Acute Paresthesias In A High School Football Player - Page #4

Working Diagnosis:
Acute Brachial Plexus Injury (stinger)

We recommended withholding from football and all contact activities for one week as well as initiating home rehab exercises for ROM and strengthening.

We counseled him that it may take 1-2 weeks to fully recover, however his trainer would assess him daily for symptoms, range of motion, and strength.

The patient had mild symptoms that persisted for only three days after this visit. Over the following week he gradually increased his activity and had full, painless range of motion and full strength. He resumed full game participation by athletic trainer clearance fourteen days following the injury (nine days after the clinic visit). He completed the rest of the season without any further exacerbations.

He did not follow-up in our clinic due to the resolution of symptoms.

Author's Comments:
Testing Learning Points:
In the case of stingers, it is recommended that electrodiagnostic testing (i.e. electromyography) only be pursued if symptoms persist longer than three weeks.1 Magnetic resonance neurography of the brachial plexus is not indicated unless EMG and spine MRI are inconclusive.2

One small study has shown that ultrasound may be more sensitive and as specific as MRI for detection of nerve pathology in patients with suspected brachial plexopathy or mononeuropathies.3

Additional Learning Points:
It is recommended that return to play only be granted in contact sports once the athlete is asymptomatic and has full painless range of motion.4

According to Seddon’s classification, the patient’s injury was most consistent with a neuropraxia (type I). The pathologic process involves demyelination and recovery typically occurs within minutes to six weeks.

Acute brachial plexus injuries most commonly involve the superior trunk that combines the C5 and C6 nerve roots.

Editor's Comments:
This case illustrates a classic stinger/burner. While most of these resolve within minutes on the sideline, some can have persistent symptoms for as long as several weeks.

Some notes for this specific history: no mention of whether this patient had full strength prior to initial RTP. There is no mention of history of stingers or history of neck pain.

Return to play on same day of injury is allowed when the athlete has full ROM of shoulder and neck without pain, full strength, complete resolution of symptoms. Check both sides there can be subtle differences.

Current recommendations are to remove from play for the remainder of the season after 3rd stinger in one season, or if symptoms are severe and prolonged. If any other extremities are involved, this is a C-spine injury until proven otherwise.

Consider imaging if >2 stingers in the past to evaluate for cervical stenosis or congenital vertebral fusion (Klippel Feil)5

1. Kuhlman, G. Shefner, JM. Burners: Acute brachial plexus injury in the athlete (stingers). UpToDate. Updated 2014 Feb 17. Cited 10 Dec 2014.

2. Dynamed. Brachial Plexopathy. Updated 2014 May 20. Cited 10 Dec 2014.

3. Zaidman CM, Seelig MJ, Baker JC, Mackinnon SE, Pestronk A. Detection of peripheral nerve pathology: comparison of ultrasound and MRI. Neurology. 2013 Apr 30;80 (18):1634-40.

4. Kepler CK, Vaccaro AR. Injuries and abnormalities of the cervical spine and return to play criteria. Clin Sports Med. 2012 Jul; 31(3):499-508.

5. Levitz CL, Reilly PJ, Torg JS. The pathomechanics of chronic, recurrent cervical nerve root neuropraxia. The chronic burner syndrome. AJSM 1997; 25(1): 73-6.

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