Post-Concussion Neck Pain and Return to Sport
A 19-year-old collegiate soccer player had a head-to-collar collision 12 days ago. She was removed from play, had a headache and dizziness that resolved over 5 days, and has been symptom-free at rest for a week. She now has persistent neck pain and stiffness with turning her head to check over her shoulder, and she reports that heading the ball provokes a brief headache. Her team physician cleared her for a graded return. On exam she has limited cervical rotation (55 degrees right, 70 left), tenderness of the upper cervical paraspinals, no neurologic deficits, negative vertebral artery screen, and normal cranial nerve exam. She is eager to play in a match in 4 days.
1. How do you differentiate residual cervical spine dysfunction from ongoing concussion, and why does it matter for her plan?
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The two can overlap, and both can produce headache and dizziness, so the exam must separate them:
- Cervical spine involvement is supported by restricted and painful rotation, paraspinal tenderness, and symptom provocation with cervical movement and heading (which loads the neck).
- Ongoing concussion would be suggested by symptom provocation with cognitive or exertional tasks (symptom-limited exercise testing), vestibular/oculomotor findings, or symptoms at rest.
It matters because the management differs: cervical dysfunction responds to manual therapy and neck strengthening, while concussion requires graded aerobic and cognitive exertion with symptom monitoring. Treating neck pain as "still concussed" delays recovery; clearing her as "just neck pain" without exertional testing risks returning an incompletely recovered athlete.
2. Given the 4-day match, what is your recommendation and how do you justify it?
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Recommend against match play in 4 days and propose a staged return instead. Justification:
- She still has provoked symptoms with heading and restricted, painful cervical rotation, meaning she has not demonstrated tolerance to sport-specific loads.
- Return-to-sport decisions should follow a graded progression (light aerobic, then sport-specific drills without contact, then full contact) with symptom monitoring at each step; she has not completed this.
- A match involves unpredictable head and body contact, and her neck is not yet able to tolerate it.
Plan: begin cervical and scapular strengthening and manual therapy, add graded heading and sport-specific drills, and advance if she remains symptom-free. Communicate clearly with the athlete, coach, and team physician. The athlete's eagerness is understandable but is not a clinical criterion.