Brachial Plexus Injuries (Burners and Stingers)

By admin On Nov 30, 2023

Ovid: 5-Minute Sports Medicine Consult, The

Geoffrey Kuhlman

Basics

Traction to the plexus when the shoulder is depressed and the head is forced away from the injured side
Compression of cervical nerve roots when the head is forced toward the side of injury
Direct blow to the brachial plexus at the supraclavicular fossa

Description

Acute trauma to the neck and shoulder area injuring the brachial plexus
Typically causes burning or stinging pain in the upper shoulder radiating down the entire upper extremity, hence the names “burner” and “stinger”
Most commonly involves the upper trunk of the plexus or cervical nerve roots C5 and C6

Epidemiology

Incidence

Exact incidence unknown due to underreporting by athletes
Common in contact sports (football, wrestling, hockey); football career incidence reported between 49% and 65%
Frequent recurrence, reported as high as 87% (1)

Risk Factors

Previous burner
Limited range of motion of the neck or shoulder

General Prevention

Neck roll, shoulder pad lifter, or rigid collar (eg, Cowboy Collar) in football might reduce injury risk.
SORT-C (strength of recommendation taxonomy, level C)

Etiology

Most are limited to neurapraxia, nerve dysfunction with demyelination
Minority involve axonotmesis, with subsequent Wallerian degeneration and eventual regeneration of axons

Diagnosis

History

Mechanism of injury (falling on an outstretched arm suggests alternative injury) (2)
Details of symptom quality, severity, and location (bilateral or lower extremity symptoms indicate cervical fracture or cord injury until proven otherwise; symptoms not typical of burners mandate search for an alternative diagnosis)
Modifying factors (limitation or pain with shoulder motion suggests alternative shoulder diagnosis)
Initial vs recurrent injury (recurrence typically requires more aggressive rehabilitation)

Physical Exam

Signs and symptoms (2):
- Burning or stinging pain radiating down 1 arm circumferentially (ie, nondermatomal pattern)
- Sometimes numbness, paresthesias, and weakness in the extremity
- Athlete often immediately holds the arm close to the body
- Symptoms often last a few minutes, but can persist for weeks, particularly in recurrent episodes.
Physical examination (2):
- Inspection (asymmetry or postural abnormality to address in therapy)
- Palpation (tenderness suggests alternative diagnosis; spasm is common but nonspecific)
- Neurologic examination (strength, sensation, reflexes to localize injury, rule out cord injury)
- Weakness most common in deltoid, biceps, and rotator cuff
- Tinel sign at the supraclavicular fossa (positive result indicates plexus injury)
- After serious cervical injury is ruled out, Spurling's neuroforaminal compression test (disc herniation, burner from cervical foraminal stenosis)

Diagnostic Tests & Interpretation

Not routine
X-ray cervical spine if fracture, dislocation, or cervical instability suspected (anteroposterior, lateral, oblique, flexion, extension)
MRI or CT typically not needed; many false-positive results

Imaging

Cervical spine x-rays if recurrent injury, findings localizing to 1 cervical level, or symptoms in more than 1 extremity (3)
MRI cervical spine if x-rays are unrevealing to identify neuroforaminal stenosis, disk herniation, or mass as possible causes of nerve root impingement (3)

Diagnostic Procedures/Surgery

Electromyogram/nerve conduction velocity (EMG/NCV) if symptoms last 3 wks for confirmation, localization, and prognosis (EMG normalization lags far behind clinical and neurologic recovery, so follow-up EMG generally not indicated) (3)

Differential Diagnosis

Cervical injury (fracture, dislocation, spinal cord injury, disc herniation)
Glenohumeral dislocation
Acromioclavicular separation
Clavicle fracture
Thoracic outlet syndrome (when chronic, recurrent)

P.55

Treatment

Stretch tight muscles at neck and shoulder
Strengthen neck, shoulder, and muscles weakened by injury
These strategies apply, regardless of injury mechanism.

Additional Treatment

General Measures

Chest-out posture
Ensure correct playing technique.
Maintain strength and flexibility of neck and shoulder.

Additional Therapies

No contact sports until asymptomatic and normal neurologic examination (3,4)

Complementary and Alternative Medicine

Football players can consider neck roll, shoulder pad lifter, or rigid collar when returning to play.

Ongoing Care

Follow-Up Recommendations

Schedule follow-up until symptoms and examination normalize.

References

1. Sallis RE, Jones K, Knopp W. Burners: an offensive strategy for an underreported injury. Physician Sports Med. 1992;20:47–55.

2. Kuhlman GS, McKeag DB. The “burner”: a common nerve injury in contact sports. Am Fam Physician. 1999;60:2035–2040, 2042.

3. Standaert CJ, Herring SA. Expert opinion and controversies in musculoskeletal and sports medicine: stingers. Arch Phys Med Rehabil. 2009;90:402–406.

4. Safran MR. Nerve injury about the shoulder in athletes, part 2: long thoracic nerve, spinal accessory nerve, burners/stingers, thoracic outlet syndrome. Am J Sports Med. 2004;32:1063–1076.

Additional Reading

Aval SM, Durand P Jr, Shankwiler JA. Neurovascular injuries to the athlete's shoulder: part I. J Am Acad Orthop Surg. 2007;15(4):249–256.

Aval SM, Durand P Jr, Shankwiler JA. Neurovascular injuries to the athlete's shoulder: part II. J Am Acad Orthop Surg. 2007;15(5):281–289.

Dimberg EL, Burns TM. Management of common neurologic conditions in sports. Clin Sports Med. 2005;24(3):637–662. PMID 16004923

Dimberg EL, Burns TM. Management of common neurologic conditions in sports. Clin Sports Med. 2005;24:637–662, ix.

Rihn JA, Anderson DT, Lamb K, et al. Cervical spine injuries in American football. Sports Med. 2009; 39(9):697–708.

Codes

ICD9

953.4 Injury to brachial plexus