1. Cervical Spine Pathologies and Special Tests
Orthopedic Assessment III – Head, Spine, and Trunk with Lab
PET 5609C

2. Pathologies Brachial Plexus Pathology: Brachial Plexus Neuropraxia:
Common name: “Burner” or “Stinger”
Definition:
“Transient brachial plexopathy involving the upper trunk”
“Temporary episode of unilateral upper extremity burning dysethesia with or without motor weakness”
“Stinger” → tingling that occurs in upper extremity after injury

3. Pathologies Brachial Plexus Pathology:
Epidemiology: (specific studies)
50% of a Division I FB team had 1 or more burners/season (Robertson et al.)
65% of DIII FB players (201) during careers / 57% > 1 burner (Sallis et al.)
70% reported additional burners that they did NOT report
↑ occurrence with defensive players (DB’s)

4. Pathologies Brachial Plexus: C5 – T1 7 cervical vertebrae
8 cervical nerves:
1st 7: exit above the corresponding vertebrae
C8: exits below the 7th cervical vertebrae

5. Pathologies Brachial Plexus Pathology: Mechanism of Injury:
Stretch of the brachial plexus:
Head forced laterally while opposite shoulder is depressed (common MOI – tackling)
C5 and C6 (most commonly affected)
Nerve root compression:
Combination of neck hyperextension and ipsilateral lateral flexion
Nerve roots impinged between vertebrae
Spinal stenosis - ↑ risk
Compression of brachial plexus:
Direct blow to Erb’s point (shoulder pads compress plexus)

6. Pathologies

7. (A) Traction to the brachial plexus (ipsilateral shoulder depression and contralateral lateral neck flexion) (B) Direct blow to the supraclavicular fossa (Erb's point) (C) Compression of the cervical roots or brachial plexus (ipsilateral lateral flexion and hyperextension)

8. Pathologies

9. Pathologies Brachial Plexus Pathology: Signs and symptoms: Grading:
Numbness and burning of the entire arm, hands, fingers
Sensation loss over dermatomes
Complete transient paralysis of affected nerves
Tenderness over the brachial plexus
Grading:
Grade 1 (Neuropraxia): transient signs/sx. last from a few minutes → 2 weeks
Grade 2 (Axonotmesis): significant sensory/motor deficits > 2 weeks and less than < 6 months
Grade 3 (Neurotmesis): symptoms 6 months → 1 year

10. Pathologies Brachial Plexus Pathology: Evaluation Inspection:
Athlete shakes arm/hand in attempt to regain feeling
Inspect cervical spine for abnormality (fracture/dislocation)
Palpation:
Cervical spine
Clavicle, humerus, scapula, sternum, ribs
SC, AC, GH joints
Shoulder musculature

11. Pathologies Brachial Plexus Pathology: Evaluation Functional Testing:
Active and passive ROM (all neck and shoulder movements)
RROM – can be performed in conjunction with myotome check
Key muscles tested: deltoid, external rotators, biceps brachii
Neurological Screening:
Upper quarter sensory/motor testing
Special Tests:
Brachial plexus stretch test
Cervical compression and distraction
Spurling test

13. Clinical Evaluation C1-C2 Neck flexion C3 Neck lateral flexion C4
Shoulder shrug C5
Shoulder abduction, ER C6
Elbow flexion, wrist extension C7
Elbow extension, wrist flexion C8
Thumb extension T1
Finger abduction and adduction

14. Pathologies Brachial Plexus Pathology: Return to Play Criteria:
Full, pain-free active and passive ROM in the cervical spine
Full, pain-free neck strength against resistance
Full strength of all shoulder and arm movements
Normal sensation in all dermatomes
Check shoulder pads/helmet to ensure proper fit
Recheck in 3-5 minutes

15. Protective Equipment:
A: Neck Roll
B: Lifter
C: Cowboy Collar

16. Pathologies Research Article #1:
Effects of Football Collars on Cervical Hyperextension and Lateral Flexion
Objective: Evaluate the effectiveness of 3 football collars in ↓ cervical ROM
Why:
MOI for stingers
Do the collars ↓ movement?
PREVENTION

17. Pathologies
Effects of FB Collars on Cervical Hyperextension and Lateral Flexion:
Methods:
Subjects: 15 D1 football players
Force applied (hand-held dynamometer)
Motion: 2-dimensional video analysis
Movement:
AROM and PROM
Hyperextension
Lateral flexion

19. Hyperextension Findings: Lateral Flexion Findings:
Can be limited by all 3 collars: (rankings)
1. Cowboy collar A-Force 3. Neck roll
Note: Passive overloading still resulted in additional 190 of hyperextension
Lateral Flexion Findings:
No collar ↓ passive lateral flexion better
than the shoulder pads alone
Standard neck roll ↓ active ROM

20. Pathologies Research Article #2:
Biomechanical Analysis of Football Neck Collars:
Objective: Perform a biomechanical analysis of neck collars through dynamic testing
Why:
MOI for head and neck injuries
Do the collars ↓ force transmission (upon impact)?

21. Pathologies Biomechanical Analysis of FB Neck Collars: Methods:
Collars (3) evaluated:
Cowboy collar (McDavid)
Bullock collar
Kerr collar
Crash-test dummy:
Shoulder pads (raised and unraised), helmet, collar
Accelerometers / load cells / angular rate sensors
Impacts:
Pneumatic linear impactor
5 m/s and 7 m/s

23. Pathologies Biomechanical Analysis of FB Neck Collars: Results:
Top of Head Impact:
Most protection: Kerr collar (Bullock – 2nd)
Why? Kerr collar contacts the base of the helmet during impact → redirects some load to shoulders
Front Impact:
Most protection: Kerr collar (all provided ↑ protection)
↓ head and neck movement **
Side Impact:
Kerr – minimal protection
Cowboy and Bullock – no protection

24. Peak Values for Front Impact: Normal Shoulder Pad Configuration

25. Pathologies Cervical Nerve Root Impingement: History:
Onset: Acute of chronic
Pain: Radiating symptoms into trapezius, scapula, shoulder, arm, wrist, and hand
MOI: Compression or irritation of nerve
Predisposing conditions:
Disc pathology, narrowing of intervertebral foramina, facet degeneration

26. Pathologies Cervical Nerve Root Impingement: Inspection: Palpation:
Posture of head
Palpation:
Point tenderness
Functional Tests:
Pain with extension, lateral bending toward same side, and rotation
AROM, PROM, RROM
Neurological Tests:
Upper quarter screen:
Muscle weakness, paresthesia, diminished reflexes
Special Tests:
Cervical compression test (↑ symptoms)
Cervical distraction test (↓ symptoms)
Spurling test / Vertebral artery test / Abduction test

28. Special Tests Brachial Plexus Traction Test: Patient position:
Seated
ATC position:
Standing behind the patient
Procedure:
One hand placed on side of the patient’s head; other hand over the AC joint (same side)
Cervical spine is laterally bent and opposite shoulder depressed
Positive test:
Radiating pain on the side opposite the lateral bending
Stretching of brachial plexus
Radiating pain on the side toward the lateral bending
Compression of cervical nerve roots between 2 vertebrae

29. MOI is duplicated in attempt to replicate the athlete’s symptoms
MOI is duplicated in attempt to replicate the athlete’s symptoms. Radiating pain down left shoulder – traction injury / Radiating pain down right shoulder – compression injury. Perform bilaterally and do NOT perform with suspected cervical spine fracture and/or dislocation.

30. Special Tests: Cervical Compression Test: Patient position:
Sitting
ATC position:
Standing behind the athlete with hands interlocked over the top of the patient’s head
Procedure:
Press down on the crown of patient’s head
Positive test:
Pain in upper cervical spine and/or upper extremity
Implication;
Compression of the facet joints and narrowing of the intervertebral foramen

31. Special Tests
Cervical Compression Test: Attempts to duplicate patient’s symptoms by ↑ pressure on cervical nerve roots. Do NOT perform test until cervical fracture, dislocation, or instability has been ruled out.

32. Special Tests Spurling Test (Foraminal Compression): Patient position:
Seated
ATC position:
Standing behind the athlete with hands interlocked over crown of patient’s head
Procedure:
Patient laterally flexes the head while a compressive force is placed along patient’s cervical spine
Positive test:
Radiating pain down patient’s arm
Implication:
Nerve root impingement

33. Special Tests
Spurling’s Test: Attempts to compress a cervical nerve root. Do NOT perform until a cervical fracture, dislocation, or instability has been ruled out.

34. Special Tests Cervical Distraction Test: Patient position:
Supine (relaxes the muscles acting on the cervical spine)
ATC position:
At head of patient with one hand under the occiput and the other on top of the forehead (stabilizing head)
Procedure:
Apply traction on patient’s head, causing distraction of cervical spine
Positive test:
Relief or reduction in symptoms
Implications:
Compression of the cervical facet joints and/or stenosis of neural foramina

35. Cervical Distraction Test: Attempts to relieve patient’s symptoms by ↓ pressure on cervical nerve roots. Do NOT perform test until cervical fracture, dislocation, or instability has been ruled out.

36. Special Tests Vertebral Artery Test: Patient position: ATC position:
Supine
ATC position:
Seated at head of the patient with hands placed under the occiput to stabilize the head
Procedure:
Passively extend and laterally flex the cervical spine (1)
Head is rotated toward the laterally flexed side and held for 30 seconds (2)
Positive test:
Dizziness, confusion, nystagmus, unilateral pupil changes, nausea
Implication:
Occlusion of the cervical vertebral arteries

37. Vertebral Artery Test: Used to assure the competency of the vertebral artery prior to initiating treatment or rehabilitation techniques that may compromise a partially occluded artery. Do NOT perform until the presence of a cervical fracture, dislocation, or instability has been ruled out.
Positive Test: Refer to physician