Cervical Strains

Ovid: 5-Minute Sports Medicine Consult, The

Cervical Strains
Jeffrey M. Mjaanes
Jason Lee
  • Cervical strain refers to a stretch-type injury within the muscle substance or at the myotendinous junction of the cervical and upper back muscles. In addition to the muscle and tendons, injury commonly involves the ligamentous structures of the cervical spine.
  • Synonym(s): Cervical sprain; Whiplash (whiplash-associated disorders)
  • Most frequently caused by whiplash injury, ie, hyperextension of the cervical spine from a rear-end motor vehicle collision
  • More than 1 million cases per year are reported in the U.S. More common in urban areas with a greater number of motor vehicles.
  • Higher incidence seen in females
  • More common in adults than children (especially persons ages 30–50 yrs)
  • Incidence associated with sports is unknown.
  • In general, collision sports are responsible for a high number of injuries to the head and neck.
Risk Factors
Speculated: Age, level of conditioning, prior history of neck injury, cervical degenerative disc disease, head position at time of impact, mechanism of injury, personality traits, and psychosocial factors
  • Acutely, cervical strain occurs as the result of a blow to the head or neck during muscular contraction. In motor vehicle accidents, the causative force is usually a rear-end collision leading to a hyperextension then hyperflexion of the neck. The applied force often creates an eccentric contraction causing microscopic or gross tensile failure, most often at the myotendinous junction and in ligamentous structures.
  • Muscles with high ratios of type II or fast-twitch muscle fibers demonstrate a higher risk for strains or shearing-type injuries.
  • Healing process divided into 3 stages:
    • Destructive phase: Starting with hematoma formation, myofibrillar necrosis, and the initiation of the inflammatory response
    • Repair phase: Involves phagocytosis of necrotic tissue and regeneration of myofibers and the formation of fibrous tissue in areas of damages
    • Remodeling: Entails maturation of the regenerated muscle tissues and reorganization of scar tissue based on the stresses placed on the zone of injury
  • Cervical strains can also be chronic in nature and related to repetitive stress or abnormal postural biomechanics.
  • When taking the history, it is essential to determine the mechanism of injury. For example, if the injury is the result of a motor vehicle accident, important information includes the approximate speed of the vehicles, the location of the patient within the vehicle (driver, front seat passenger, etc.), and whether the patient was restrained.
  • Onset, time course, and location of symptoms (anatomical pain drawings may be helpful in providing an overview of the pain pattern)
  • Presence of any neurological symptoms and course: Upper or lower extremity sensory changes, pain radiating into the arms past the elbows, or weakness in upper extremities
  • Activities and head positions that aggravate or alleviate symptoms
  • Prior episodes of similar symptoms, previous neck injury or surgery
  • Previous treatment, including modalities, medications, physical therapy, traction, manipulation, injection, and surgical treatments
  • Social history, including level of physical activity, occupation, job satisfaction, ongoing litigation, and use of nicotine, alcohol, and/or other substances
  • Pain is the most common presenting complaint in cervical strains. Frequently, patients may have minimal pain immediately after the injury but have increasing pain severity several hours to days later. Pain may be referred to the shoulder, upper limb, and head.
  • Soft tissue swelling may be present.
  • Muscle spasm or tightness
  • Limitation in range of motion at the neck
  • Neck fatigue, stiffness, pain at rest and/or with movement
  • Other symptoms may include unusual skin sensations at head/face, dizziness, lightheadedness, concentration and memory deficits, tinnitus, blurred vision, hearing difficulties, and other cranial nerve deficit complaints.
Physical Exam
  • Observation: Head and neck posture, movement during normal conversation, weak or stiff movement
  • Range of motion: Active range of motion, usually reduced, particularly in directions stretching the injured muscles
  • Palpation: Tenderness, usually noted along the cervical paraspinal muscles; may be present along muscles where symptoms are referred, muscles with associated hypertonicity, or “spasm”
  • Generally normal neurologic examination, although subjective sensory deficits may be present
  • Careful manual muscle testing for evidence of deficits in myotomal distribution
  • Sensory examination for dermatomal deficits in sensation, hyperesthesia, inconsistent or “nonanatomical” pattern
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  • Deep tendon reflexes/muscle stretch reflexes and Hoffman or Babinski signs helpful in identifying myelopathy, radiculopathy, and brachial plexopathy
  • By definition, all provocative tests are negative.
  • Spurling's test is performed by extending the neck and rotating the head, and then applying downward pressure on the head. Considered positive if pain radiates into the limb ipsilateral to the side the head is rotated. Specific but not sensitive in diagnosing acute radiculopathy.
  • Lhermitte's sign is performed by passively flexing the neck. Considered positive if “electric-like” sensation radiates down the spine. Positive with cervical stenosis, myelopathy, spinal cord injury due to tumor, multiple sclerosis, and other conditions.
  • Axial compression test is performed by gently applying an axially directed pressure on top of the seated patient's head. The patient's neck is in neutral. Pain radiating distal to the elbow is considered positive for likely radicular origin. Manual distraction often greatly reduces neck and limb symptoms in patients with radiculopathy.
Diagnostic Tests & Interpretation
  • In the management of cervical strain, radiographs are usually not necessary. In trauma patients, however, plain radiographs are used to rule out other potentially serious conditions, such as fractures or dislocations.
  • Minimum views include anteroposterior, lateral, and oblique cervical spine views for evidence of acute fracture or subluxation with trauma.
  • Open mouth view for evidence of atlantoaxial instability and odontoid fractures. Flexion and extension lateral views are helpful to look for evidence of spinal instability.
  • According to the National Emergency X-Radiography Utilization Study (NEXUS) (1992), Low-Risk Criteria (NLC) cervical-spine radiography is indicated for patients with trauma unless they meet all of the following 5 criteria:
    • No posterior midline cervical spine tenderness
    • No evidence of intoxication
    • A normal level of alertness
    • No focal neurologic deficit
    • No painful distracting injuries
  • CT offers superior sensitivity for detection of acute fractures than plain radiographs. When combined with myelography, CT has significant sensitivity and specificity for radiculopathy and stenosis.
  • Relatively low cost and able to be performed quickly, so ideal in emergency room setting with trauma and vehicular accident victims
  • Performed as indicated
  • MRI is the study of choice to detect soft tissue pathology, including disc and ligament disruption and nerve root or spinal cord compression/injury.
  • Indicated in the acute setting of the patient with multiple injuries to rule out cervical instability
  • Also indicated for patients with deterioration in neurologic findings in order to detect spinal cord changes
Diagnostic Procedures/Surgery
  • Electrodiagnostic studies used to diagnose nerve root dysfunction when the diagnosis is uncertain or to distinguish a cervical radiculopathy from other lesions that are unclear on physical examination
  • Ideally performed 3 or more wks after injury, as diagnostic abnormalities will first be seen 18–21 days after the onset of radiculopathy
  • Diagnostic fluoroscopic-guided medial branch anesthetic block may be performed to assess for facet-mediated pain in patients resistant to treatment.
Differential Diagnosis
  • In evaluation of the patient with acute and subacute neck pain, it is essential to rule out more serious conditions, such as fractures, dislocations, instability, and spinal cord injury. In chronic neck pain, other diagnoses, such as neoplasia, must be considered.
  • Differential diagnosis includes:
    • Cervical fracture
    • Cervical instability, subluxation, or dislocation
    • Disc annulus fibrosis injury
    • Facet joint injury
    • Myofascial pain
    • Cervical radiculopathy
    • Myelopathy
    • Brachial plexus injury
    • Thoracic outlet syndrome
    • Peripheral nerve entrapment (eg, suprascapular nerve)


Ongoing Care
847.0 Neck sprain

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