Working Diagnosis:
Chiari Type I Malformation

Treatment:
She was sent to neurosurgery for further evaluation at that time. Almost 1 year after the increased frequency of her symptoms, the athlete underwent a successful decompressive suboccipital craniectomy and cervical laminectomy.

Outcome:
The athlete is no longer having episodes but has not returned to competitive sports at this time.

Editor's Comments:
Chiari 1 malformation consist of herniation of the cerebellar tonsils at least 5 mm below the foramen magnum, which reduces space available for the spinal cord. The most common clinical presentations of Chiari type I malformations arise from increased intracranial pressures. More than 80% of patients present with suboccipital headaches, followed by ocular disturbances (retrobulbar pain, photophobia, diplopia, flashers, floaters, blurred vision, and visual field cuts), otoneurological symptoms (dizziness, disequilibrium, vertigo, hearing loss, and tinnitus), gait ataxia, and generalized fatigue. In rare cases, a more focal neurological deficit such as isolated muscle weakness or a focal sensory deficit can occur. MRI of the cervical spine is the imaging modality of choice.
Symptomatic individuals should be disqualified from participation and referred to a spine specialist but return to play can be considered after decompression. For asymptomatic individuals, however, there is no absolute contraindication to contact sports and a discussion involving a spine specialist should take place about the possibility of symptom occurrence or severe neurological injury.
Chari 1 malformation in contact sports and the decision to return to play should remain a case by case decision requiring the involvement of a spine specialist.

References:
Zang D, Melikian R, Papavassiliou E. Chiari I Malformation Presenting as Shoulder Pain, Weakness, and Muscle Atrophy in a Collegiate Athlete. Curr Sports Med Rep. 2016 Jan-Feb;15(1):10-2.

Kirschen MP, Alles J. Ethical implications of an incidentally discovered asymptomatic Chiari malformation in a competitive athlete. Continuum (Minneap Minn). 2014 Dec;20(6 Sports Neurology):1683-7.

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