Brachial Plexus Injury in Sports Medicine Treatment & Management

Updated: Oct 31, 2022
  • Author: Thomas H Trojian, MD; Chief Editor: Sherwin SW Ho, MD  more...
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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. [19]

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. [20]

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. [21]

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.

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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.

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.

Although the time missed from athletic activities is 2.9 days on average, more than 79% of athletes are able to continue their regular training program after a simple stinger. [13]

Recurrent stingers warrant assessment of equipment, inclusion of a cowboy collar for football players, and the coach to assess tackling technique. Athletes with anatomic abnormalities, such as intervertebral foramina stenosis, are at high risk for reoccurrence of a stinger. [13]

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Maintenance Phase

Rehabilitation Program

Physical Therapy

Continued maintenance of cervical muscle strength, conditioning, and protection is recommended.

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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.

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