NECK PAIN (Cervicalgia)

Neck pain is a common condition that affects the general population as well as athletes. There are various structures that can cause pain that include: muscles, tendons, ligaments, joints and discs. In addition, various nerves about the neck can also be affected and cause pain.

Most neck pain is related to postural issues which occur with our prolonged unusual posture during day to day activities such as driving, reading and work. It is often associated with a forward head round shoulder posture. Over time this results in stress of the muscles of the neck as well as onto the bones, joints and discs causing neck pain. When a nerve in the neck is irritated by a bone spur or disc it can cause pain that radiates into the arm which can also cause numbness and occasionally weakness.

Cervical spine strains and sprains frequently occur as a result of a whiplash injury, which often occurs as the result of motor vehicle accidents, falls, sports-related accidents, or other traumatic events that cause a sudden jerk of the head and neck.  For further details see:

The most frequent cervical injuries in athletes are probably acute strains and sprains of the musculature of the neck, as well as soft-tissue contusions. For further details see:

Diseases like rheumatoid arthritis, meningitis or cancer also cause neck pain.

The evaluation of the athlete with a potential neck injury begins with a detailed history. The clinician will obtain the following information from the patient:
1.    Mechanism of injury; how, when, and where the injury took place, with particular attention regarding the position of the head and neck at the time of the injury
2.    Location of the pain
3.    Aggravating and relieving factors (eg, sneezing, coughing, traction)
4.    Presence, location, and duration of any neurologic symptoms
5.    The use of a body pain diagram to understand the athlete’s pain distribution may be helpful in directing further evaluation.
6.    History of a previous neck injury

The patient comes with complaints of pain and stiffness. In acute cervical sprain, the athlete complains of a jammed-neck sensation, with localized pain in the neck.

At the time of the injury, the individual experiences pain; however, the pain may subside after a few minutes, allowing the athlete to return to full sport participation. Later, swelling, and tenderness may become evident. Neck motion becomes painful and often reaches a peak several hours later or on the following day.

Referred pain, especially to the occipital area or the shoulder and if there is nerve irritation radiation of pain and/or numbness or tingling spreads into the arm, neck, chest and/or shoulders. in any of his/her extremities. Torticollis may be observed on physical examination, but decreased neck movement is more commonly noted. Palpating the injured area commonly reveals tenderness. For further details see:

1.    Plain radiographs (x-rays)
Radiography of the cervical spine is usually the first diagnostic test ordered in patients who present with neck and limb symptoms, and more often than not, this study is diagnostic of cervical disc disease as the cause of the radiculopathy

2.    Computed tomography (CT) scanning
CT scanning is performed in patients who have abnormal plain radiographs or in whom there is a strong clinical suspicion of a fracture with inconclusive radiographs. CT scanning with myelography is preferable to plain CT for assessment and localization of spinal cord compression, any underlying atrophy and in evaluating athletes with possible cervical stenosis.

3.    Magnetic Resonance Imaging (MRI)
MRI is usually indicated in patients with neurologic deficits and when plain radiographic films and CT scans do not provide enough information for definitive management. The MRI findings must be used in conjunction with the patient's history and physical examination findings as abnormalities have also been found in asymptomatic subjects.

4.    Electromyography (EMG)/nerve conduction test
If there is loss of sensation and/or weakness, then an EMG/nerve conduction testing can be helpful in determining what nerve is compressed and how severe it is. It is also done when the diagnosis is uncertain or to distinguish a cervical radiculopathy from other lesions when the physical examination findings are unclear. Although electrodiagnostic studies are very sensitive and specific, normal EMG results in a patient with signs and symptoms consistent with a cervical radiculopathy do not exclude the diagnosis of cervical radiculopathy.

5.    Other tests - labs, lumbar puncture may be ordered depending on the presenting symptoms.

1.    Initial treatment
Ice packs for 15-20 minutes every 1-2 hours or have an ice massage for 5-10 minutes every 1-2 hours (if no neurologic history or deficit is present). This treatment aids in decreasing muscle spasms, decreasing pain, and promoting vasoconstriction.

2.    Physical Therapy
Fortunately, most neck pain issues can be managed with a comprehensive rehabilitation program. Physical therapy treatment is given to increase and improve balance, power, and endurance of the cervical muscles as well as other muscles in the kinetic chain, to normalize posture, to enable the patient to return to unrestricted sport-specific activities. To aid in active neck movement, transcutaneous nerve stimulation (TENS) or cryokinetics (exercising while the musculature is numbed with ice) may also be used. Athletes who have limited ROM and severe pain with a history of a collision can be placed in cervical immobilization in order to rest the musculature and assist with pain control. Manual therapy, including soft-tissue and manipulative techniques, still may be needed to help eliminate vertebral motion restrictions and improve the flexibility and motion of the soft tissues so that cervical PROM and AROM are normalized. Criteria for return to play are absence of pain, a full pain-free ROM, a negative Spurling test, and a normal neurologic examination. A neck roll should be properly fitted and used in athletes at risk for a repeat injury (eg, a middle linebacker in football). For further details see:

3.    Various vitamin supplements and medications can also be used to control pain and allow for improvement in daily function.
NSAIDs - Ibuprofen (Motrin, Ibuprin), Naproxen (Naprosyn, Naprelan, Anaprox),
Tricyclic antidepressants- Amitriptyline (Elavil), Nortriptyline (Pamelor, Aventyl HCl)
Muscle relaxants- Cyclobenzaprine (Flexeril)

4.    Surgical Intervention
Generally, patients should show progressive improvement over the first 6-8 weeks with conservative treatment. If there is no significant improvement in this time frame, consider a surgical evaluation. Early surgical intervention is recommended in any athlete found to have cervical instability. Patients with a progressive neurologic deficit or long tract signs are referred to a spine surgeon. Spinal manipulation is not indicated in patients with frank radiculopathy.

5.    Other Treatment (Injection, manipulation, etc.)
Cervical epidural steroids have been used in patients whose conditions have not had satisfactory responses to medications, traction, and a well-designed physical therapy program. It may help decrease trigger zones and referred pain and help improve muscular flexibility. Multiple and repeated injections are discouraged.

6.    Alternative treatments
Acupuncture has been used to treat radicular pain with some success. This treatment can be considered if pain control is not achieved with physical therapy and medications or in conjunction with these treatments. In addition, acupuncture can be tried instead of cervical epidural injection in patients who are hesitant or who do not wish to proceed with this procedure.

7.    Radiofrequency denervation treatment
In patients with chronic symptoms that are unresponsive to a progressive rehabilitation approach, diagnostic zygapophyseal joint injections may help to identify a potentially treatable process, which may respond to radiofrequency denervation treatment in a properly selected patient group.

Long-term complications that may develop from cervical injuries include chronic pain, headaches, depression, disability, incomplete neurologic recovery, loss of full neck movement, and radiographic changes that indicate disc-space narrowing, persistent loss of normal cervical lordosis, and/or osteophyte formation.

The prognosis for athletic cervical spine sprains/strains and cervical radiculopathy is excellent, with proper treatment. The time frame for this decision depends on the ability of the patient to progress through the various phases of rehabilitation.

For participants in football or wrestling, strengthening of the muscle groups supporting the cervical spine is imperative. Athletes are advised to add a minimum of 1 cm to their neck circumference. Warm-up of the neck and the cervical spine should be emphasized, especially in contact sports.
Proper sport technique is usually of great importance in the prevention and rehabilitation of many cervical radiculopathies. This includes a proper ball toss in tennis, a proper body turn and proper breathing in swimming, and proper head positioning when trackling in football. Proper head and neck positioning should be emphasized in all sports. Wrestlers should be instructed to avoid the maneuver of bulling the neck into a hyperextended position while attempting or blocking a takedown.

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Yasmin was, and always will be, a shining example of a how a person can achieve anything with hard work and a life-affirming attitude. She gave more than she took, she loved more than she feared, and she nurtured her family and friends at every opportunity. We will always remember Yasmin as a woman of strength, courage and compassion. 

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Please consult your own physician for appropriate management about your medical condition.