Although the overall incidence of significant cervical spine injuries in sports is low, the potential devastating consequences if such an injury is missed mandate strict vigilance by all primary responders at an athletic event. As such, the first priority when evaluating an athlete with a potential neck injury is to assess for an unstable bony or ligamentous injury. As it can be difficult at the time of injury on the athletic field to determine the extent of cervical injury or to differentiate between a fully recoverable injury, such as cervical cord neuropraxia, and a permanent case of quadriplegia, the athlete with the concerning findings must be immobilized at the head and neck and transported to a medical facility for further evaluation [2]. For further information on the acute response to head and neck injuries, please see accompanying chapter, “Sideline Response and Transport.”

Once it has been established that no unstable injuries exist, the evaluation of cervical muscle strains and stable ligamentous sprains can proceed. Key factors to examine include vital signs, inspection of neck/shoulders and back, palpation of spine, active and passive range of motion, strength testing, and a thorough neurological examination.

Inspection of the neck should be performed from all views (anterior, posterior, and lateral). The examiner should evaluate for any external signs of trauma, such as abrasions, lacerations, contusions, or erythema that may indicate the location of underlying injury. In addition, the inspection should assess for any rotational deformity or, if the condition is chronic, muscle atrophy. Palpation for bony tenderness or palpable deformities can indicate bony or ligamentous injury. Palpable muscle spasm can provide information about which muscles and underlying structures may be involved. If there is no concern for unstable spinal injury, active range of motion should be assessed before passive, in order to reduce the potential for further injury on passive testing. First, assess active range of motion for cervical flexion, extension, lateral bending, and lateral rotation. This is most simply accomplished by asking the athlete to touch chin to chest and then look upwards. The patient is then asked to touch the ear to the ipsilateral shoulder while keeping the shoulder relaxed. Normal range of lateral bending is approximately 45° [3]. Lateral rotation can be assessed by asking the athlete to twist the chin toward the right and left. The normal range of lateral rotation is 60–80° [3]. Next, test the neck muscles for strength in flexion, extension, lateral bending, and rotation. A detailed neurologic exam is important as it may elicit neurologic deficits, which can be subtle and might suggest a soft tissue injury such as ligamentous sprain or intervertebral disc herniation.

For athletes with concerning injuries that are transported to the hospital for further evaluation, the history and physical are key elements to help dictate need for further testing or imaging. Details from the history can provide insight into possible diagnoses. Important elements to cover include the chief complaint, nature of the pain, and full characterization of neck pain including location, radiation, onset, nature, temporal pattern, aggravating or relieving factors, and any associated symptoms. Information about the mechanism of injury can provide clues to typical associated patterns of injury. Flexion injuries tend to compress anterior elements while disrupting posterior elements; associated injuries include anterior wedge vertebral body fractures, chip fractures, anterior dislocations, rupture of the posterior ligaments or ligamentum flavum. Extension injuries tend to compress the posterior elements and disrupt the anterior elements with associated injuries including bony injury to spinous processes, facets, and neural arch or rupture of the anterior longitudinal ligament and anterior disc. Compression injuries are more likely to occur when the neck is in slight flexion rather than neutral position [4].

While obtaining the past medical history, it is especially important to ascertain information on previous injuries or on any predisposing medical conditions. More common examples of predisposing conditions include Trisomy 21, Klippel-Feil syndrome, achondroplasia, Morquio syndrome, Marfan syndrome, Larsen syndrome, or any history of cervical spine surgery or arthritis as this may increase the frequency of significant injury to the cervical spine. A comprehensive review of systems is important to include in the history and can provide further clues to the nature and severity of possible cervical spine injury as well as other possible injuries.

Determining return to play is a difficult challenge and tends to be determined on an individual basis after the extent of the injury is assessed [5]. Proposed minimum criteria include no neck tenderness or spasm; no neck or arm pain; no numbness, weakness, or paresthesias at rest or on axial compression; and full range of motion without pain [6].