissue abnormalities (ligamentous disruption, disk protrusion).
G. Treatment. The most important aspect of the management of cervical spinal injury is immobilization. Neck immobilization should be maintained until a definitive diagnosis has been made. For example, football-related cervical spinal injuries are managed by transporting the patient (with helmet in place) on a backboard. The patient is log-rolled onto a backboard with vigilant head stabilization. The face guard is left in place unless respiratory difficulty is encountered, in which cases it is removed. The neck is never moved passively until a fracture or dislocation is ruled out.
Note: In cases of spinal cord injury, the administration of IV methylprednisolone should be strongly considered because this agent has been shown to improve neurologic recovery if given within 8 hours of injury. H. Common cervical spinal problems
1. "Burners" or "stingers." These injuries represent a stretch of the brachial plexus with a transient loss of motor power and transient pain radiating down the arm(s). This phenomenon usually occurs in football players. Most often, the symptoms are temporary and usually resolve within 1 to 2 minutes. The person can generally return to play the day of injury. With more severe brachial plexus injuries (i.e., persistent pain or weakness), nerve damage may result. Consequently, neurologic loss and pain will persist. These athletes cannot return to play and should be carefully examined in a controlled, off-field setting.
2. Ligamentous sprain. These injuries occur when a force moves a joint through an abnormal range of motion. This condition presents with localized neck pain and muscle spasm. The neurologic and radiographic examination findings are usually normal. Treatment consists of immobilization (semirigid collar), local heat, muscle relaxants, antiinflammatory medicines, and restriction of activity. Athletes can return to play when the symptoms resolve.
3. Cervical spinal fractures—stable. These types of fractures include C-1 burst fractures (Jefferson fracture), most odontoid fractures, traumatic C-2 spondylolisthesis (hangman's fracture), compression fracture of a vertebral body without comminution, and spinous process fracture (clay shoveler's fracture). Most of these fractures are treated with rigid immobilization (halo vest) until healing is complete.
4. Cervical spinal fractures and subluxation—unstable. Cervical spinal subluxation/dislocation usually presents with neurologic loss. These injuries require immediate immobilization and should ultimately be reduced. MRI is useful for assessing soft-tissue damage in these cases. Cervical traction or surgical reduction and stabilization are frequently indicated.
5. Cervical disk herniation. This phenomenon is uncommon in young athletes but may be seen in axial compression injuries sustained during rugby or football. Again, MRI is the best diagnostic modality for assessing patients for potential disk problems.
II. Thoracolumbar spine. Repetitive stresses to the ligamentous and bony supports of the thoracic (dorsal) spine can result in an overuse syndrome with subsequent acute or chronic back pain. Spondylolysis is a unilateral or bilateral fracture of the pars interarticularis. This lesion is frequently nontraumatic and may represent a congenital lesion or stress fracture. However, spondylolysis can occur acutely, especially in gymnasts, weight lifters, and football linemen. Spondylolisthesis is a fracture of the pars interarticularis, which is associated with translation of one vertebral body over another. It is frequently observed in the lumbar spine, especially at the L5-S1 junction.
A. History. Pain is usually localized to the low back and, less commonly, to the buttocks and posterior thighs. Radicular symptoms are uncommon.
B. Physical examination. Hamstring tightness is common. Point tenderness may be noted along the dorsal thorax.
C. Diagnostic studies. Oblique views of the lumbosacral spine usually demonstrate the spondylolytic lesion (lucency at the neck of the "Scotty dog"). A stress fracture of the pars interarticularis that is not obvious on plain radiographs may be demonstrated by means of bone scintigraphy.
D. Treatment consists of local measures, including heat, nonsteroidal antiinflammatory drugs (NSAIDs), muscle relaxants, and rest during the acute period. Modification of activity or bracing is usually required. Surgical fusion is indicated only in cases of severe spondylolisthesis or unrelenting pain.
III. Shoulder. Sports that require repetitive overhead arm motion (baseball, racquet sports, swimming) place unusual stresses on the supporting structures of the shoulder. Injuries to the shoulder capsule, rotator cuff musculature, biceps tendon, scapular stabilizers, and shoulder musculature are common. Most of these problems are discussed in ChapterJ 5. Additional shoulder problems, unique to overhead athletes, are discussed in this section.
A. Little Leaguer's shoulder typically affects adolescents and teen-agers and represents a separation of the proximal humeral epiphysis. The observed physeal abnormality is likely caused by repetitive forces associated with the acceleration phase of the pitching cycle (extreme humeral abduction and external rotation to forward flexion and internal rotation).
1. History. These typically young patients complain of arm pain during and after throwing.
2. Radiographs reveal widening of the proximal humeral growth plate and demineralization and fragmentation adjacent to the epiphyseal plate. Occasionally, loose bodies are noted in the glenohumeral joint.
3. Treatment is conservative. Patients are prohibited from throwing until clinical and radiographic healing has occurred.
B. Rotator cuff tendinitis usually occurs as a result of overuse or in cases of subtle glenohumeral subluxation. It responds well to conservative measures (ice, NSAIDs, rest). Rehabilitation is most effective in relieving symptoms.
C. Posterior capsular tears, which occur in throwers, can result in ossification of the posterior capsule near the glenoid labrum. These lesions occur secondary to traction on the capsule during the acceleration and follow-through phases of the pitching cycle. Treatment initially consists of rest, NSAIDs, strengthening exercises, and restriction of pitching.
D. Internal impingement syndrome typically occurs in baseball pitchers. Lesions occur at the posterosuperior margin of the glenoid in the undersurface of the rotator cuff tendons (partial tears). These lesions are attributed to impingement of the rotator cuff on the bony margin of the glenoid during the cocking phase of the pitching motion (abduction, external rotation). Treatment is conservative (activity modification, NSAIDs). Recalcitrant cases may require debridement of the lesion.
E. Instability. Global instability (anterior, posterior, inferior) of the shoulder can occur in overhead athletes because of microtrauma to the shoulder capsule. The shoulder usually does not frankly dislocate but rather feels "loose" to the patient. Many cases can be treated with physical therapy; surgical stabilization may be necessary in severe cases.
IV. Elbow. The diagnosis and treatment of problems of the elbow require an understanding of the anatomy and function of the joint.
A. Anatomy and function. The elbow is a hinge joint. Elbow flexion and extension occur at the articulation of the humerus and ulna. Rotation takes place at the proximal radioulnar and radiocapitellar joints.
B. Joint stability. During valgus stress, primary stability is derived from the bony fit of the ulnohumeral and radiocapitellar joints. Secondary stability is derived from the restraint provided by the medial (ulnar) collateral ligament. The lateral (radial) collateral ligament and the anconeus muscle provide some resistance to varus loads; however, bony constraint is much more important in resisting these forces. Most throwing activities subject the elbow to valgus stress.
C. Common elbow problems. Overhead athletes (throwers, tennis players) place tremendous, repetitive valgus forces on the medial side of the elbow. These forces result in the application of compressive forces on the lateral elbow during the acceleration phase of throwing. Forceful extension during follow-through (extension overload) leads to posterior compartment lesions (loose bodies, osteophytes). Medial elbow tension-overload injuries include acute valgus instability and chronic valgus instability, both of which can be complicated by ulnar neuropathy.
Was this article helpful?
Everything you wanted to know about. How To Cure Tennis Elbow. Are you an athlete who suffers from tennis elbow? Contrary to popular opinion, most people who suffer from tennis elbow do not even play tennis. They get this condition, which is a torn tendon in the elbow, from the strain of using the same motions with the arm, repeatedly. If you have tennis elbow, you understand how the pain can disrupt your day.