Medical Report: Randy and Shermer's Neck

Long report focused on Randy's Shermer's Neck symptoms and treatment.

The occurrence of Shermer’s Neck is one of the ultra-endurance cyclist’s most feared problems. The onset can be very quick. The only commonly reported prodromal symptoms (warning symptoms) are tightness and discomfort in the upper trapezius, and erector muscles of the cervical spine. This leads, after a variable period of time, to rapidly progressive loss of the ability to extend the neck, and to neck and upper back pain.

There were a number of periods with higher winds, and also some very long descents where Randy spent many hours in the aero position prior to this. Our experience indicates that riding in the aero position may hasten the onset of Schermer’s Neck. Randy began to have prodromal symptoms by about 600-650 miles into RAAM. He complained only once or twice of upper back and neck pain before abruptly realizing that he could not extend his neck to see, nor could he properly position his head when he attempted to climb in the standing position shortly before coming into Durango, CO. We deployed an adjustable Laerdal Cervical Collar as immediate first aid. For the reader who experiences Schermer’s and attempts to use a cervical collar, you should know that this solution is very confining and uncomfortable. Also, the collar completely prevents neck rotation as they are designed to protect a broken cervical spine. Thus, with the collar on, Randy could no longer rotate his head at all to see to the side or behind him. He was, however, able to ride on while we addressed the issue.

When Rehab to Racing signed on to provide sports medical and physical therapy support for Team Mouri, Mary and I began to study the range of reported medical and physical problems. First, there is almost no scientific literature on this group of athletes. There are a few antidotal reports; mostly case reports and letters to the editor. The ultra-cycling blogosphere is replete with what from a scientific point of view are wildly variant statements of the origin, treatment, and prevention of Schermer’s Neck. These are often stated with certainty and conviction. We could find no single instance of a statistically valid survey or scientific study of the causation or treatment of Schermer’s Neck.

There are a number of theories of the causation of Schermer’s. These range from “Spinal mis-alignment”, to sternocleidomastoid muscle spasm, to weakness of neck muscles in general, to sequelae of prior neck injuries. Treatment recommendations are even vaguer. There are only two reports in the literature of physical examinations by medical experts of Shermer’s victims immediately after onset. One common thread seems to be the once Schermer’s occurs on an ultra ride, then the rider is stuck with the problem until they can rest (off the bike) for at least 24-48 hours. Randy has a past history of Schermer’s, which occurred after about 600 miles during the Paris Brest Paris Brevet ride.

We examined Randy with acute onset Schermer’s. First, there was no evident active sternocleidomastoid muscle spasm at all. Both were tender to deep palpation. Maximal discomfort on examination occurred in the upper trapezius, and the cervical erector spinae muscles. There were several trigger points in this area. Motor exam revealed that Randy had near complete inability to extend his neck against gravity. Attempting to do so caused posterior muscle pain in the previously mentioned muscle groups. Thus the current R2R theory of Schermers causation is that these muscle groups have simply been exercised to failure. Failure onset is accelerated by fatigue induced muscle spasm. This theory is strongly supported at present by Randy’s response to subsequent treatment.

At present we are 1800 miles into RAAM 2011. Randy is not using a collar at all. Randy can extend, and rotate his neck with only minimal discomfort. He has had no analgesics at all except 2 ibuprofen 200 mg tabs when the problem first started what seems like days ago. He rides about 20-30% of the time in the modified aero position with our McGivered chin support. We changed out his stem, raising the handle bars approx. 5 cm.

Additional therapy based on preventing/treating muscle spasm, while using the chin rest to give intermittent rest to the neck extensor muscles, has resulted in progressive resolution of Randy’s Schermer’s symptoms while at the same time he has had three back to back 300+ mile days through all of Colorado, and Kansas.

Chemically, we have markedly increased Randy’s [Mg] and [K] intake. Also, we immediately started the muscle relaxant methocarbamol 750 mg TID. Potassium intake has also been increased by feeding potassium rich foods. Immediately at onset, our expert Massage Therapist, Connie Griffith massaged his beck extensor muscles and upper trapezius. She has helped all follow vehicle staff learn to massage the neck extensors at every single stop. Randy’s neck continued to improve at this point.