After a “Stinger” During a Football Game, There Is Weakness of the Deltoid, Rotator Cuff, and Biceps and Triceps. Why Did This Happen and When Would You Allow Him to Return to Play Again?
“Stingers,” also called “burners,” are a common occurrence in all levels of American football, occurring in up to 65% of college players.1 Also called transient brachial plexopathy, they are thought to be either traction or compression injuries to the brachial plexus or cervical nerve roots. Typically, the athlete presents with an inability to move the involved extremity and complaint of a burning sensation and numbness that is usually circumferential, rather than dermatomal.2 The upper trunk of the brachial plexus (C5, C6) is most commonly involved and thus there is usually weakness in shoulder abduction, external rotation, and arm flexion.3
Three mechanisms of injury are described in the literature. The first is neck extension and ipsilateral lateral neck flexion, causing compression injury to the nerve roots due to narrowing of the intervertebral foramen. This narrowing is most pronounced at the C4/C5 and C5/C6 level, corresponding to the most common nerve roots involved.4 Burners associated with this mechanism are more likely in more mature athletes with preexisting cervical degenerative changes. The second mechanism described is a stretch injury of the upper brachial plexus caused by lowering the ipsilateral shoulder and contralateral neck flexion. This is felt to be the predominant mechanism in younger athletes without preexisting cervical disease. Finally, least commonly described, is a direct blow to the brachial plexus at Erb’s point, its most superficial location. This is located superior to the medial clavicle, just lateral to the sternocleidomastoid. A direct blow here can cause compression of the nerves against the bony scapula.5
Cervical stenosis has been studied as a risk factor using the Torg ratio of the width of the spinal canal divided by the width of the vertebral body. Meyer and colleagues found that college athletes with a Torg ratio of less than 0.8 had a 3-fold increase in sustaining burners.1 Castro and colleagues found that the Torg ratio did not influence initial stinger occurrence, but noted that players who experienced multiple stingers had significantly smaller Torg ratios than those who only experienced a single stinger. They also noted that defensive backs were the most likely to experience stingers.6
Sideline evaluation of the patient should include a thorough examination of the cervical spine, including palpation for localized tenderness or deformity, and active range of motion within the limits of comfort should be checked. Thorough neurologic examination, including strength testing of all muscle groups, sensory testing in all dermatomes, and deep-tendon reflexes, is essential. The shoulder should be examined for injury to the clavicle, acromioclavicular, and glenohumeral joints. Symptoms may be elicited with percussion over Erb’s point or with Spurling’s maneuver. Any localized tenderness over the cervical spine or limited range of motion should prompt immediate cervical spine precautions and transfer to a hospital for radiologic evaluation to rule out cervical spine fractures, facet dislocations, or other cervical spine injuries. Stingers are always unilateral and any bilateral involvement or hemiparesis indicates a spinal cord injury and should be treated accordingly.
Management of stingers is largely supportive. Most resolve within minutes, without any residual weakness. The athlete should be removed from competition until all symptoms completely resolve. For a first-time stinger, the athlete may return to play the same day if the symptoms have completely resolved. Table 9-1 shows return-to-play criteria as described by Vaccaro and colleagues.7 In 5% to 10% of cases, neurologic deficit may last hours, days, or even weeks.5 In these cases, rehabilitation should focus on regaining strength in all affected muscle groups, and full cervical spine motion prior to considering return to play.
Prevention of stingers in football players is important and revolves around education, coaching, and equipment. Improper tackling techniques are felt to be responsible for many stinger injuries. Training to avoid head down tackling positions with knowledgeable coaches needs to be emphasized. Protective neck rolls and shoulder pads can be worn to limit cervical extension and lateral flexion and possibly decrease stinger injuries.
1. Meyer SA, Schulte KR, Callaghan JJ, Albright JP, Powell JW, Crowley ET, el-Khoury GY. Cervical spinal stenosis and stingers in collegiate football players. Am J Sports Med. 1994;22:158-166.
2. Hershman EB. Brachial plexus injuries. Clin Sports Med. 1990;9:311-329.
3. Weinberg J, Rokito S, Silber JS. Etiology, treatment, and prevention of athletic “stingers.” Clin Sports Med. 2003;22:493-500.
4. Yoo JU, Zou D, Edwards WT, Bayley J, Yuan HA. Effect of cervical spine motion on the neuroforaminal dimensions of human cervical spine. Spine. 1992;17:1131-1136.
5. 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.
6. Castro FP Jr, Ricciardi J, Brunet ME, Busch MT, Whitecloud TS 3rd. Stingers, the Torg ratio, and the cervical spine. Am J Sports Med. 1997;25:603-608.
7. Vaccaro AR, Watkins B, Albert TJ, Pfaff WL, Klein GR, Silber JS. Cervical spine injuries in athletes: current return-to-play criteria. Orthopedics. 2001;24:699-703.