Alar Ligament Test: Difference between revisions

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=== Lateral Flexion  ===
=== Lateral Flexion  ===


With the patient in supine, place one hand on the occiput and use the other hand to pinch the spinous process and lamina&nbsp;of C2. With the head in neutral laterally flex the head to one side. &nbsp;Due to the alar ligament attachments (side of the odontoid process to the medial aspect of the occipital condyles)&nbsp;you should feel the spinous process move to the contralateral side as the ligaments become taut.&nbsp;<span style="line-height: 1.5em;">Absence of the spinous process moving to the opposite side may indicate alar ligament injury. </span>  
First proposed by Aspinall<ref>Aspinall W. Clinical testing for the craniovertebral hypermobility syndrome. J Orthop Sports Phys Ther. 1990;12:47–54.</ref> has been described for both sitting<ref>Gibbons P, Tehan P. Manipulation of the Spine, Thorax and Pelvis: An Osteopathic Perspective. Edinburgh, Scotland: Churchill Livingstone; 2004</ref><ref>Westerhuis P. Cervical instability. In: von Piekartz HJM, ed. Craniofacial Pain: Neuromusculoskeletal Assessment, Treatment and Management. Edinburgh, Scotland: Butterworth Heinemann Elsevier; 2007:119–147</ref> and supine<ref>Hing W, Reid D. Cervical Spine Management: Pre-screening Requirement for New Zealand. Auckland, New Zealand: New Zealand Manipulative Physiotherapists Association; 2004</ref> positions.


<span style="line-height: 1.5em;">An altyernative method is to block the spinous process of C2 from moving. &nbsp;This will stress the intact ligament and you should encounter a firm end-feel in this case. Significant movement may indicate ligamentous injury.</span>  
In performing this test, the spinous process and lamina of the axis are stabilized by the therapist to prevent both side bending and rotation of the segment. Slight compression is applied through the crown of the head to facilitate atlanto-occipital side bending. Passive side bending then is applied using pressure through the patient's head; in effect, directing the patient's ear toward the opposite side of the neck.  
 
If fixation of the axis is adequate, the normal coupled movement will not be permitted to occur. Hence, no lateral flexion should occur. Testing is recommended to be performed in 3 planes (neutral, flexion, and extension) to account for variation in alar ligament orientation<ref name="Beeton">Beeton K. Instability in the upper cervical region: clinical presentation, radiological and clinical testing. Man Ther. 1995;27:19–32.</ref>. For a side-bending stress test to be considered positive for an alar ligament lesion, excessive movement in all 3 planes of testing should be evident<ref>Pettman E. Stress tests of the craniovertebral joints. In: Boyling JD, Palastanga N, eds. Grieve's Modern Manual Therapy: The Vertebral C</ref><ref name="Beeton" />.


=== <span style="line-height: 1.5em; font-size: 13px; font-weight: normal;">The alar ligament can have 3 directions of fiber orientation: craniocaudal, horizontal, and caudocranial. It is therefore recommended the test to be performed in 3 planes of neutral, flexion, and extension</span><ref>Aspinall W. [http://www.ncbi.nlm.nih.gov/pubmed/18787255 Clinical Testing for the Craniovertebral Hypermobility Syndrome]. J Orthop Sports Phys Ther. 1990;12(2):47-54.</ref><span style="line-height: 1.5em; font-size: 13px; font-weight: normal;">.</span>  ===
=== <span style="line-height: 1.5em; font-size: 13px; font-weight: normal;">The alar ligament can have 3 directions of fiber orientation: craniocaudal, horizontal, and caudocranial. It is therefore recommended the test to be performed in 3 planes of neutral, flexion, and extension</span><ref>Aspinall W. [http://www.ncbi.nlm.nih.gov/pubmed/18787255 Clinical Testing for the Craniovertebral Hypermobility Syndrome]. J Orthop Sports Phys Ther. 1990;12(2):47-54.</ref><span style="line-height: 1.5em; font-size: 13px; font-weight: normal;">.</span>  ===

Revision as of 19:31, 27 January 2014

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Purpose
[edit | edit source]

To assess the integrity of the alar ligaments and thus upper cervical stability.

Both the side-bending and rotation stress tests for the alar ligaments are based on preventing the inherent coupling of rotation and lateral flexion in the occipito-atlanto-axial complex.  That is, lateral flexion of the occiput on the atlas is accompanied by immediate ipsilateral rotation of the axis beneath the atlas. This rotation was proposed by Dvorak and Panjabi[1] to result from tension generated in the alar ligaments.

Technique
[edit | edit source]

Lateral Flexion[edit | edit source]

First proposed by Aspinall[2] has been described for both sitting[3][4] and supine[5] positions.

In performing this test, the spinous process and lamina of the axis are stabilized by the therapist to prevent both side bending and rotation of the segment. Slight compression is applied through the crown of the head to facilitate atlanto-occipital side bending. Passive side bending then is applied using pressure through the patient's head; in effect, directing the patient's ear toward the opposite side of the neck.

If fixation of the axis is adequate, the normal coupled movement will not be permitted to occur. Hence, no lateral flexion should occur. Testing is recommended to be performed in 3 planes (neutral, flexion, and extension) to account for variation in alar ligament orientation[6]. For a side-bending stress test to be considered positive for an alar ligament lesion, excessive movement in all 3 planes of testing should be evident[7][6].

The alar ligament can have 3 directions of fiber orientation: craniocaudal, horizontal, and caudocranial. It is therefore recommended the test to be performed in 3 planes of neutral, flexion, and extension[8].[edit | edit source]

[edit | edit source]

Rotational[edit | edit source]

With the patient in sitting grip the lamina and spinous process of C2 between finger and thumb. While stabilising C2 passively rotate the patients head left or right. If more than 20-30 degrees of rotation is possible without C2 moving it is indicative of injury to the contralateral alar ligament[9] especially if the lateral flexion alar ligament stress test is also positive. 

The range of craniocervical rotation during rotation stress testing of intact alar ligaments should typically be 21 degrees or less[10].

Evidence[edit | edit source]

Both side-bending and rotation stress testing have been validated to result in a measurable increase in length of the contralateral alar ligament[11].

Recent Related Research (from Pubmed)[edit | edit source]

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References[edit | edit source]

  1. ↑ Dvorak J, Panjabi MM. Functional anatomy of the alar ligaments. Spine. 1987;12:183–189.
  2. ↑ Aspinall W. Clinical testing for the craniovertebral hypermobility syndrome. J Orthop Sports Phys Ther. 1990;12:47–54.
  3. ↑ Gibbons P, Tehan P. Manipulation of the Spine, Thorax and Pelvis: An Osteopathic Perspective. Edinburgh, Scotland: Churchill Livingstone; 2004
  4. ↑ Westerhuis P. Cervical instability. In: von Piekartz HJM, ed. Craniofacial Pain: Neuromusculoskeletal Assessment, Treatment and Management. Edinburgh, Scotland: Butterworth Heinemann Elsevier; 2007:119–147
  5. ↑ Hing W, Reid D. Cervical Spine Management: Pre-screening Requirement for New Zealand. Auckland, New Zealand: New Zealand Manipulative Physiotherapists Association; 2004
  6. ↑ 6.0 6.1 Beeton K. Instability in the upper cervical region: clinical presentation, radiological and clinical testing. Man Ther. 1995;27:19–32.
  7. ↑ Pettman E. Stress tests of the craniovertebral joints. In: Boyling JD, Palastanga N, eds. Grieve's Modern Manual Therapy: The Vertebral C
  8. ↑ Aspinall W. Clinical Testing for the Craniovertebral Hypermobility Syndrome. J Orthop Sports Phys Ther. 1990;12(2):47-54.
  9. ↑ Magee, D. Orthopaedic Physical assessment Elsevier.
  10. ↑ Osmotherly PG, Rivett D, Rowe LJ.. Toward understanding normal craniocervical rotation occurring during the rotation stress test for the alar ligaments. Phys Ther. 2013 Jul;93(7):986-92. doi: 10.2522/ptj.20120266.
  11. ↑ Osmotherly PG, Rivett DA, Rowe LJ. Construct validity of clinical tests for alar ligament integrity: an evaluation using magnetic resonance imaging. Phys Ther. 2012 May;92(5):718-25.[FULL TEXT]
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