Cervical Injury in a Female Master Group Long Distance Triathlon Athlete: A 12-Week-Recovery Case
- 1. Department of Orthopaedics and Traumatology, Federal University of São Paulo, Brazil
- 2. Hospital IFOR rede D’or, Brazil
- 3. Hospital Regional de São José Homero Miranda Gomes, Brazil
Abstract
Cycling injuries are becoming more common since the increasing number of participants in athletic forms of cycling. Given that, physicians must be ready to deal with different situations, the aim is to secure an early recovery to the sport. In this casereport we show a 51 year-old Brazilian female long distance triath-lon athlete who suffered a non-surgical cervical fracture and was ready to compete in the Ironman® world championship only 12 weeks after the accident
Citation
de Oliveira DT, Teixeira AM, Franciozi CE, Malheiros Luzo MV, Salvioni Ueta RH, et al. (2017) Cervical Injury in a Female Master Group Long Distance Triathlon Athlete: A 12-Week-Recovery Case. Ann Sports Med Res 5(1): 1108
Keywords
Cyclism , Cervical fracture , Return to play
INTRODUCTION
Sports injuries have been reported in multiple contact and non contact sports, as a merican football [1], rugby [2], hockey [3], snow boarding [4] and cycling [5]. The vast majority of injuries that occur in road and trail cyclists are lacerations, abrasions, contusions and upper extremity fractures [5]. Even though cervical spine injuries are relatively rare, special attention should be taken since it takes a variety of forms and may be relatively benign, such as in spinous process fractures, but it also may result acatastrophic injury, such as after cervical fracture/dislocation [6]. In some cases, it is possible to deal with non-catastrophic injuries of the cervical spine through a faster rehabilitation program aimed at the return-to-playas soon as possible.
CASE PRESENTATION
A 51 year-old female athlete who belongs to the Brazilian long distance triathlon elite team, suffered an accident when she was riding her bike while training for the Ironman® world championship, which was held in Kona, Hawaii, just 12 weeks after the date of the accident. The accident happened when suddenly a piece of metal rod got stuck in the front wheel radius. She flipped over and hit her forehead on the pavement. The athlete was wearing all the protective gear and was cycling at an average speed of 40 Km/h. At the pre-hospital care, she achieved 15 points on the Glasgow Coma Scale [7]. The pre-hospital trauma life support was applied and she was immediately transferred to the trauma hospital reference. The advanced trauma life support was applied, and then she was transferred to the orthopedics unit.
When the athlete came to us, she presented with a deep cut on the left side of her forehead, as well as some skin abrasions on the left side of her abdomen and both her knees.But what drew our attention the most was the fact that the patient was complaining of severe pain in her neck and we felt crepitation in the lower cervical palpation. No neurological disabilities were found, which led her to an “E” score in the Frankel grading chart [8]. After that, while she was still wearing the cervical collar, the x-rays were taken as we can see in Figure (1).
Then a CT scan was performed and fractures in different areas of C6 and C7 were found as shown in Figure (2).To evaluate the trauma extension to soft tissues and the posterior ligamentous complex, an MRI was performed as shown in Figure (3).
Figure 1: A- Signs of malalignment of the spinal processes and a suspicious fracture sign of a transverse process. B- In the lateral view, signs of chronic degeneration of the lower cervical area and also a fracture of the C6 spinal process.
Figure 2: A- In the coronal view, C7 left transverse process fracture. B- In the sagittal view, C6 spinal process fracture. C- C6 left lamina and spinal process fractures in the axial view. There were no injuries involving the spinal canal or the intervertebral foramen at any level.
Figure 3: T2 weighted sagital image showing edema around the fracture. No other injuries were found.
In order to establish the treatment, the sub-axial spine injury classification [9] was applied and since there was no morphological abnormality, no disco-ligamentous injury, and no neurological dysfunction, our final diagnosis was a stable nonsurgical cervical fracture.
At the beginning of the treatment, for the first four weeks she remained wearing a rigid cervical collar in an absolute rest period. At the end of the week 4, she was still complaining of pain and that her cervical movements were very limited. New x-rays were taken and we could see that bone healing was in progress and there weren’t any new findings, as shown in Figure (4). During the next 3 weeks she underwent a physical therapy program aimed at analgesia, muscular strength and progressive range of motion. Then, as she was making progress, in week 5 and still wearing the cervical collar, she started progressive indoor bike training (stationary cycling). On week 6, she was able to start swimming using a front snorkel, to immobilize neck movement during the training. Finally, on week 7 after more x-rays were taken we could see signs suggesting that her bone had healed completely. At that time, she was totally pain-free and with a total range of motion, and wasable to return to play. From week 7 onwards she returned to training without limitations and on week 12 she was able to compete. Figure 5 illustrates the treatment time line.
Twelve weeks after the accident she completed the Ironman® world championship race in 13 hours 47 minutes. Her only complaint was of little pain in the lower neck region during the cycling stage.
Nowadays she is still training and competing long distance triathlon races around the world. She has no complaints related to the trauma.
DISCUSSION
There is no consensus about which type of rehabilitation program is to be followed in athletes with cervical fractures nor
Figure 4: Bone healing in progress without other new findings.
Figure 5: This is a timeline about the treatment weeks. The week 0 represents the moment of the accident and week 12 the world championship race day
the minimum time to return to sports. Despite this, what is well established is that the return-to-play depends on a pain free full range of movement with no radiological findings suggesting instability [10].
The present case shows a stable sub-axial cervical fracture with disco-ligamentous integrity and a normal neurological status, through non-surgical fracture care. Some bony injuries, such as spinous process fractures or unilateral laminar fractures do not cause instability and may require no treatment or only the immobilization with the use of a cervical collar [10]. As an essential part of the treatment, the cervical collar was maintained until the end of the 7th week, when the neck pain complaint stopped.
Our physical therapy protocol involved a multiphasic approach that was both progressive and sequential. Firstly, after the total rest period, we emphasized passive and active assisted pain-free exercises to aid in re-establishing the range of motion. Analgesic procedures like massage or transcutaneous electrical stimulation system (TENS) were always performed at the end of the sessions. After that, in a dynamic strengthening phase, our objective was to improve strength and muscular endurance. Flexion, extension and rotational concentric and eccentric exercises were introduced gradually. In the final preparation to return-to-play we progressively implemented functional demands on the neck complex, like the training of cycling neck position and swimming neck movements. During this time, taking into account the fracture pattern and low associated risks, we started a modified training program in the 5th week with stationary cycling and in the 6th week with swimming training using a front snorkel device, aiming not having to move the head laterally for breathing. All the training sessions were monitored and were interrupted if any signals or symptoms were identified. We believe that this adapted training program was essential for the athletic recovery and worked as a good base preparation for the last 4 weeks before the competition, when she returned to the regular training. At the beginning of the 8th week she returned to cycling as recommended by some studies [2,6].
The little neck complaints perceived during the last part of the cycling stage were probably due to the short time of training without the cervical collar, and so, possibly she wasn’t riding her bike in an adequate fit position.
In a recent systematic review, athletes that had undergone surgical treatment after cervical fractures returned to sports after a mean of 6 months [11]. In non-surgical cases, the rehabilitation time depends on the specific sport and the patient’s recovery. In our case, the patient was able to compete only 12 weeks after the accident.
Taking into account the short period of rehabilitation, the patient’s age and the type of competition, which is extremely strenuous, the final result was very satisfactory. As there is a paucity of similar cases at the literature thanks to its rarity and no consensus regarding rehabilitation and minimal time to return to sports, the related rehabilitation process and time to return to competition can be used as a model to similar sports injury cases, mainly involving time dependent athlete recovery due to important competitions as the 12 weeks rehabilitation protocol demonstrated to be safe and fast at this case report.
