Fig. 1.1
Cervical spine fractures, dislocations, and subluxations for high school, collegiate, and professional football players decreased substantially beginning in 1977 as a result of rule changes implemented in 1976, which banned head-first blocking, tackling, and spearing. From Torg et al. [51] © 1990, reprinted by Permission of SAGE publications
Proposed Methods of Injury Prevention
Anatomical factors may play a role in the risk of cervical spine fracture or quadriplegia. Individuals with cervical spine stenosis, narrowing of the cervical spinal canal, have an increased risk for suffering permanent neurological injury [50, 54]. Further, the combination of anatomy and playing style may increase the risk for cervical spine fracture or dislocation. The combination of spinal stenosis, persistent straightening of the typically curved cervical spine, radiographic abnormalities, and a history of headfirst tackling has been termed “spear tackler’s spine,” and, in the athletic setting, may present for an increased risk for cervical spine fracture [52].
Once headfirst tackling was banned from American football in 1976, the rate of catastrophic cervical spine injuries steadily decreased (see Fig. 1.1) [55]. Further, the removal of the word “intentional” in 2005 made any type of headfirst tackling illegal and allowed referees to call a penalty without having to interpret intention of the player, creating a safer playing environment [56]. While these rule changes have been effective in reducing the incidence of cervical spine fractures and quadriplegia, proper instruction remains a key component in preventing catastrophic injuries. A poorly executed block or tackle may be one cause of cervical spine fractures [47], so coaches play a pivotal role in athlete protection. Avoidance of any repeated posture which creates a vulnerable position for an athlete, including leading with the top of the head or an impact that combines a headfirst and slightly flexed neck posture, should be stressed by all coaches in all sports.
Burners and Stingers
Biomechanics and Pathophysiology
Burners and stingers are typically transient events involving sensory and/or motor function loss in the arms resulting from a rapid stretch of the brachial plexus or compression of the exiting nerves to the upper extremity [54]. During a collision, particularly those involving younger athletes, the shoulder nerves may stretch when the head is abruptly flexed laterally while simultaneously the shoulder is displaced in a downward direction, stressing the nerves that travel from the cervical spine into the upper extremity, resulting in a burning sensation down the arm [50]. This injury is always unilateral and rarely persists beyond 30 min but has been documented to go on for days to months in rare circumstances [50]. For a further discussion of burners and stingers, please see the chapter by Kerr et al.
Epidemiology
Various risk factors have been explored related to the occurrence of a burner or stinger. It appears that they take place most often during participation in American football or wrestling [50]. As with cervical spine injuries, burners or stingers have been implicated to occur more frequently in athletes with a spinal stenosis [50]. Continued presence of this injury may be indicative of a lesion in the brachial plexus or underlying dislocation of the shoulder joint [57], and a physician referral should be made if stingers or burners are experienced frequently.
Proposed Methods of Injury Prevention
Of particular importance following a burner or stinger is proper management, including ruling out any cervical spine or spinal cord injury, which may be the cause of the reported pain [54]. But as no randomized control trials exist examining this type of injury, strong evidence to support prevention measures is sparse [54]. Expert opinion has identified risk factors following the first burner or stinger, which may help to prevent further burners or stingers. Following any type of cervical spine injury, an athlete should not return to play until they have demonstrated full strength and full range of motion in the injured areas [54]. By identifying residual symptoms, neck pain, or incomplete strength or range of motion, the healthcare provider may help to allow time for proper recovery and reduce the risk of sustaining a future burner or stinger.
The use of proper fitting protective equipment such as shoulder pads, cowboy collars, and neck rolls may reduce the risk of these injuries [58], but there is little currently available evidence supporting their use [57, 59, 60]. However, adherence to proper equipment regulations, instruction of proper tackling technique, and appropriate conditioning are all currently employed in order to reduce the likelihood of sustaining a burner or stinger.
Conclusion
While it may be impossible to completely eliminate the risk of injury, reducing risks of all types of injury, from severe to mild, may be achievable with proper education, training, equipment, and medical management to reduce the likelihood of a repeat injury. Future research should prospectively examine each of these components individually and when performed in conjunction with each other in order to identify how well these strategies help reduce head or neck injury rates. In addition, research will help advance the development of innovative and clinically implementable ways to proactively help athletes compete in sport activities in a safer manner.
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