The cervical spine or neck is a very mobile area of the body. It is made up of several small joints that work together to allow for a large range of motion in many directions, much like the shoulder. Generally the more range of motion an area naturally has, the last natural stability it has. Excessive stress placed on the supporting soft tissue “envelope” can lead to ligamentous “sprains” and muscular “strains”, which frequently co-exist as a result of a single insult. This is commonly referred to as a neck strain. Sometimes a neck strain happens over time with text neck or lots of looking down, or something at once like in a wrestling injury. The severity of a neck strain or sprain is dependent upon the magnitude, direction, and persistence of the applied forces. Sprain/strain injuries can vary from imperceptible to dangerous, with greater forces generating higher risks of destabilizing injury.
What do ligaments do?
Ligaments serve as the primary “static” stabilizer and act to limit end range of motion. Forces causing movement beyond the normal range of motion can damage ligaments including the anterior longitudinal ligament, posterior longitudinal ligament, ligamentum flavum, facet capsule, interspinous ligament, supraspinatus ligament and intervertebral disc.
What to muscles do?
Muscles act as a “dynamic” stabilizer, protecting the cervical spine throughout its normal range of motion. Strains often result from an eccentric muscular contraction in response to an unexpected external force like when being rear ended or tackled on the football field. Injury can also result from a low stress contraction that is sustained for a long period of time- like looking down at your phone. Stressors that cause sustained or overwhelming muscular contraction can damage muscles in the front, side, and back of the neck as well as the upper back. Sometimes this stress can affect the tendons too, which is the part of the muscle that attaches to the bone.
How do you get a neck strain?
Whiplash injuries are the leading cause of acute neck strains and sprains followed by sporting accidents. Athletes are at highest risk when playing contact sports like football, hockey or wrestling, or when performing high-speed activities like skiing. Sporting injuries often occur as the result of a blow to the head while the athlete is moving forward, resulting in an extension injury. Activities of daily living like pushing, pulling, moving heavy objects and falls are also frequently associated with acute cervical soft tissue injury, and long periods of looking down or computer use.
What happens to the muscles and the ligaments when they are injured?
Sprain/strain injuries may result from a single traumatic event or from chronic repetitive mechanical overloading. Stressors applied over an extended period of time can lead to muscle fatigue, inflammation and micro-tearing. Less acute origins of cervical soft tissue injury include; prolonged static postures in poor workstations, overhead activity, poor bra support, sedentary lifestyles, repetitive movements, pregnancy and obesity. Weakness of the cervical musculature, particularly the deep neck flexors, may be a predisposing factor to injury.
Are neck strains common?
Neck strains and sprains are common. While it is difficult to estimate specifics for this diagnosis, the lifetime prevalence of neck pain has been estimated at 70%. Over one million US adults suffer cervical sprain/strain from whiplash injury alone each year. Gender prevalence is also difficult to pinpoint, but research has shown that both neck pain and sprains from whiplash-type injuries are more common in females. Cervical sprains and strains affect all age groups. While adult tissue may be less elastic and more prone to injury, children are at an elevated risk for sprain/strain as a result of inherent ligamentous laxity and the inability of immature facets and uncinate processes to resist pathologic motion.
What are the symptoms?
Symptoms from sprain/strain type injuries may begin abruptly but more commonly develop gradually in the hours or days following an insult. Complaints often include constant dull neck pain that intensifies or becomes sharp with movement. Rest may relieve acute symptoms but often leads to inactivity-stiffness. The pain is generally limited to the cervical spine, trapezius or interscapular regions but may sometimes refer to the anterior neck and upper arm. Suboccipital headaches are common, particularly when the upper cervical spine is involved. Injury to the upper cervical facet capsules can cause altered proprioceptive input and result in varying degrees of vertigo. Additional symptoms may be generated from concurrent muscular spasm or overlapping myofascial involvement.
How is it diagnosed?
A patient’s history will help in determining which specific structures might have been damaged. A facial injury would suggest an extension mechanism, likely involving the SCM, longus or rectis muscle groups. A blow to the back of the head or another type of flexion injury would affect the trapezius, spinal erectors, splenius or semi spinalis muscle groups while a rotation or lateral flexion-based injury might involve the levator, scalene, SCM, trapezius or splenius group.
Clinical presentation of cervical sprain/strain generally includes poorly localized pain, swelling and loss of range of motion. Pain on passive end-range of motion testing suggests ligamentous involvement, while pain on resisted range of motion testing suggests a muscular contribution. Palpation may demonstrate spinous process tenderness and paraspinal spasm. Acute spasm develops as a protective splinting mechanism secondary to de-stabilizing injuries. Myofascial pain syndrome may develop in response to chronic overloading, particularly in the presence of upper crossed syndrome. Motion palpation may demonstrate altered intersegmental mobility, ranging from restriction to hypermobility. Your doctor will also perform an orthopedic assessment.
In cases of significant trauma, clinicians should be particularly vigilant for concurrent head injury or the presence of cervical instability. Neurologic evaluation of uncomplicated sprain/strains is generally normal and the presence of any neurologic deficit should raise suspicion of more threatening diagnoses, including instability or disc lesion.
Will I need an x-ray?
Clinicians may need cervical radiographs, including flexion extension views, to rule out fracture or instability, generally it depends on whether or not there was trauma associated with the injury and the age of the patient. The American College of Radiology suggests imaging post-traumatic neck pain when there is a dangerous mechanism of injury. High risk candidates include those who over 65 years of age, have radiating neurologic signs or symptoms, have midline cervical spine tenderness or significant (greater than 50%) loss of range of motion. Radiographs may also be appropriate for patients with a history of cancer, bone disease, systemic disease, inflammatory arthropathy, steroid use, immunosuppression, fever or prior cervical surgery, in those with suspected congenital defect or instability or in those whose pain is unusually severe, progressive or prolonged.
How can chiropractic and physical therapy help?
Controlling pain and inflammation are the initial goals of treatment. Ice, massage, neck exercises, and NSAIDS can assist this process. Gentle range of motion exercises and isometric strengthening should be implemented to tolerance in the acute phase of healing.
The second goal of treatment is restoration of normal mobility and joint function. Myofascial release and stretching exercises may be needed for the scalene, trapezius, levator, pectoral, SCM and other paracervical muscles. Nerve mobilization techniques may be necessary to restore normal neurodynamics. Spinal manipulation is a valuable tool for the restoration of normal joint mechanics in sprain/strain injuries. Clinicians must be judicious in the application of spinal manipulation in order to avoid further damage to hypermobile joints. Restrictions in the upper thoracic spine are common in cervical pain patients and need to be addressed.
The final phase of treatment, stabilization, will include home exercises to increase strength and decrease the chance of re-injury. Clinicians should pay particular attention to activating the deep neck flexor muscles in chronic neck pain patients. (27). Upper crossed syndrome is a common counterpart to chronic sprain/strain injuries and should be identified and managed. Ergonomic and postural training may include a discussion of workstation ergonomics, sleep posture and modification of activities of daily living to promote healing and prevent recurrence of symptoms.