eMedicine Specialties > Sports Medicine > Neurological
Brachial Plexus Injury
Updated: Sep 5, 2006
Introduction
Background
Peripheral nerve injuries are not common in noncontact sports. However, in contact and collision sports like football and rugby, brachial plexus injuries occur often. The greater incidence of brachial plexus injuries has been suggested to be the result of direct trauma from participation in contact sports.
The result of trauma to the brachial plexus can lead to the cervical "stinger" or "burner" syndrome, which is classically characterized by unilateral weakness and a burning sensation that radiates down an upper extremity. The condition may last less than a minute or as long as 2 weeks, with the latter duration described as a chronic burner syndrome.
Frequency
United States
Brachial plexus injuries are the most common peripheral nerve injuries seen in athletes. True rate of brachial plexus injuries is difficult to determine due to significant underreporting. Many stingers last briefly and players do not seek medical attention. Clancy et al reported that 33 of 67 college football players (49%) sustained at least 1 burner during collegiate play. Sallis et al surveyed Division III college football players and reported that 65% experienced brachial plexus injuries. In addition, Sallis reported an 87% recurrence rate in these individuals. Meeuwisse reported that 7.2% of all football injuries were brachial plexus injuries.
International
True measure of international occurrence of brachial plexus injuries is undetermined due to significant underreporting in athletes and lack of studies in rugby and hockey involving brachial plexus injuries.
Functional Anatomy
Injuries to the cervical spine are common. The common level of injury is at C5-C6. Damage to other areas of the spinal area can lead to an array of motor and sensory deficits. The following is a list of cervical nerve roots with the associated area of potential motor and sensory deficits:
- C4 - Trapezius; shoulder; top of shoulders
- C5 - Deltoid, rotator cuff; shoulder abduction; lateral upper arm or distal radius
- C6 - Biceps, rotator cuff; elbow flexion; lateral forearm and thumb
- C7 - Triceps; elbow extension; index and middle finger tips
- C8 - Extension of fingers; distal thumb; fourth and fifth fingers
Sport Specific Biomechanics
The following 3 mechanisms are common to brachial plexus injury:
- Traction caused by lateral flexion of the neck away from the involved side (similar to the mechanism in birth trauma)
- Direct impact to the Erb point causing compression to the brachial plexus (often associated with poor-fitting shoulder pads)
- Nerve compression caused by neck hyperextension and ipsilateral rotation (The neural foramen narrows in this mechanism.)
Clinical
History
Commonly, the athlete may complain or describe burning and/or sensation of numbness in the proximity of the neck, shoulder, or upper extremity. The following symptoms usually follow a blow to the head, trapezius, or shoulder:
- "Dead arm"
- Pain in neck
- Burning sensation in neck
- Dysesthesias
- Affected extremity may feel weak or heavy
- Paresthesias
Symptoms can last anywhere from a few seconds to weeks, depending on the extent of injury. Numbness in both upper extremities should alert the physician to a possible cervical cord injury.
Physical
The physician should keep a high index of suspicion for potential cervical fracture and/or cord injury in the face of an athlete with any degree of altered level of consciousness. In the alert and awake athlete, a full neurological examination is warranted.
- Assessment of immediate mental status
- Cervical nerve root assessment (motor and sensory)
- Tenderness over Erb point
- Spurling test
- This test is best performed once cervical spine and neurologic assessment has been completed and no risk of potential spine injury is present.
- The test is performed by extending the cervical spine with the head rotated toward the affected shoulder while cautious, but firm, axial loading is administered.
- The purpose of the Spurling test is to reproduce the symptoms of a brachial plexus injury by manipulation of the neck. A positive Spurling test successfully reproduces the patient's symptoms.
- On-field management and assessment of the injury is determined at the time of injury and should include the following:
- Specific symptoms
- Durations of symptoms
- Cervical ROM within pain threshold when no suspicion of cervical fracture is present
- Assessment for motor deficits
- Grip strength
- Early mobilization of the affected region
- Icing of the affected region with care not to ice the peripheral nerve
Causes
Classically, burner syndrome occurs as a result of a blow to the side of the head, shoulder, and/or Erb point.
- Burners are typically classified as grade 1 or grade 2.
- Grade 1 describes neurapraxia, which is interruption of nerve function associated with demyelination. Remyelination occurs within 3 weeks of the incident, and axonal integrity is preserved. Weakness in muscle strength may be initially present in the acute examination. This may quickly develop and resolve in minutes but can also have a delayed onset.
- Grade 2 involves axonotmesis, which is axonal damage and Wallerian degeneration. Weakness in muscle strength is often present; persistent weakness or bilateral involvement should raise the suspicion of a higher-grade lesion and further diagnostic studies should be performed.
Differential Diagnoses
| Acromioclavicular Joint Injury | Cervical Spine Sprain/Strain Injuries |
| Cervical Disc Injuries | Shoulder Dislocation |
| Cervical Discogenic Pain Syndrome | Shoulder Impingement Syndrome |
| Cervical Radiculopathy | Thoracic Outlet Syndrome |
Other Problems to Be Considered
Spinal cord injury
Cervical spine acute bony injuries
Cervical spine chronic bony injuries
Workup
Laboratory Studies
- Lab studies generally are not indicated for the diagnosis of brachial plexus injuries.
Imaging Studies
- Ancillary tests are often limited to radiographic studies.
- Radiography can be used to rule out bony involvement against peripheral nerves. This is common in patients with severe neck pain, limited ROM, weakness, or chronic pain. Complete cervical spine radiographs often include the following multiple views: anteroposterior (AP), lateral, odontoid view, bilateral, and obliques.
- Initial radiographs may reveal clues to spinal canal stenosis as a cause of the symptoms experienced. MRI of the spine may likely elucidate any evidence of canal stenosis.
- Magnetic resonance imaging (MRI) is used to determine any involvement of the cervical spine or nerve roots as the cause of the brachial plexus injury. MRIs should be reserved for athletes with recurrent stingers or symptoms that last more than a week. Clinical judgment is needed as some cases warrant MRI if symptoms persist for more than 24 hours.
Other Tests
- The electromyographic (EMG) studies are rarely necessary in the evaluation of stingers. The delay in development of abnormal activity limits their use to patients who have symptoms that last at least 2 weeks. EMG testing can help the physician confirm diagnosis and localize any possible lesions.
Treatment
Acute Phase
Rehabilitation Program
Physical Therapy
At onset of injury, nonsteroidal anti-inflammatory drugs (NSAIDs), early mobilization, and moist heat packs are the favorable methods of treatment for acute injuries. In the subacute phase, a gradual progression from ROM activity to cervical and shoulder muscle strengthening is recommended.
Medical Issues/Complications
If symptoms persist (eg, persistent weakness, chronic neurapraxia) regardless of therapy, further consideration for additional imaging and referral should be undertaken.
Surgical Intervention
Surgical intervention is rarely needed, is injury-specific, and should be directed by a neurosurgical or orthopedic spine surgeon.
Consultations
Neurosurgery spine/orthopedic spine
Other Treatment
Manipulation is not recommended as a first line intervention, but it may be a helpful adjunct after full medical assessment has been completed.
Recovery Phase
Rehabilitation Program
Physical Therapy
In the recovery phase, cervical muscle strengthening and conditioning should be continued. Strength training programs are used to fully recover the strength that the athlete had prior to the injury. Training should be focused on muscles supporting the injured brachial plexus nerve, such as the shoulders and the surrounding cervical spine region. The neck also should be protected (eg, use of cervical neck rolls, cervical pillows) until strength is regained.
Consultations
If needed, continue follow-up care with a neurologist, and/or spine specialist.
Maintenance Phase
Rehabilitation Program
Physical Therapy
Continued maintenance of cervical muscle strength, conditioning, and protection is recommended.
Medication
The goals of pharmacotherapy are to reduce morbidity and prevent complications.
Opiate-Narcotics
Analgesia is important to obtain in the setting of brachial plexus nerve injuries. This can be accomplished by use of anti-inflammatory and/or opiate-narcotic medications. Analgesia may facilitate further assessment of the athlete, as well as their willingness to participate in therapy sessions.
Hydrocodone and acetaminophen (Lortab, Norcet, Vicodin)
Drug combination indicated for moderate to severe pain.
Dosing
Adult
1-2 tab PO q4-6h prn
Pediatric
Not established
Interactions
Coadministration with phenothiazines may decrease analgesic effects; toxicity increases with CNS depressants or tricyclic antidepressants
Contraindications
Documented hypersensitivity; high altitude cerebral edema (HACE) or elevated intracranial pressure (ICP)
Precautions
Pregnancy
D - Unsafe in pregnancy
Precautions
Tablets contain metabisulfite which may cause hypersensitivity; caution in patients dependent on opiates since this substitution may result in acute opiate-withdrawal symptoms; caution in severe renal or hepatic dysfunction; may cause drowsiness (Do not drive heavy machinery while taking medication)
Hydrocodone and ibuprofen (Vicoprofen)
Drug combination indicated for short-term (less than 10 d) relief of moderate to severe acute pain
Dosing
Adult
1-2 tab PO q4-6h prn pain; not to exceed 5 tab/d
Pediatric
Not established
Interactions
Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; monitor PT closely (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Contraindications
Documented hypersensitivity; 3rd trimester of pregnancy
Precautions
Pregnancy
C - Safety for use during pregnancy has not been established.
Precautions
Caution in impaired renal function, peptic ulcer disease, impaired thyroid function, asthma, hypertension, edema, heart failure, increased intracranial pressure, and erosive gastritis; duration of action may increase in elderly patients
Oxycodone and acetaminophen (Percocet, Roxicet, Roxilox, Tylox)
Drug combination indicated for the relief of moderate to severe pain.
Dosing
Adult
1-2 tab or cap PO q4-6h prn pain
Pediatric
0.05-0.15 mg/kg/dose oxycodone PO; not to exceed 5 mg/dose of oxycodone q4-6h prn
Interactions
Phenothiazines may decrease analgesic effects of this medication; toxicity increases with coadministration of either CNS depressants or tricyclic antidepressants
Contraindications
Documented hypersensitivity
Precautions
Pregnancy
C - Safety for use during pregnancy has not been established.
Precautions
Duration of action may increase in elderly patients; be aware of total daily dose of acetaminophen patient is receiving; do not exceed 4,000 mg/d of acetaminophen; higher doses may cause liver toxicity
Nonsteroidal anti-inflammatory drugs (NSAIDs)
Have analgesic and antiinflammatory activities. Their mechanism of action is not known, but may inhibit cyclo-oxygenase activity and prostaglandin synthesis. Other mechanisms may exist as well, such as inhibition of leukotriene synthesis, lysosomal enzyme release, lipoxygenase activity, neutrophil aggregation, and various cell-membrane functions.
Ibuprofen (Motrin, Ibuprin)
DOC for patients with mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.
Dosing
Adult
600-800 mg PO tid prn
Pediatric
10 mg/kg/dose PO q6h
Interactions
Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; monitor PT closely (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Contraindications
Documented hypersensitivity; peptic ulcer disease, recent GI bleeding or perforation, renal insufficiency, or high risk of bleeding
Precautions
Pregnancy
B - Usually safe but benefits must outweigh the risks.
Precautions
Category D in third trimester of pregnancy; caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in anticoagulation abnormalities or during anticoagulant therapy
Ketoprofen (Oruvail, Orudis, Actron)
For relief of mild to moderate pain and inflammation. Small dosages initially are indicated in small and elderly patients and in those with renal or liver disease. Doses over 75 mg do not increase therapeutic effects. Administer high doses with caution and closely observe patient for response.
Dosing
Adult
25-50 mg PO q6-8h prn; not to exceed 300 mg/d
Pediatric
3 months to 12 years: 0.1-1 mg/kg PO q6-8h
>12 years: Administer as in adults
Interactions
Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; monitor PT closely (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Contraindications
Documented hypersensitivity
Precautions
Pregnancy
B - Usually safe but benefits must outweigh the risks.
Precautions
Category D in third trimester of pregnancy; caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in anticoagulation abnormalities or during anticoagulant therapy
Naproxen (Naprosyn, Naprelan, Anaprox)
For relief of mild to moderate pain; inhibits inflammatory reactions and pain by decreasing activity of cyclo-oxygenase, which results in a decrease of prostaglandin synthesis.
Dosing
Adult
500 mg PO, followed by 250 mg q6-8h; not to exceed 1.25 g/d
Pediatric
<2 years: Not established
>2 years: 2.5 mg/kg/dose PO; not to exceed 10 mg/kg/d
Interactions
Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; monitor PT closely (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Contraindications
Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency
Precautions
Pregnancy
B - Usually safe but benefits must outweigh the risks.
Precautions
Category D in third trimester of pregnancy; acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with preexisting renal disease or compromised renal perfusion risk acute renal failure; leukopenia occurs rarely, is transient, and usually returns to normal during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrants further evaluation and may require discontinuation of drug
Follow-up
Return to Play
Clinical findings are key in determining an athlete's possibility of returning to play. Full recovery of affected muscles must be determined to prevent further injury and recurrence of burner syndrome. Athletes in contact sports involving the neck should be able to support their weight at the neck leaning at a 45° angle. If this is possible without symptoms, then return to play is highly probable.
Some athletes may have very mild residual asymmetry in strength as a result of the initial injury. Close attention should be paid to the degree of disparity in extremity strength as the athlete returns to participation. Serial EMGs may be of little utility in this setting, as EMG changes can persist for months to years. However, in the setting of an acute change in strength pattern, reassessment may be warranted.
Recurrent stingers warrant assessment of equipment, inclusion of a cowboy collar for football players, and the coach to assess tackling technique.
Complications
Chronic burner syndrome
Prevention
Use protective equipment (eg, neck rolls, air cushions) in football players. Proper technique in contact sports (eg, tackling) is necessary, and improper methods (eg, spearing) should be discouraged. Coaches and referees involved with heavy contact sports also should discourage unnecessary tackling and contact. Cervical and paracervical muscular strengthening and conditioning are recommended.
Prognosis
Prognosis is good, yet some possibility of chronic symptoms may remain.
Education
For excellent patient education resources, visit eMedicine's Back, Ribs, Neck, and Head Center and Sports Injury Center. Also, see eMedicine's patient education articles Shoulder and Neck Pain and Neck Strain.
Miscellaneous
Medicolegal Pitfalls
- Lack of consideration for a cervical spine injury can be problematic. The initial assessment by the sideline personnel and physician should maintain a healthy degree of suspicion for underlying spine injury. Some specialists maintain that a burner is a diagnosis of exclusion.
- For persistent symptoms of a burner, a complete assessment, and sometimes a multidisciplinary evaluation, may need to take place to avoid premature return to play.
- Overlooking brachial plexus injury can lead to further damage to peripheral nerves without proper management.
References
Clancy WG Jr, Brand RL, Bergfield JA. Upper trunk brachial plexus injuries in contact sports. Am J Sports Med. Sep-Oct 1977;5(5):209-16. [Medline].
Cramer CR. A Reconditioning Program to Lower the Recurrence Rate of Brachial Plexus Neurapraxia in Collegiate Football Players. J Athl Train. 10 1999;34(4):390-396. [Medline].
Kuhlman GS, McKeag DB. The "burner": a common nerve injury in contact sports. Am Fam Physician. Nov 1 1999;60(7):2035-40, 2042. [Medline].
Levitz CL, Reilly PJ, Torg JS. The pathomechanics of chronic, recurrent cervical nerve root neurapraxia. The chronic burner syndrome. Am J Sports Med. Jan-Feb 1997;25(1):73-6. [Medline].
Markey KL, Di Benedetto M, Curl WW. Upper trunk brachial plexopathy. The stinger syndrome. Am J Sports Med. Sep-Oct 1993;21(5):650-5. [Medline].
Sallis RE, Jones K, Knopp W. Burners. Offensive strategy for an underreported injury. Phys Sports Med. 20(11):47-55.
Stracciolini A. Cervical burners in the athlete. Pediatr Case Rev. Oct 2003;3(4):181-8. [Medline].
Weinberg J, Rokito S, Silber JS. Etiology, treatment, and prevention of athletic "stingers". Clin Sports Med. Jul 2003;22(3):493-500, viii. [Medline].
Weinstein SM. Assessment and rehabilitation of the athlete with a "stinger". A model for the management of noncatastrophic athletic cervical spine injury. Clin Sports Med. Jan 1998;17(1):127-35. [Medline].
Williams J, Hoeper E. Brachial plexus injury in a male football player. Curr Sports Med Rep. Jun 2004;3(3):125-7. [Medline].
Keywords
brachial plexus injury, stinger, burner, cervical nerve pinch syndrome, chronic burner syndrome, peripheral nerve injury
Contributor Information and Disclosures
Author
Thomas H Trojian, MD, Assistant Professor of Family Medicine, Fellowship Coordinator, Sports Medicine Fellowship Director, Department of Family Medicine, University of Connecticut School of Medicine; Team Physician, University of Connecticut, Department of Athletics
Thomas H Trojian, MD is a member of the following medical societies: American Academy of Family Physicians, American College of Sports Medicine, American Medical Society for Sports Medicine, and Society of Teachers of Family Medicine
Disclosure: Nothing to disclose.
Coauthor(s)
Federico E Vaca, MD, FACEP, Team Physician, Department of Emergency Medicine, University of California Irvine; Clinical Assistant Professor, University of California at Irvine School of Medicine
Federico E Vaca, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians, American College of Sports Medicine, Association for the Advancement of Automotive Medicine, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.
Oniel Young, BS, College of Osteopathic Medicine of the Pacific
Disclosure: Nothing to disclose.
Medical Editor
Janos P Ertl, MD, Clinical Assistant Professor, Department of Orthopedic Surgery, Chief of Orthopedic Trauma, University of California at Davis; Director of Amputee Clinic, Kaiser Hospital
Janos P Ertl, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, Hungarian Medical Association of America, Orthopaedic Trauma Association, and Sierra Sacramento Valley Medical Society
Disclosure: Nothing to disclose.
Pharmacy Editor
Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.
Managing Editor
Marlene DeMaio, MD, Consulting Staff, Department of Orthopedic Surgery, Assistant Professor, Bone & Joint/Sports Medicine Institute, Naval Medical Center
Marlene DeMaio, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Orthopaedic Surgeons, American College of Sports Medicine, American Orthopaedic Foot and Ankle Society, and American Orthopaedic Society for Sports Medicine
Disclosure: Nothing to disclose.
CME Editor
Jon Whitehurst, MD, Consulting Staff, Rockford Orthopedic Associates
Disclosure: Nothing to disclose.
Chief Editor
Sherwin SW Ho, MD, Section of Orthopedic Surgery and Rehabilitation Medicine, Associate Professor, Department of Surgery, University of Chicago
Sherwin SW Ho, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, and Arthroscopy Association of North America
Disclosure: Nothing to disclose.
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