Precautionary Ligament Testing
of the Upper Subcranial Region
David A. Hoyle, PT, DPT, MA, OCS, MTC, CEAS
Select Medical Outpatient Division Family of Brands
“Improving Quality of Life”
Objectives
 Understand the complexity of the joint integrity of the
craniocervical junction.
 Be able to perform tests to assess the integrity of the:
 Alar ligaments
 Transverse Ligament
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Serious Injury Due to Neck Pain
 NATA includes Cervical Spine Injuries as one of the 10
covered conditions in its position statement on the
prevention of sudden death in athletes.1
 Physical Therapists often work with individuals with
neck pain and these are frequently from a traumatic
nature. 2
 Athletic Trainers and Physical Therapists should be
skilled in making assessments of ligamentous stability
when making decisions about return to play and
treatment advise.
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Incidence
 According to a recent report of the reasons for ED
visits by teenage athletes, SCI accounted for < 1% of all
visits.3
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Severity
 Recognition1
 During initial assessment, the presence of any of the
following, alone or in combination, requires the initiation of
the spine injury management protocol: unconsciousness or
altered level of consciousness, bilateral neurologic findings
or complaints, significant midline spine pain with or without
palpation, or obvious spinal column deformity.
• Evidence Category: A1
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Athletic Case Sample
Am J Orthop (Belle Mead NJ). 2014 Jun;43(6):272-4.
Delayed presentation of a cervical spine fracture dislocation with posterior ligamentous disruption in a gymnast.
Momaya A, Rozzelle C, Davis K, Estes R1.
Abstract
Cervical spine injuries are uncommon but potentially devastating athletic injuries. We report a case of a girl
gymnast who presented with a cervical spine fracture dislocation with posterior ligamentous disruption several
days after injury. To our knowledge, this type of presentation with such severity of injury in a gymnast has not
been reported in the literature. The patient was performing a double front tuck flip and sustained a hyperflexion,
axial-loading injury. She experienced mild transient numbness in her bilateral upper and lower extremities lasting
for about 5 minutes, after which it resolved. The patient was neurologically intact during her clinic visit, but she
endorsed significant midline cervical tenderness. Plain radiographs and computed tomography imaging of the
cervical spine revealed a C2-C3 fracture dislocation. She underwent posterior open reduction followed by C2-C3
facet arthrodesis and internal fixation. This case highlights the importance of very careful evaluations of neck
injuries and the maintenance of high suspicion for significant underlying pathology.
PMID: 24945477 [PubMed - in process]
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Anatomy Review
 Upper Craniocervical junction
 Occuput with Foramen
Magnum
 C1/Atlas
 C2/Axis
 Approx 80 deg of transv plane
motion.
 40 deg each direction prin at
AA
 Approx 23 deg of total sagittal
plane motion.
 13 degrees at OA
 10 degrees at AA
 Approx 16 deg of frontal plane
motion
 8 each direction at OA
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Anatomy Review
Alar Ligaments
 Alar lig limit rotation
 Left alar checks right
rotation and left
sidebending.
 Right alar checks left
rotation and right
sidebending.
 Also tightnes in a
subcranial flexed
position.
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Anatomy Review
Cruciform Ligament
 Superior Longitudinal
Band
 Inferior Longitudinal Band
 Transverse Band
 Transverse lig. instability
 Limits anterior glide of axis
on atlas which occurs with
subcranial flexion
 In flexion distance from ant
arch to dens < 2-3mm
(child 3-4).
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Transverse Ligament Instability
 Clinical PresentationHistory of flexion injury
with neck pain.
 Diffuse motor loss
occurs with pyramidal
tract injury.
 Radiographic findings of
increased atlantodental
interval > 3mm
 Wheeless’ Textbook of
Orthopeadics
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Anatomy Review
Apical Ligament
 Functional importance
limited.
 A cranial continuation
of the notochord.
 Between the foramen
magnum and the alars
dorsal to the atlantooccipital membrane and
ventral to the superior
band of the cruciform
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Anatomy Review- Tectorial
Membrane
 Tectorial membrane
 a continuation of the
posterior long. Lig.
 Becomes taught with
subcranial nodding
limiting AA flexion.
 Also becomes taught
with subcranial
backward bending
limiting AA extension.
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Den’s or Peg Fracture
 .
Literature on Detecting Instability
 Upper Cervical Ligament Testing in a Patient with Os
Odontoideum Presenting with Headaches- Minkin
 Upper Cervical Ligament Disruption in a Patient with
Persistent Whiplash Associated Disorder- Elliot
 Clinical Assessment Techniques for Detecting Ligament
and Membrane Injuries in the Upper Cervical Spine
Region- A Comparison with MRI Results- Kaale
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Alar Ligament Test
 Description
 Patient is supine and the therapist grips and
stabilizes the spinous process of the axis. The
head and atlas are then side bent around the
coronal axis of the atlantoaxial joint. Ipsilateral
rotation of the axis is prevented by the
stabilization of the axis. The end feel and the
amount of motion are assessed. If the alar
ligament is intact, little to no side bending can
occur and the end feel should be capsular. The
test is then repeated with rotation of the head
and atlas on the axis and the end feel is
assessed
 Result
 No excessive motion wasnoted and the end feel
was capsular
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Alar-odontoid Ligament Integrity Test
 Test is done supine in
slight flexion with one
finger on either side of
spinous process of C2
 With SC lateral flexion,
immediate movement
into contralateral finger.
 With SC rotation,
immediate movement
into ipsilateral finger.
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Sharp-Purser Test
 Description
 The palm of one hand is placed on the
patient’s forehead and the spinous process
of the axis is then gently fixed by a pinch
grip of the thumb and fingertip pads of the
other hand. The head and neck are then
gently flexed. Through palmar pressure on
the forehead, the occiput and atlas are
translated posteriorly. The unique feature of
this test is that the stress component is
intended to relieve the symptoms rather
than aggravate them. It has also been
reported that a clunk may be noted as the
atlas reduces on the axis.
 Results
 Relieved lower extremity paresthesias. No
excessive motion was noted and no sense
of sliding or “clunking” was noted
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Transverse Ligament Test
 Description
 Patient supine with the head supported by a
pillow in the neutral position. The therapist
supports the occiput in the palms of the hands
and the third, fourth, and fifth fingers while the
2 index fingers are placed in the space between
the occiput and the C2 spinous process, thus
overlying the neural arch of the atlas. The head
and C1 are then lifted (sheared) anteriorly
together, while the head is maintained in its
neutral position and gravity fixes the rest of the
neck. The patient is instructed to report any
symptoms other than local pain and soreness.
The sensation of a lump in the throat or the
presence of cardinal signs or symptoms
indicates a positive test.
 Result
 Positive for bilateral lower extremity
paresthesias
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References
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Casa DJ1, Guskiewicz KM, Anderson SA, Courson RW, Heck JF, Jimenez CC, McDermott BP, Miller MG, Stearns
RL, Swartz EE, Walsh KM. National athletic trainers' association position statement: preventing sudden death
in sports. J Athl Train. 2012 Jan-Feb;47(1):96-118.
Childs JD, Cleland JA, Elliott JM, Teyhen DS, Wainner RS, Whitman JM, Sopky BJ, Godges JJ, Flynn TW;
American Physical Therapy Association. Neck pain: Clinical practice guidelines linked to the International
Classification of Functioning, Disability, and Health from the Orthopedic Section of the American Physical
Therapy Association. J Orthop Sports Phys Ther. 2008 Sep;38(9):A1-A34.
Nalliah RP, Anderson IM, Lee MK, Rampa S, Allareddy V, Allareddy V. Epidemiology of Hospital-Based
Emergency Department Visits Due to Sports Injuries. Pediatr Emerg Care. 2014 Jul 24. [Epub ahead of print]
Momaya A, Rozzelle C, Davis K, Estes R. Delayed presentation of a cervical spine fracture dislocation with
posterior ligamentous disruption in a gymnast. Am J Orthop (Belle Mead NJ). 2014 Jun;43(6):272-4.
Mintken PE1, Metrick L, Flynn TW. Upper cervical ligament testing in a patient with os odontoideum
presenting with headaches. J Orthop Sports Phys Ther. 2008 Aug;38(8):465-75.
Elliott JM, Cherry J. Upper cervical ligamentous disruption in a patient with persistent whiplash associated
disorders. J Orthop Sports Phys Ther. 2008 Jun;38(6):377.
Kaale BR, Krakenes J, Albrektsen G, Wester K. Clinical assessment techniques for detecting ligament and
membrane injuries in the upper cervical spine region--a comparison with MRI results. Man Ther. 2008
Oct;13(5):397-403.
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