Toward Understanding Normal Craniocervical Rotation Occurring During the Rotation Stress Test for the Alar Ligaments.

The rotation stress test is suggested for checking alar ligament integrity. Although some authors, in the literature regarding the rotation stress test, accept that rotation will occur during testing, estimates of range occurring with a normal test response vary between 20 and 40 degrees. None of these estimates are based on formal examination of the test.  The purposes of this study were: (1) to examine the range of craniocervical rotation occurring during rotation stress testing for the alar ligaments in individuals who are healthy and (2) to investigate a measurement protocol for quantifying rotation.  A within-subject experimental study was conducted in which sixteen participants went through magnetic resonance imaging in neutral and end-range rotation stress test positions. Measurements followed a standardised protocol relative to the position of the axis. A line connecting the transverse foramena of the axis created a reference plane. The position of the occiput in the head-neutral position was calculated as the angle formed between a line joining the foramina lacerum and the reference plane. Measurements were repeated at the end-range test position. Total rotation of the occiput was calculated as the difference in angles measured in neutral and test positions. Measurement was performed on 4 occasions, and reliability of measurements was assessed using the standard error of measurement (SEM) and the intraclass correlation coefficient (ICC).  Measurement of rotation of the occiput relative to a stabilised axis ranged between 1.7 and 21.5 degrees.  Sustaining the test position for imaging added to the chance of loss of end-range position and image quality. The authors found that testing could be performed only in the neutral position, not in 3 planes as often described.

The study found that the range of craniocervical rotation during rotation stress testing of intact alar ligaments should ordinarily be 21 degrees or less. Rotation may be quantified using the method protocol outlined.

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On a proximal topic I treated a physical therapist today who sustained an injury tot he upper cervical spine in college when her roomate who was study a manipulative discipline practiced a manuever. This was the Pt’s second visit and I defer discussing he work done on the lower body. She had an interesting presentation in which isolated occipital rotation was preserved albeit with some resistance to passive testing whereas side-bending of the occiput on C1 was not. Lacking a CT scan with 3D reformnates as would be ideal and even better with a 3D printed model as is available I was left to speculate. It may be that the occipital condyle and/or C1 superior articulation on the right either had a deeper concavity/convexity allowing this, or alternately; there may have been a greater horizontal orientation on that side. An additional speculation is of course, none of the above. Treatement focused on restoring occipital sidebanding to the left and side-glide (curvilinear) to the right. She was very p[leased with the gain in range and reduction in pain. I did a brief film pre and post but do not film the actual technique. I treat it as close to neutral as I can preferring not to stress the upper cervical at end ranges of the entire cervical spine in extension, flexion, rotation, and side bending, same for passive accessory glides. I will post a you tube video on the topic.

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