Patients with Down Syndrome may develop laxity in ligaments. This can result in atlantoaxial instability in the cervical spine, with subluxation and the potential for spinal cord compression. The American Academy of Pediatrics issued guidelines in 1984 for sports participation in patients with Down Syndrome based on the information available at that time.



(1) All patients with Down Syndrome participating in sports with the potential for trauma to the head and neck should have lateral radiographs of the cervical spine in neutral, extension and flexion positions prior to beginning training or competition.

(2) If the distance between the posterior aspect of the anterior arch of the atlas and the anterior surface of the odontoid process <dens> of the axis is > 4.5 mm, OR if the odontoid process is abnormal, then there should be:

(a) restrictions on participation in sports that involve trauma to the head and neck

(b) followup at routine intervals

(3) Repeat radiographic screening is not indicated in asymptomatic patients who have previously shown normal findings.

(4) A patient with atlantoaxial instability and neurologic signs and symptoms associated with spinal cord compression should:

(a) be restricted in all strenuous activities (not just in sports involving high risk of trauma to the head and neck)

(b) be considered for operative stabilization of the cervical spine

(5) A patient with Down Syndrome who does not have evidence of atlantoaxial instability may participate in all sports. Followup is not required unless musculoskeletal or neurologic signs or symptoms develop.


Sports considered high risk for trauma for the head and neck include:

(1) contact sports (football, wrestling, soccer, etc.)

(2) tumbling

(3) gymnastics

(4) diving

(5) swimming using the butterfly stroke

(6) trampoline



• The need for screening all patients with Down Syndrome by lateral spine radiographs prior to sports participation and the need to restrict sports participation in patients with atlantoaxial instability has been challenged by several authors.

• While mild atlantoaxial laxity is seen in a significant percentage of patients with Down Syndrome (13% according to Cohen), evidence of spinal cord compression is seen in only about 2% of patients. The changes in lateral cervical spine radiographs do not appear to be predictive of progression to spinal cord compression.

• Patients with normal lateral cervical spine radiographs may have other lesions capable of causing spinal cord compression and unrestricted participation in sports by these patients can be hazardous.

• There is a need for better ways of identifying patients at risk for catastrophic neurologic injury.


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