Brachial Plexus Injury in Sports Medicine 

Updated: Jun 19, 2017
Author: Thomas H Trojian, MD; Chief Editor: Sherwin SW Ho, MD 

Overview

Background

Peripheral nerve injuries are not common in noncontact sports. However, in contact and collision sports such as football and rugby, brachial plexus injuries occur often. In a study of Canadian football, brachial plexus injuries were reported to be 26% (21%-32%) of players, during the 2010 football season.[1] In an American football study, the lifetime rate of brachial plexus injuries was 50.3%.[2] The greater incidence of brachial plexus injuries has been suggested to be the result of direct trauma from participation in contact sports.[3, 4, 5, 6, 7, 8]

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.

Epidemiology

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.[9] This is supported by Starr's work.[2]

Sallis et al surveyed Division III college football players and reported that 65% experienced brachial plexus injuries.[10] In addition, Sallis reported an 87% recurrence rate in these individuals. Meeuwisse reported that 7.2% of all football injuries were brachial plexus injuries.[11] The positions most frequently involved varies between Canadian and American football but linebackers are common in both. In Canadian football offensive linemen and wide receivers are involved and in American football it is running backs and defensive lineman.[1, 2] This difference may be due to the different rules of the games with the Canadian Football League having 66% passing plays and the National Football League having 56% passing plays.

Kawasaki et al investigated the incidence of stingers in 569 young rugby players and found that the prevalence of a history of stingers was 33.9% and 20.9% experienced a stinger during the season. The study also reported that 37.3% of players experienced a reinjury during a single season.[12]

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:

  1. Traction caused by lateral flexion of the neck away from the involved side (similar to the mechanism in birth trauma)

  2. Direct impact to the Erb point causing compression to the brachial plexus (often associated with poor-fitting shoulder pads)

  3. Nerve compression caused by neck hyperextension and ipsilateral rotation (The neural foramen narrows in this mechanism.)

 

Presentation

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 between neck and shoulder

  • 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 neurologic 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. Spinal stenosis can also increase your risk of developing a stinger.

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.

 

DDx

 

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.

Ultrasound can provide only partial information because of the clavicle, and difficulty to see the outlet tract at the spine.[13] In brachial plexus cases, US may be useful but it cannot replace magnetic resonance imaging (MRI) which can be crucial for assessing the root avulsions that frequently occur in brachial plexus injury.[13] Though, Zhu et al showed that the nerve root can be seen with high resolution ultrasound.[14] Its portable and economic nature makes ultrasound a reasonable first choice in the evaluation.[15]

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.

Bertelli et al reviewed the sensory losses and pain symptoms of 150 patients with brachial plexus lesions that were evaluated and operated on. Sensory losses were believed to be documented on the basis of dermatomal root distribution and pain symptoms were believed to be attributed to lower root avulsion. Prior to surgery, patients underwent clinical evaluation and CT myelo scanning with intradural contrast. Hand and finger sensation were evaluated preoperatively; upper root lesions showed hand sensation was preserved. In C8-T1 root injuries, diminished protective sensation was observed on the ulnar aspect of the hand. C8 and T1 injuries always were avulsed from the cord. This indicated an overlapping of the dermatomes, which was not as widely reported. Hand sensation was largely preserved in patients with partial injuries particularly on the brachial side.[16]

Sulaiman et al reviewed the clinical outcomes in patients who underwent nerve transfer operations for brachial plexus reconstruction at Louisiana State University over a 10-year period, evaluating recovery of elbow flexion and shoulder abduction. The authors found that nerve transfers for repair of brachial plexus injuries resulted in excellent recovery of both elbow and shoulder functions. They also noted that patients who had direct repair of brachial plexus elements in addition to nerve transfers tended to do better than those who had only nerve transfer operations.[17]

Terzis and Barmpitsioti studied the use of wrist fusion in patients with brachial plexus injuries with multiple root avulsions resulting in wrist instability, imbalance, and inability to control the placement of the hand in space. Of 35 patients who underwent wrist fusion and answered questionnaires about their overall perceptions, 97.14% were satisfied with wrist stability and 88.57% reported that the procedure enhanced the overall upper limb function. The Disabilities of the Arm, Shoulder and Hand score was 59.14 +/- 12.9, reflecting moderate ability in daily activities. According to the authors, wrist fusion in patients with brachial plexus palsy is recommended as a complementary procedure, offering a stable, painless carpus, with improvement of overall upper limb function and appearance.[18]

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

Medication Summary

The goals of pharmacotherapy are to reduce morbidity and prevent complications. Drugs containing opiates, such as codeine, are typically used immediately following the injury. Antidepressant and anticonvulsant medications may also be useful. A device called transcutaneous electrical nerve stimulation (TENS) sometimes provides relief in conjunction with pharmacotherapy.

Opiate-Narcotics

Class Summary

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.

Hydrocodone and ibuprofen (Vicoprofen)

Drug combination indicated for short-term (less than 10 d) relief of moderate to severe acute pain

Oxycodone and acetaminophen (Percocet, Roxicet, Roxilox, Tylox)

Drug combination indicated for the relief of moderate to severe pain.

Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)

Class Summary

Have analgesic and antiinflammatory activities. Their mechanism of action is not known, but they 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.

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.

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.

 

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 eMedicineHealth's First Aid and Injuries Center. Also, see eMedicineHealth's patient education articles Shoulder and Neck Pain and Neck Strain.