Neck injuries are common among athletes. When assessing the nature of a neck injury, valuable diagnostic tools include considering any neurologic component and comparing the initial symptoms with the current symptoms, according to Jeffrey L. Gum, M.D., a spine and orthopedic surgeon with Norton Leatherman Spine.

A video of the event or an eyewitness account of the injury from someone other than the patient can also be helpful.

“I think it’s important to have somebody else describe the inciting event, especially when it comes to spinal cord, brain and cervical area,” Dr. Gum said.

A thorough history should also include the location of any abrasions, bruising or any other obvious trauma, the location of pain and whether there is nerve-related pain into the arm (radicular pain) or weakness.

Types of neck pain include pain with limited motion, pain associated with whiplash, headaches related to neck pain and neck, and radicular pain. With spine injuries, weakness is usually accompanied by pain. Weakness without pain usually suggests peripheral issues.

Strains, sprains and contusions are the most common diagnoses. They present with spasms and tenderness but no neurologic element.

Imaging if neurological symptoms are present

“I go to imaging very quickly if there’s a neurologic component, especially if the symptoms are persistent,” said Dr. Gum, who is also an associate clinical professor at the University of Louisville School of Medicine.

A key diagnostic tool for neck injuries in athletes is the upright, rather than supine, X-ray. Flexion and extension views can be helpful depending on other information from the diagnostic workup. Magnetic resonance imaging (MRI) is another primary diagnostic tool, and really the most useful. Computed tomography (CT) scan, especially for the bone detail it provides, can be helpful if the diagnosis or treatment is unclear, according to Dr. Gum.

Typically, if an athlete is involved in high-energy trauma, a CT scan will already have been done in the emergency department before an orthopedist sees the patient.

When the imaging does not correlate with the symptoms or the patient presents with a peripheral issue, electromyography (EMG) is a useful diagnostic tool.

Return to play

“A lot of times, it’s a diagnosis of exclusion. If there’s nothing wrong on imaging and no neurologic symptoms, the treatment most of the time is activity modification: NSAIDs, ice, heat and physical therapy. The majority of folks heal well with this and get back quickly,” Dr. Gum said.

In collision sports such as football, hockey or gymnastics, injuries are typically forced hyperflexion, usually in the subaxial cervical spine, C3 through C7. If there’s transient neuropraxia without stenosis, athletes can return to play.

Among football players, a common injury is root or brachial plexus neuropraxia, resulting in unilateral burning pain radiating from neck to hand. More than half of college football players experience a “stinger” or “burner” during a four-year career. These are reversible, peripheral nerve injuries that typically resolve in 24 hours.

However, if the symptoms persist for more than two weeks, these patients should be evaluated with MRI, according to Dr. Gum.

Elite athletes with an acute cervical disc herniation can also return to play most of the time, usually without surgery, but are often sidelined for months. Acute cervical disc herniation resolves at three months about 80% of the time.

For athletes who undergo surgery, the National Football League permits players with a single-level fusion at C4 or lower to return to play. Players with single-level fusion C3 or higher cannot. Many states and organizations follow these guidelines.

“If it’s a non-displaced fracture, and it heals, it’s fine to go back. If it’s C3 or higher, it’s a big deal, and you should not play collision sports,” Dr. Gum said.

With multi-level fusion, most athletes are not returning to collision sports. In contact sports such as basketball, lacrosse and soccer, athletes can typically return to play even after a two-level fusion.

Care for the spine should begin with the initial evaluation on the field. Every athlete who goes down with a neck injury should be treated as though they have an unstable spine fracture and have cervical immobilization for transfer.

The athlete should be treated for airway, breathing and circulation. Jaw thrust should be used for airway management. The patient’s neck should be kept in a neutral position. Traction should be avoided, and the patient should be logrolled to a spine board.

In football players, the face mask should be removed, and the helmet and pads should remain on. Sandbags and foam can be used if it’s difficult to place a collar.