The Atlantoaxial Joint is made up of the atlas and axis, C1 and C2 respectively. The atlas has inferior and medially directed convex facets that are about 20 degrees inferior to the horizontal plane (Neumann, 2010). The axis has superior and laterally directed convex facets that match the 20 degrees of slope inferior to the horizontal plane of the atlas. The joint results in convex-on-convex surfaces (Abernethy, 2013). Due to the anatomy here, there is no sidebend possible at the AA joint. Instead, this joint is responsible for almost half of cervical rotation. Additionally, there is some flexion and extension possible here via bilateral C1 rolling anterior and gliding posteriorly for flexion; the opposite occurs for extension. The axis is different from typical vertebrae because of possession of the dens (odontoid process) (Neumann, 2010). It is theorized that the dens is the remnant of the body of the atlas. This base provides a rigid axis of rotation at the AA joint. The dens is held against the anterior tubercle of the atlas by the transverse ligament, forming a synovial joint between the dens and anterior arch.

When evaluating a patient with shoulder or neck pain, it is important to consider all of the structures that may contribute to their current symptoms. These structures include local muscles, peripheral or central nervous system dysfunction, soft tissue stabilizing structures, among others. Next, use this information in combination with other portions of the subjective history (mechanism of injury, description of symptoms, and pattern of symptoms) to identify the one or two primary causes of the problem.

Since muscle atrophy was present (without signs of a single muscle trauma or strain), it is important to investigate other muscles with the same segmental and peripheral nerve contributions. This will determine if the weakness is localized or present in multiple muscle groups. Below I review the pectoralis muscle with a special emphasis on the sternocostal fibers. 

Later in the evaluation, the patient remembered that his biceps brachii and pectoral muscle strength had gradually decreased on his right (involved side) versus his left over the past few months while strength training.  

This statement is very important because it most likely ruled out a muscle strain, and ruled in nervous system dysfunction. Further physical examination helped rule out red flags for cervical myelopathy. Additionally, muscle strength testing found weakness in other C5, C6, and C7 muscles. At this point, I concluded that he was safe for treatment, but needed regular reassessment to ensure no further progression of neurological symptoms. 

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A potential location for pathology and treatment of neural tension is the thoracic spine. Remember that the thoracic spine contains the critical zone where the vertebral canal is narrowest. The spinal cord can easily become compressed here, leading to pain/neural tension along the path of a nerve. A nerve can become irritated anywhere in the body. Additionally, sometimes neural tension in the thoracic spine may be related to the cervical spine. With cervical radiculopathy or Cloward’s Area, thoracic/scapular pain can be coming from the cervical spine. When the patient presents with thoracic restrictions, a manipulation to the mid-thoracic spine often improves pain and neural tension by improving mobility. This doesn’t only apply to thoracic pain. There is research showing that patients with shoulder or neck pain may benefit from thoracic manipulation. In fact, there is a clinical prediction rule recommending thoracic manipulation for neck pain (non-validated):

• Symptoms < 30 days
  
• No symptoms distal to shoulder
  
• Looking up does not aggravate symptoms
  
• FABQ Physical Activity Score < 12
  
• Diminished upper thoracic spine kyphosis
  
• Cervical extension ROM < 30 deg      (Cleland et al, 2007)​

​In theory, why does this manipulation work? Think of it as a reset button as it also may have an impact on the sympathetic nervous system. In fact, if we are thinking about the nervous system as a whole, a manipulation to the thoracic spine can impact anywhere in the body, whether it be through improving neural mobility (all nerves are connected head to toe physically and electrically) or just as a novel stimulus to the nervous system! Whether you want to incorporate manual therapy, exercise or just implement part of your examination, consider assessing the thoracic spine for at least all spinal patients, if not more. While there are many methods of assessing the thoracic spine and rib cage, check out this video below detailing how we do some segmental mobility and gross motion assessment.

For more information on topics like these, check out our FREE Cervical Spine Mini Course on how to treat Cervical Radiculopathy!

PHYSICAL THERAPY PHASE (0-3 months)
During the first 12 weeks following trauma or onset of symptoms, patients are generally improving. From a physiological perspective, collagen is maturing, remodeling, and getting stronger. In this stage patients are almost solely attending physical therapy and performing corrective exercises. At the end of 12 weeks, patients likely will feel 60-70% back to their prior level of function. Individuals who perform desk jobs should be back at full duty; more strenuous jobs are still on partial duty.

COMBO GYM + CONTINUED PHYSICAL THERAPY REHAB (3-6 months)
From 3-6 months the patient usually begins their normal gym routine (strength training and cardiovascular exercise) while performing rehabilitation concurrently. I generally think of this phase as someone attending PT 1x/week and performing their gym routine 3-4x/week. In this phase, the individual is starting to feel significantly better, but they have not reached full strength yet. They still have some discomfort (not necessarily pain), and transitional movements, such as getting out of bed and getting up from a chair are still not normal. Ultimately, they still need more work! 

FULL RETURN TO NORMAL ACTIVITY/SPORT (6-12 months)
From 6-12 months, the patient has typically stopped their formal rehabilitation program. They are now performing their normal gym routine and daily activities. The individual continues to progress strength, mobility, flexibility, but now has all the tools needed to be independent. The occasional flare up may occur (especially if a novel training movement is incorporated), but is not anticipated. At the end of the 9-12 months, they should have reached life as usual.

Many patients do NOT realize how long post-surgery rehabilitation takes. In my active cash-based population, many of my patient's have self proclaimed high pain tolerances and feel better relatively quickly. Despite subjectively feeling strong, practitioners must remember that scar tissue continues to mature and remodel for 2+ years! Strengthening and retraining movement patterns will take months (even after the patient feels better). Reaching 100% pain free and 'normal' activity generally takes longer than someone will anticipate. Being honest and giving appropriate education early on can change a patient's outlook on their condition. Use this graph when educating your patients!
​-Jim Heafner PT, DPT, OCS

Cervical radiculopathy has many different symptoms than myelopathy. In radiculopathy, the nerve root (not the spinal cord) is the involved structure. When the nerve root is placed under compression or tension (or any additional stress), individuals will typically have a myotomal pattern of weakness, a dermatomal pattern of sensory loss, hyporeflexia, positive Spurlings Maneuver, positive Distraction Test, decreased cervical rotation to the involved side, and a positive median nerve tension test. 

For more information on treating cervical radiculopathy and myelopathy, please check out our new course on the ​Orthopedic Management of the Cervical Spine! In this course, we cover cervical anatomy, examination, differential diagnosis, advanced treatment strategies, case studies, and more!