Stingers Injury; Causes, Symptoms, Diagnosis, Treatment

Stingers also called a burner or nerve pinch injury is a neurological injury suffered by athletes, mostly in high-contact sports such as ice hockey, rugby, American football, and wrestling. The spine injury is characterized by a shooting or stinging pain that travels down one arm, followed by numbness and weakness. Many athletes in contact sports have suffered stingers, but they are often unreported to medical professionals.

The burner or stinger syndrome is one of the most common injuries in football and most likely represents an upper cervical root injury. Other sports reported include wrestling, hockey, basketball, boxing, and weightlifting. The athlete experiences radiating pain, numbness, or tingling down one upper limb, usually lasting less than 1 minute. Recurrences are common and can lead to permanent neurologic deficits. Burners are usually diagnosed and treated based on physical examination findings, but radiographs, MR imaging, and electrodiagnostic testing may help localize the precise level of injury, identify other associated pathology, and quantify neurologic injury. Management should include education on proper tackling techniques, restoration of neck motion, functional strengthening, and carefully fitted orthosis.[Rx]

A stinger, or burner, is a transient reversible peripheral nerve injury of the upper extremity caused by trauma to the cervical spine and shoulder; the classic injury occurs with football tackling.^[rx] A study of collegiate American football players shows that stingers occur in 50% to 65% of these athletes over the course of their careers, with relatively high recurrence rates.^[rx] The primary symptom, which begins immediately after contact, is burning pain radiating down an upper extremity in a circumferential rather than dermatomal distribution.⁴ Other symptoms include weakness, numbness, and paresthesias.^[rx] A range of clinical courses have been described following a stinger injury, although pain lasting more than 24 hours is generally uncommon.^[rx]

In fact, it’s safest to assume that trauma victims have a spinal injury until proven otherwise because:

• The time between injury and treatment can be critical in determining the extent of complications and the amount of recovery
• A serious spinal injury is not always immediately obvious. If it is not recognized, more severe injury may occur
• Numbness or paralysis may develop immediately or come on gradually as bleeding or swelling occurs in or around the spinal cord

Stingers get their name from the intense, electric-like pain that characterizes the injury. Symptoms also include sensations of tingling and/or weakness in the arm and hand. Typically, the pain lasts 10 seconds or less, but sometimes continues for hours or even days.

A burner, or a brachial plexus injury, are other common terms for a stinger and they refer to the same injury.

Anatomy of Stingers / Burner Injury

The brachial plexus is affected most often by a downward or backward force against the shoulder. A nerve plexus is an area where nerves branch and rejoin. The brachial plexus is a group of nerves in the cervical spine from C5 to C8-T1. This includes the lower half of the cervical nerve roots and the nerve root from the first thoracic vertebra.

The nerves leave the spinal cord, go through the neck, under the clavicle (collar bone) and armpit, and then down the arm.

The brachial plexus begins with five roots that merge or join together to form three trunks.

The three trunks are upper (C5-C6), middle (C7), and lower (C8-T1). Each trunk then splits in two, to form six divisions. These divisions then regroup to become three cords (posterior, lateral, and medial).

Finally, there are branches that result in three nerves to the skin and muscles of the arm and hand: the median,ulnar, and radial nerves.

Causes

Causes

• Spinal lesions and tumors
• Spinal infections or inflammation
• Violent injuries to the lower back (gunshots, falls, auto accidents)
• Birth abnormalities
• Spinal arteriovenous malformations (AVMs)
• Spinal hemorrhages (subarachnoid, subdural, epidural)
• Postoperative lumbar spine surgery complications
• Spinal anesthesia
• Traumatic events leading to fracture or partial dislocation (subluxation) of the low back (lumbar spine) result in compression of the cauda equina.
• Spinal fracture or dislocation
• Epidural hematoma (may also be spontaneous, post-operative, post-procedural or post-manipulation)
• Infections in the spinal canal (spinal epidural abscess) can cause deformity of the nerve roots and spinal column.
• Symptoms generally include severe back pain and rapidly worsening muscle weakness.
• Infective – epidural abscess, tuberculosis (Pott disease)

Grading of Stingers / Burner Injury

There are three classifications of brachial plexus stingers beginning with the mildest classification as a Grade I injury and progressing in severity through to a Grade III injury. 

• A Grade I –  injury is called a neuropraxia injury and results in a temporary loss of sensation and/or loss of motor function (ability to use muscles). This is thought to occur due to a localized conduction block in the nerve bundle that prevents the flow of information from the spinal cord to the innervated areas. Because this is only a “block”, the symptoms are transient and may only last from several minutes to several days.
• Grade II – injuries are more significant injuries because there may be actual damage to the nerves known as axonotmesis. Axonotmesis is defined as damage to the axon of the nerve without severing the nerve. These types of injuries may produce significant motor and/or sensory deficits that last at least two weeks. Because the growth of an injured axon is a very slow process (a rate of 1 to 2 mm per day), it takes several weeks for the regrowth to occur. However, once the regrowth as occurred, full function of the athlete’s motor and sensory functions are restored. The most severe plexus injury is a Grade III injury – Athletes with these types of injuries may not have a full recovery and may be considered to have sustained a catastrophic injury because the neurological symptoms may last up to one year.
• A Grade III – is known as a neurotmesis injury and is defined as a complete severance of the nerve. Athletes who have sustained this type of injury have a poor prognosis and may need surgical intervention.

Symptoms of Stingers / Burner Injury

In general condition

Here are some of the symptoms a person who has had a stinger trapped nerve injury might say

• It sent a stinging pain down my arm to my fingers,
• It was a burning feeling in my neck down my shoulder-blade into my upper arm,
• I felt an electric shock run from my neck down into my fingers,
• I got pins and needles feeling in my forearm or fingers,
• I have a pain underneath my shoulder-blade into the back of my arm,
• I have lost some of the strength in my arm,
• I can’t lift my arm properly,
• I feel very weak trying to do a push-up.

In athletes

The extent and persistence of symptoms varies considerably and depends on a number of factors, including the type and force of the impact, prior injury to the area, and the individual’s anatomy.

Typical stinger symptoms include one or a combination of the following

• Athletes often describe a stinger as a burning pain or feeling like an electric shock shooting down the arm
• The pain usually lasts only a few seconds or minutes (though it can continue for longer)
• Sometimes a player’s arm will look limp after the injury, or the player will shake the arm to get rid of the lightning-bolt sensation
• Arm and hand weakness will usually present as difficulty lifting the arm away from the body, difficulty bending the elbow, and a weak grip
• The weakness and numbness is usually brief, but can last weeks, months, or years as the brachial plexus nerve complex gradually heals
• The individual may also experience warmth in the injured area, numbness, or a pins-and-needles tingling sensation
• After the initial injury, neck pain and muscle spasms, or cramps, may develop
• Typically, a stinger only affects just one arm at a time

Rarely, especially in cases where there has been repeated injury to the brachial plexus, the stinger may result in permanent damage, such as some degree of chronic weakness.

Types of Stingers / Burner Injury

The following types of impact are common causes of a stinger injury:

• Brachial plexus is stretched. For example, when one shoulder is pushed down and the neck is forced to the side in the opposite direction, away from the shoulder. This causes the brachial plexus to stretch too far.
• A direct impact occurs to the brachial plexus. This occurs when someone is hit in the area where the shoulder joins the neck, causing a direct impact to the brachial plexus. An example of this is when a football player gets hit in this area by an opposing player’s helmet.
• The neck is forced back and to the side. If an athlete is hit in a way that forces the head and neck suddenly back and to the side, this compresses the nerves in the neck, typically the C5-C6.

Other injuries that may occur at the same time as a stinger include

• Spinal cord injury – If the pain and/or neurological symptoms extend on both sides of the body, or to both the arms and the legs, it is possible that the spinal cord has been injured. In this situation, the injured person should be kept immobilized and taken to the hospital immediately as a precaution. It is important to have an imaging study of the spinal cord prior to consideration for return to play.
• Concussion – Concussion symptoms include dizziness, headache, sleepiness, blurry vision, and memory loss.
• Nerve root injury – Pain and neurological symptoms in the shoulder, arm, and hand can develop if a nerve root has been irritated or if it is compressed, as in the case of a herniated disc. The pain radiates to other parts of the body and is known as radiculopathy.
• Spinal fracture – A fracture could occur from the same impact that caused the stinger.
• Soft tissue damage – The sudden impact can cause damage to the ligaments (the tissue connecting two bones) of the cervical spine.

Diagnosis of Stingers / Burner Injury

The majority of burners occur due to tackling in impact sports such as American football and rugby union. While burners are usually brief and self-limited, recovery can take weeks or months in some cases. The injury often recurs and occasionally leads to a chronic syndrome.

Subjective Assessment:

• Immediate, acute traumatic onset of pain/burning/paresthesia/pins and needles/weakness.
  • It is important to acquire details on the pain quality, intensity, location and radiation.
  • Typically presents with symptoms circumferentially radiating down the arm.
• Reports recent history of trauma to the area.
• Common in young athletes competing in contact sports.
• Previous history of burners.

Objective Assessment

Observation

• Shaking of the upper extremity 
• Holding upper extremity close to their body 
• Atrophy or asymmetry in the neck 
• Shoulder depression
• Atrophy of deltoid or supraspinatus 
• Altered motor patterns when using the shoulder 

These changes can take several weeks to develop.

Palpation

• Tenderness
• Muscle spasm
• Vertebral tenderness

These symptoms are not specific to burners syndrome and should alert clinicians to differential diagnoses. Symptoms can arise at the neck and/or shoulder.

Range of Motion

• Possible decrease in neck and shoulder mobility.

Strength

• Each upper myotome should be tested for strength
• Burners usually involve the C5/6 nerve roots, which innervate many muscles of the shoulder, elbow and wrist, and should be tested individually
  • Deltoid – abduction
  • Supraspinatus – abduction (full can)
  • Infraspinatus – external rotation
  • Biceps brachii – elbow flexion
  • Pronator Teres – forearm pronation
  • Triceps brachii – elbow extension
  • Adductor digiti minimi – abduction of the 5th digit.

There may be a decrease in shoulder and neck strength. This can either be acutely or develop several days later

Sensation

• Burning
• Paresthesia
• pins and needles

Usually present circumferentially.

Reflexes

• Tricep
• Brachioradialis

Possible reduction in the speed of reflexes.

Special Tests

• Spurling test 
• Tinel test over supraclavicular fossa for tenderness

Both tests may be positive for burners.

Evaluation of Motor Function in stinger and Other Brachial Plexus Injuries

MUSCLE	INNERVATION	CLINICAL TEST
Deltoid	Axillary (C5, C6)	Shoulder abduction
Supraspinatus	Suprascapular (C5, C6)	“Full can” abduction*
Infraspinatus	Suprascapular (C5, C6)	External rotation
Biceps brachii	Musculocutaneous (C5, C6)	Elbow flexion
Pronator teres	Median (C6, C7)	Forearm Pronation
Triceps brachii	Radial (C7, C8)	Elbow extension
Abductor digit minimi	Ulnar (C8, T1)	Fifth digit abduction

Physical exam

• full cervical ROM
• no tenderness
• unilateral transient weakness in C5, C6 muscles (deltoid, biceps)
• can have positive Spurling test

Radiographs

• usually unremarkable
• C-spine images indicated with recurring symptoms
  • to rule out fx and cervical stenosis

MRI

• indicated whenever symptoms are bilateral (inconsistent with a stinger) to rule out cervical spine pathologies such as herniated disc or cervical stenosis

EMG

• indicated if symptoms persist after 3 weeks
• will show abnormalities in roots, cords, trunks, and peripheral nerves

Treatment of Stingers / Burner Injury

Non-Surgical Management

Here’s the good news: given time, whiplash should heal on its own. To help with recovery, you should:

• Ice your neck – to reduce pain and swelling as soon as you can after the injury. Do it for 15 minutes every 3-4 hours for 2-3 days. Wrap the ice in a thin towel or cloth to prevent injury to the skin.

Use a neck brace or collar – to add support, if your doctor recommends it. However, they are not recommended for long-term use, because they can actually weaken the muscles in your neck.

• Apply moist heat to your neck – but only after 2-3 days of icing it first –Use heat on your neck only after the initial swelling has gone down. You could use warm, wet towels or take a warm bath.
• Other treatments – like ultrasound and massage, may also help.

However, the following are considered to be appropriate management

• Recovery and return to full function are best aided by sympathy and encouraging the patient to take an active role in dealing with the symptoms.
• Provision of adequate analgesia.
• There is now good evidence that the use of collars in whiplash injury prolongs the recovery of the patient. Patients should be advised about neck mobilization and encouraged to remain as active as possible.

Exercises

• Patients should receive instruction about exercises. However no high-quality evidence has been found for the benefit of neck exercises for mechanical neck disorders, indicating that there is still uncertainty about the effectiveness of exercise for neck pain.
• Using specific strengthening exercises as a part of routine practice for chronic neck pain, cervicogenic headache and radiculopathy may be beneficial.

Medication

• Analgesics – Prescription-strength drugs that relieve pain but not inflammation.
• Antidepressants: A Drugs that block pain messages from your brain and boost the effects of endorphins (your body’s natural painkillers).
• Medication – Common pain remedies such as aspirin, acetaminophen(Tylenol), ibuprofen (Advil, Motrin), and naproxen can offer short-term relief. All are available in low doses without a prescription. Other medications, including muscle relaxants and anti-seizure medications, treat aspects of spinal stenoses, such as muscle spasms and damaged nerves.
• Corticosteroid injections – Your doctor will inject a steroid such as prednisone into your back or neck. Steroids make inflammation go down. However, because of side effects, they are used sparingly.
• Anesthetics – Used with precision, an injection of a “nerve block” can stop the pain for a time.
• Muscle Relaxants – These medications provide relief from spinal muscle spasms.
• Neuropathic Agents: Drugs(pregabalin & gabapentin) that address neuropathic—or nerve-related—pain. This includes burning, numbness, and tingling.
• Antibiotic –  to the management of bowel & bladders control and protect further infection. Infection causes should be treated with appropriate antibiotic therapy
• Topical Medications – These prescription-strength creams, gels, ointments, patches, and sprays help relieve pain and inflammation through the skin.
• Calcium & vitamin D3 – to improve bones health and healing fracture.
• Glucosamine & diacerein – can be used to tightening the loose tension and regenerate cartilage or inhabit the further degeneration of cartilage.
• Corticosteroid – to healing the nerve inflammation and clotted blood in the joints.
• Dietary supplement -to remove the general weakness & improved the health.
• Lesion debulking –  is required for space-occupying lesions – eg, tumors, abscess.
• If surgery cannot be performed – radiotherapy may relieve cord compression caused by malignant disease.
• Radiation therapy and Chemotherapy – may have a role in treatment if the cauda equina syndrome is caused by the tumor.
• Support or brace – A pelvic belt can be used to stabilize a joint that is too loose until the inflammation and pain subside.
• Joint injections – Numbing injections into the sacroiliac joint are used diagnostically to help identify the cause of them but are also useful in providing immediate pain relief. Typically, an anesthetic is injected along with an anti-inflammatory medication.

First-Line Drug Treatment

Some choices here are

1. Certain Anti-depressants (i.e., tricyclic antidepressants and dual reuptake inhibitors of both serotonin and norepinephrine),
2. Certain Antiepileptics (i.e., gabapentin and pregabalin),
3. Topical anesthetics (i.e., lidocaine).
4. Corticosteroid to suppress the inflammation.
5. Calcium & Vitamin D3 to strengthening the bone & promote the healing.
6. Painkiller

Second-Line Drug Treatment

1. Opioid analgesics (i.e., tramadol)

Third-Line Drug Treatment

1. Topical capsicum.

As you may have noticed normal anti-inflammatories (NSAID’s) typically don’t feature in nerve pain protocols. However, they may be used to help other pain sources, including inflammatory pain, associated with an injury.

References

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