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Case Report of Torn Ligament in Whiplash Associated Disorder

A 51-year old patient with chronic neck pain and clunking sensation went to see a physical therapist for treatment. She reported a history of two car accidents. She was rear-ended in both accidents. The second time she had her head turned to one side at the time of the impact.

The therapist performed an exam of motion and found her active neck motion very reduced. The clunking was present during active movement. It was also reproduced during testing of the alar ligament. The patient also reported dizziness, unsteadiness, fatigue, and anxiety.

The alar ligament attaches the skull to the first vertebra (C1). Its short, tough fibers keep the head from sliding too far to one side when the head is turned. Whiplash injury can cause overstretching and even rupture of this ligament. This is especially true when the face is turned to one side when the impact occurs.

Previous standard X-rays had been taken and reported as "unremarkable". The therapist suggested MRI to examine the neck for upper cervical ligamentous disruption. The MRI showed a grade II left alar ligament disruption. The patient was referred to a neurosurgeon for a treatment plan.

Surgery was not recommended because of the risk from surgical fixation to repair the problem. The patient returned to physical therapy for treatment to stabilize the cervical spine. Care was taken to prevent further disruption of the C1 segment.

After 16 weeks, the patient was able to complete all daily activities. The clunking was much better and she reported less pain and less fatigue.

References: James Elliott, PT, PhD, and Jason Cherry, PT, MS. Upper Cervical Ligamentous Disruption in a Patient with Persistent Whiplash Associated Disorders. In Journal of Orthopaedic & Sports Physical Therapy. June 2008. Vol. 38. No. 6. Pp. 377.

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