What the neck exam can show after concussion: a study in female athletes

Most of the athletes with a recent concussion history in this study had no current neck pain. Yet the researchers found differences when they examined the cervical spine. Restricted left rotation and positive manual findings were more common in that group, and their error on a flexion head-repositioning task was higher.

That is the useful clinical observation from a new paper by Hides and colleagues. It gives a reason to include the neck in a considered post-concussion examination, even when the athlete is not currently complaining of neck pain. It does not tell us that the concussion caused those findings, or that treating them would change recovery.

A closer look at the athletes and the tests

The researchers assessed 156 elite and pre-elite female athletes, aged 13–34, from water polo, football, diving, rugby sevens and cycling/BMX programmes in Queensland. Twenty-eight reported a concussion within the preceding 12 months; 128 did not. Concussion history was self-reported, and the athletes were examined at one point in time rather than followed through recovery.

A musculoskeletal physiotherapist, unaware of each athlete’s concussion history, asked about symptoms and examined the neck. The physical assessment covered active range of motion, manual examination, cervical joint-position error and maximal isometric neck strength.

The movement assessment was deliberately simple: seated active flexion, extension, rotation and side-bending, with each direction classified as restricted or unrestricted. Manual examination looked for altered segmental mobility or pain provocation at cervical and upper thoracic levels. Those are clinician findings, interpreted alongside the athlete’s history; they are not a diagnosis on their own.

For joint-position error, a laser on the forehead pointed towards a target 90 cm away. After a practice task with eyes open, athletes were blindfolded. They moved into flexion, extension or rotation and tried to return to their starting position. The examiner reset the laser to the centre between attempts; each direction was tested three times. The result was the error, in degrees, between the perceived and actual return position.

Strength was assessed separately with a fixed dynamometer during seated maximal isometric contractions. This measured force in a controlled task. It did not measure how an athlete controls rapid head movement during sport.

What was different?

Current neck pain was uncommon among athletes reporting a concussion: 24 of the 28 said they did not have it. The groups did not differ significantly in current neck pain, dizziness or headache. A history of headache or migraine, however, was more common in the concussion-history group.

On examination, the group with a recent concussion history had higher odds of a positive manual cervical finding. Restricted left rotation was recorded in 5 of 28 athletes with that history, compared with 7 of 128 without it. The study did not find the same group difference for right rotation or either direction of side-bending. The range-of-motion result is therefore quite specific; it should not be recast as a general loss of neck movement.

The head-repositioning result is especially relevant to HeadX. Median error when returning from flexion was 4.04° in athletes with a concussion history and 3.13° in those without, a statistically significant difference in this exploratory analysis. Extension and left and right rotation did not show significant group differences. Neither did the average error across all four directions. Looking at the individual movement directions matters: averaging them would obscure the flexion finding.

In a further analysis, positive manual findings were associated with restricted movement in at least one direction and with average joint-position error above the study’s 3.5° cut point. This is another reason to think of movement and repositioning tests as parts of an examination, not interchangeable measures.

Maximal isometric neck strength was not lower in the concussion-history group. Two body-mass-normalised strength measures were statistically higher in that group, but the differences were smaller than previously published measurement-change values from a different population. There is no basis here for saying that these athletes had a meaningful strength advantage.

What might this change in clinic?

The paper makes a practical case for asking about concussion and headache history, then examining the cervical spine when it is relevant to the athlete’s presentation. Current neck pain alone would not have prompted an examination for many athletes in this sample who had a recent concussion history. A brief movement examination can show whether one direction is restricted; a carefully run repositioning task can show how accurately the person returns to their chosen start point.

The laser test is straightforward in principle, but its setup matters. Target distance, starting position, vision, movement direction and number of attempts all affect what is being compared. Record them if the test will be repeated. It is more informative to say “return from flexion was less accurate under this protocol” than to label someone’s proprioception simply normal or abnormal.

HeadX tools can support clinician-led head-movement and repositioning tasks. The devices were not used in this study, so the paper is not a validation of HeadX. Its relevance is the clinical question the researchers chose to measure: whether head and neck function can reveal information that is easy to miss when an athlete has little current neck pain.

Reading the result at the right scale

This was an exploratory, cross-sectional study. Only 28 athletes reported a concussion in the previous year, and the analysis did not adjust for factors such as sport, migraine history or other possible confounders. Many comparisons were made without a multiple-testing adjustment. Some differences may not hold in a larger sample.

We also cannot tell whether a cervical finding was present before the concussion, developed afterwards or arose for another reason. The study did not test rehabilitation, return-to-sport decisions or future injury. Those questions need prospective and intervention research.

For now, the finding worth carrying into practice is modest and concrete: among these female athletes, the neck examination identified differences associated with concussion history despite little current neck pain. Left rotation, manual findings and flexion repositioning each added a different piece of information. The clinician still has to decide what each piece means for the person in front of them.

References and related reading

• Hides JA, Currie BM, Warner EA, et al. Physical examination of the cervical spine should be conducted in female athletes with a history of concussion. JSAMS Plus. 2026;8:100157. Full-text article supplied for this review.
• Leung FT, Warner E, Currie B, et al. Cervical spine and vestibulo-ocular screening in elite female athletes with a history of concussion. Musculoskeletal Science and Practice. 2025;80:103406. A related, separate study; its sample and outcomes are not pooled with those above.
• HeadX: Cervical joint-position-error clinical guide and Head repositioning accuracy after concussion.