1. Rehabilitation Following Brachial Plexopathy “Stingers”
Scott Kaylor, PT, DPT, SCS
Proaxis Therapy
Consider paring down to risk factors, treatment progression, and return to sport criteria (Jenn Backs is doing this approach).
Charbonneau et al. Brachial Neuropraxia in Canadian Atlantic University Sport Football Players: What is the incidence of “stingers”?. Clin J Sport Med 2012;22:
Appendix with symptoms, etc to include in presentation
Vaccaro et al reference to return to play criteria
Most cases were seen by ATC/therapists, not MD’s. Importance for recognition of symptoms, etc.

2. Acknowledgements Timothy McHenry III, MD Whitney Wiles, ATC
Matthew Baird, MD
Tom Denninger, PT, DPT, OCS, FAAOMPT
Chuck Thigpen, PhD, PT, ATC
- Probably leave out verbalizing in order to maximize time

3. Objectives To identify the prevalence of brachial plexopathy.
To identify the anatomy involved with brachial plexopathy injury.
To describe an evidence-based return-to-play progression that is criteria driven.
*** Cut 1st 2 bullets probably.
***Emphasis on last bullet – EBP RTP.

4. Prevalence and Incidence
Common in contact and collision sports.
Reported annual incidence of a stinger is between 49-65% in collegiate-level football players over a 4-year career
Recurrence rate 57%
5-10% of players have more serious injuries with prolonged neurological deficits
*Highlight recurrence rate stat and low % prolonged neurological deficits.
Bullet one – Vaccaro et al. RTP criteria. Spine Journal.
Levitz CL, Reilly PJ, Torg JS. The pathomechanics of chronic, recurrent cervical nerve root neuropraxia. The chronic burner syndrome. Am J Sports Med. 1997;25:73-76
Recurrence Stat: Sallis RE, Jones K, Knopp W. Burners: offensive strategy for an underreported injury. Phys Sportsmed. 1992;20:47-55.
5-10% bullet: Rihn, JA. Et al. Cervical spine injuries in American football. Sports Med 2009;39(9)

5. Signs and Symptoms Common Red Flags Unilateral UE involvement
A traumatic event
Painful sensation that radiates from their neck to their finger tips
Lancinating, burning pain, and dysesthesia usually in a dermatomal pattern.
Weakness/”dead arm”
Bilateral symptoms or symptoms into more than one limb.
Suspect spinal cord involvement
If the player remains on the “field of play” the possibility of a spinal cord injury must be considered and ruled out before he is allowed to walk.
**Dr. McHenry should cover this. Only need to mention know your signs and symptoms and monitor throughout rehab process. Do not want to exacerbate their symptoms during the rehab program.
Most frequent symptoms:
Tingling 77%, numbness 61%, weakness 44%, neck pain 17%.
69% experienced relief by shaking hands
14% experienced relief by putting self in chin to chest position.
Nerves of C5 and C6 ventral rami are most commonly injured due to inherent mobility of C5-7.
Charboneau et al.
41% tackling, 42% blocking
Blow to the shoulder was most common description 66% of players
Blow to the head was next most common description 22%
Blow to the neck 17%
Axial compression 13%
Arm traction 11%
Direct pressure to Erb’s point 9%
Location of lesion with determine symptoms: Supraclavicular lesions tend to involve both flexor and extensor musculature, whereas infraclavicular lesions typically involve either flexor or extensor musculature, but not both.
Olson, et al. Unilateral cervical nerve injuries: brachial plexopathies. Current Sports Medicine Reports 2007, 6:43-49
Weinstein 1998
Vaccaro et al. Spine Journal.

6. Symptom Duration Pain typically seconds to hours.
Rarely beyond 24-hours
May experience weakness in deltoid and supra/infraspinatus that typically resolves in 24-hours to 6 weeks.
**Not typically a lot of time lost due to these injuries. Charboneau et al. 11% lost practice days due to symptoms. 3% lost at least 1 game due to symptoms. 84% did not lose any time from play after sustaining a stinger. Mean number of practice days lost was 1.2 days and games 0.1.
Charbonneau et al. Canadian football incidence of stingers:
Symptom duration 58% minutes, 30% seconds, 8% lasting days.
Weakness typically transient, but may persist for days to weeks.
Weakness in these areas due to C5-6 being most common nerve root effected.
Weakness is more common impairment for prolonged symptoms than sensory impairment due to anterior nerve root is more vulnerable b/c thinner dural sheath, more direct alignment with spinal cord, and no dorsal ganglia to dampen effect of traction.

7. Injury Grading Grade I Grade II Grade III neurapraxia axonotmesis
neurotmesis
Dr. McHenry should cover this topic too.
**Injury grading to help determine prognosis.
Olson et al. Unilateral cervical nerve injuries: brachial plexopathies. Current Sports Medicine Reports 2007, 6:43-49.
Neurapraxia: all structures of the nerve remain intact. There is a focal demyelination, which causes a conduction block on EMG, but no axonal loss. Clinical symptoms of sensation and/or motor function loss are typically recovered in minutes but may last up to 6 weeks.
Axonotmesis: EMG eval shows an axonal injury through positive waves and fibrillation potentials 2-3 weeks after injury. Pathologically, the axon is disrupted and Wallerian degeneration occurs distally from the injury site. The epineurium is left intact allowing axonal regrowth at a rate of 1-2 mm/day. Recovery is generally complete but could take months.
Neurotmesis: complete disruption of axons, endoneurium, perineurium, and epineurium. Motor and sensory deficits persist for at least a year. EMG show acute denervation. Regeneration may occur in a disorganized fashion. Recovery requires operative repair and the prognosis is variable, ranges from complete recovery to none at all.
Severe intraneural damage occurs before a peripheral nerve breaks. The perineurium and epineurium are more flexible and extensible than the fiber itself. This is important because the intact perineurium can provide a pathway for fibers to regenerate when the nerve is damaged.

8. Management Pain control Restore ROM Muscle facilitation
Phase I
Phase 2
Phase 3
Phase 4
Pain control
Restore ROM
Muscle facilitation
Improve muscular endurance
Improve shoulder mobility as needed
Incorporate extremity movements with stabilization
Improve muscle strength
Implement sport specific activities without contact
Initiate contact drills
Return to play
Management broken up into 4 phases, each with specific goals and criteria to progress on to the next.
Always let symptoms be your guide. Do not want exacerbation during treatment.
Rehab should be proactive vs. wait and see approach
Part I
The time from initial onset of symptoms to complete resolution
Extremity is rested and supported in a sling and pain is controlled with PT modalities and medication if necessary phase 1
Part II
Rehabilitation regime
The affected extremity and entire upper body Is rehabilitated to regain strength in all muscle groups, including those with subclinical involvement
Phases 2-4

9. Phase I Rehabilitation
Pain control
Restore cervical ROM
Initial muscle facilitation
Believe that this is where we can make a big impact with our athletes early. Restore “normal” cervical spine. Lots of tools in our tool box to make early impact.
Sling for comfort to unload shoulder girdle from being tractioned. Might also be necessary depending on muscle weakness present.
Cervical collar to limit cervical extension. Weinstein 1998.
Ann Phys Rehab Med 2009 – mechanical and manual traction group demonstrated significant relief in symptoms vs. traditional rehab group.

10. Phase I Rehabilitation
Manual Therapy
Traction
Joint mobilization
Soft tissue mobilization
Modalities
E-stim
**Manual therapy techniques provide analgesic benefit plus normalization of segmental and myofascial dysfunctions with the goal to regain normal cervical lordosis and spinal mechanics.
Manual traction as an analgesic tool to unload the nerve roots, more easily tolerated than mechanical, better control of neck position, allows for gradual force application, easier to adjust in a timely manner based off of patient feedback.
Joints mobs, specifically lateral glides: If cervical segmental motion restriction is present it can be contributing factor of impeding natural recovery. Cervical mobilizations reduce pain and disability. Studies illustrate the benefit of movement-based treatment approach of patients with peripheral neurogenic pain.
In the presence of significant degenerative changes traction may be irritative if the spinal nerve is fixed as a result of scarring or bony spurring. - Weinstein 1998
Soft tissue mobilization to anterior scalenes – sidelying, head supported, treatment hand on TPs, rotate away and slight side bend toward to put scalenes on slack, gently extend neck to perform myofascial release.
Joint mobilization and soft tissue mobilization will restore the mobility of hypomobile segments.
Anterior scalene: O=anterior tubercles of TP C3-6, I=scalene tubercle and upper surface of rib 1
Middle scalene: O=TP of C2-C7, I=upper surface of rib 1 between tubercle and groove for subclavian artery.
Inherent mobility of midcervical segments causes 5-7 nerve root-spinal nerve complexes to be most susceptible to injury.
Jellad et al. The value of intermittent cervical traction in recent cervical radiculopathy. Annals of Physical and Rehabilitation Medicine 52 (2009)

11. Phase I Rehabilitation
1st Rib Mobilization
Elevated 1st rib due to scalene spasm
Assess with cervical rotation lateral
flexion test
If scalene spasms may need to do 1st rib mobilization if stuck in an elevated position.
Cervical Rotation Lateral Flexion Test = patient in sitting position, examiner passively rotates head away from affected side, examiner gently side flexes the head (ear to chest) passively. Side flexion should be opposite of rotation. Test is considered positive if a bony restriction blocks the lateral flexion.
Supine 1st rib mobilization: palpate 1st rib posteriorly, drop caudally just below the mastoid process, this should identify the landmark of 1st rib. Side flex to same side and rotate away to reduce stress of scalene muscles on 1st rib and allows the rib to “drop” during mobilization. Direct force to the contralateral ASIS. Force is modulated based on positive patient response.
Mobilization is over/near Erb’s point, careful not to reproduce symptoms.

12. Phase I Exercise Examples
Supported chin tucks
With biofeedback
**Release of tight neck musculature may reveal underlying hypermobilities that were driving the protective spasm, which is why we incorporate stability training early in this phase as well. - Weinstein 1998
Lab breakout tomorrow to go through stabilization progression!
**Neck retractions have been shown to provide cervical nerve root decompression (Abdulwahab S, Sabbahani M. Neck retractions, cervical root decompression, and radicular pain. JOSPT 2000;30:4-12)
Motor deficits can occur early following onset of neck pain and do not resolve automatically as symptoms improve.
**HEP - Chin tuck on an hourly basis
May want to use biofeedback of blood pressure cuff (JMMT 2008)
Mechanical Diagnosis and Therapy (MDT) (JMMT 2008)
Primary goal is to isolate and facilitate deep muscles of the cervical spine. (Longus colli and capitus)
Emphasis should be placed on putting your patient in a supportive position to promote relaxation of the superficial muscles and use verbal and tactile cueing to get a smooth isolated contraction that the client can eventually hold while breathing.
As master isolation the position should progress to one that is less supportive and cueing should diminish.
**These muscles do not spontaneously return – they need to be re-educated on how to be recruited.
After 2-3 weeks of training the multifidus should become automatic again.
JOSPT 2000;30(1):4-12. Abdulwahab and Sabbahi – neck retractions appear to alter H-reflex amplitude and promote cervical root decompression and reduce radicular pain in patients with C7 radiculopathy. Exacerbation of symptoms in the reading posture.
H-reflex is elicited by electrical stimulation, measure of muscle reaction time, bypasses the muscle spindle, assess reflex activity at spinal cord.

13. Phase I Rehabilitation
Neural Dynamics
Sliders vs. tensioners to
increase excursion
Do NOT want to increase
strain during healing
Assess neural dynamics with ULTT, look for symmetry. Careful with examination, strong or sustained testing may be contraindicated with sensitized or compromised neural tissue.
Sliding technique = combined movements of at least 2 joints in which one movement lengthens the nerve bed that would cause increasing tension while the other movement simultaneously decreases the length of the nerve bed which unloads the nerve.
**Sliding technique may enhance dispersal of local inflammatory products in and around the nerves.
**Nerve gliding exercises may also limit fibroblastic activity and minimize scar formation. via normal and early use of mesoneurial gliding tissues.
CAREFUL WITH EXAMINATION, strong or sustained neurodynamic testing may be contraindicated with sensitized or compromised neural tissue. Neural tissue are highly sensitive to physical insults – may produce hypoxia through application of tension or compression.
Clear differences b/w sliding and tensioning techniques.
Longitudinal excursion of median nerve was approximately 2x for sliding technique while strain remained fairly constant.
Peak strain substantially larger for tensioning technique than for sliding technique.
Tensioning techniques can create pumping action reducing intraneural swelling and circulatory compromise. Sliding technique may also do this if sliding through an area of increased pressure.
Injured and irritated nerves frequently become pressurized as endoneurial fluid pressure increases.
Associated w/endoneurial edema, ischemia, slowing and pooling of axoplasmic flow, and disruption of pressure gradients which normally allow adequate perfusion of blood into neurons.
Garden hose trapped in long grass example.
Shacklock 2005 – mechanical and physiological mechanisms act together to explain clinical phenomena.
Neural tissue may be hypersensitive (pathophysiology), tension problem (mechanical), or combination.
Mechanical fault could also be a compression problem that relates to the tissues that form mechanical interface to the nervous system.
Lumbar nerve root example – study showed correlation directly with reduced intraneural blood flow and reduced ROM of the SLR. Onset of abnormal changes in physiology occurred at exact same position in ROM of SLR that had produced symptoms during clinical exam.
**Neural tissues are highly sensitive to physical insults and may produce hypoxia through the application of tension and compression.
The inflammatory soup consists of fluids and cells including enzymes, acids, prostaglandins, histamine, and macrophages. This acidic environment creates peripheral nerve sensitivity.
Need structural differentiation maneuver – release wrist extension to see if effects neck symptoms, or if is just musculoskeletal tightness.

14. Phase I Rehabilitation
Cervical ROM
Adjust and progress positioning
Position changes to improve motion without causing symptoms
Rotation in supine
Supine on a wedge for flexion/extension
Regaining cervical spine ROM is essential. **It has been shown that persistent nerve-root inflammation is consistent with restricted motion and could put them at higher risk for another brachial plexus injury.

15. Criteria to Begin Phase II
Full cervical ROM
Resolution of upper extremity symptoms
Not necessarily full resolution of strength
Be able to maintain a supine chin tuck for 30 seconds
Resolution of UE symptoms at rest? Or with AROM?
Not doing aggressive strengthening program in phase I because early progressive resistance exercises in presence of axonal dysfunction could slow down or reverse spontaneous neurologic recovery. - Weinstein 1998

16. Phase II Rehabilitation
Improve shoulder mobility as needed
Improve muscular endurance
Incorporate extremity movements with stabilization.
Exercises should be single plane.
Focus on stabilizing contractions with basic motions and exercises.

17. Phase II Rehabilitation
Shoulder mobility
Manual work as needed to restore joint and tissue mobility
Particularly to anterior structures that are causing them to have forward head and shoulder position – causes increase in upper extremity symptoms in individuals with cervical radiculopathies.
Maintain with self stretching and reinforce ROM with active movements.

18. Phase II Exercise Examples
Quadruped and prone chin tucks
Cervical stabilization with extremity movements
“No Money”
Dying bug
Half kneel chop and lift
Upper extremity exercises
Bands
PNF
Isotonics
Progress demands of stabilization exercises. Progress from supine to upright
At this point we’re going to implement shoulder girdle and thoracic extensor musculature strengthening and then couple it with upper limb strengthening. - Weinstein 1998 Clinics in Sports Medicine
Co-contraction of the axial musculature while simultaneously performing UE strengthening maximally recruits the spinal stabilizers – Weinstein Clinics in Sports Med 1998

19. Phase II Exercise Examples
Shoulder Strengthening
In addition to stabilization exercises with extremity movements want to incorporate upper extremity strengthening to target specific weaknesses your athlete may present with utilizing tubing and isotonics.
PNF exercises are great to provide you feedback on their strength and gains they are making and a nice transition to functional patterns.

20. Phase II Exercise Examples
Half Kneel Chop and Lift
Progress to more functional patterns requiring stability at multiple joints. Can start without resistance and then progressively add resistance to more specifically match the complex movement patterns of the athlete’s sport. – Weinstein 1998.

21. Criteria to Begin Phase III
Be able to hold chin tuck with head lift (without helmet) for 30 seconds
> 4/5 upper extremity strength to be able to perform light-to-moderate upper extremity strengthening without symptoms
- Strength is improving, but may not be all the way symmetrical at this point.

22. Phase III Rehabilitation
Improve muscular strength
Implement sport specific activities without contact
All exercises at this stage should attempt to duplicate normal fluid, multi-planer activities.
Need to be able to move in all directions without eliciting symptoms.
Swiss ball exercises, running, non-contact drills at practice would be appropriate in addition to progressing their strength base.

23. Phase III Exercise Examples
Cervical Strengthening
Participation in weight lifting with team
Strengthen neck prime movers in addition to segmental stabilizers.
Weight lifting under guidance of sports medicine staff and strength coaches.

24. Phase IV Rehabilitation
Criteria to begin phase IV
Be able to maintain a chin tuck with head lift wearing a helmet > 30 seconds
No symptoms
Full upper extremity strength
Within 10% of contralateral side with handheld dynamometer or isokinetic machine.
Want to look at repeated strength to assess endurance vs. a one time strength test.
If you do not have access to that equipment using your best judgment with MMT.

25. Phase IV Rehabilitation
Initiate contact drills
Percussion to Erb’s Point
Spurling’s Test
Return-to-play
Could initiating contact drills be considered pre-game warm-ups the following week if took all week for symptoms to resolve or to progress rehab?

26. Return to Play Criteria
General RTP Criteria:
Adequate time to heal from primary injury
Absence of underlying conditions that pose undue risk of further injury
Resolution of all symptoms
Full, pain-free ROM
Appropriate cardiovascular fitness
Normal strength
Ability to perform sport-specific skills without symptoms
Same game if complete resolution of symptoms, return-to-baseline ROM and strength profile.
If all has gone according to plan to this point should be ready for return to play. End of the day they need to return to baseline.
Same game if no history of stinger within that season or < 2 in different seasons.
General RTP criteria: Standaert and Herring. Expert Opinion and Controversies in MSK and Sports Medicine: Stingers. Arch Phys Med Rehabil 2009;90:402-6

27. Slow-to-No Symptom Resolution
Communication with and referral to team physician
Further imaging
Radiographs
MRI
CT scan or SPECT scan
EMG study
**Probably just need to mention bullet # 1. Dr. McHenry will cover the other 2 bullets.
Bullet 1 = For the PT and ATC’s this equals referral back to physician.
Bullet 2
1st stinger is significant and sustained – s/he should not be allowed to participate in current contest until MRI is performed to rule out significant disc herniation or other structural abnormality.
If persistent symptoms – cervical radiographs (AP, lateral, C1 to T1, and odontoid views) and a cervical MRI should be performed
If suspicion of an occult cervical spine fracture get CT or SPECT
occult fracture is a fracture that does not appear on xray. Not present on standard imagining until weeks after injury.
Bullet 3 – EMG study, get info from Weinstein and Herring
Abnormal spontaneous activity takes approximately 2 weeks to develop and may require 3-5 weeks to maximize. Most useful role of electrodiagnostic studies is to evaluate persistent weakness at 2-3 weeks which may show a regeneration type pattern.
Suspected nerve-root injury should be further evaluated with an MRI.
Electrodiagnostic results are controversial markers for RTP. Bergeld demonstrated that, despite strength improvements following a stinger, EMG could continue to be abnormal in 80% of athletes as long as 5 years f/u.
Conservative treatment does not always equate to nonoperative rehabilitation. If surgical intervention is the appropriate treatment option, for example, in the clinical setting of progressive weakness following nerve injury, early referral is key to minimizing permanent nerve dysfunction, secondary deconditioning, and lost time from competition. - Weinstein 1998

28. Prevention Identifying those at risk Proper tackling techniques
Post-season questionnaire
Proper tackling techniques
Avoid dropping shoulder
Continued eye contact with opposing player should allow for more upright position
High riding shoulder pads to absorb impact
Protective neck rolls
Prevent excessive lateral flexion & extension of neck
NEVER connect straps from helmet to shoulder pads
Do not want protective equipment to compromise ability to move and get into safe positions. Increase risk of cervical spine injury.
Avoid dropping shoulder should prevent head and neck from being driven into excessive extension.

29. Brachial Neuropraxia Postseason Questionnaire
Clin J Sport Med. 2012; (22)6
Brachial Neuropraxia – Canadian Football Incidence of Stingers. Clin J Sport Med. 2012; (22)6
Position
History of stingers, including #, symptoms, duration, etc.
Postseason questionnaire could be useful to help identify those who did not report stinger during the season so you can provide targeted prevention program in the offseason.

30. Key Points
Stingers are common and history of stinger increases likelihood of sustaining subsequent stinger.
Use criteria to drive rehabilitation progressions.
Do not return to play if have not returned to baseline.
Communication with sports medicine team is important, particularly in the presence of slowly resolving symptoms.
Stingers are common and history increases likelihood of another one.
Use a systematic approach with criteria to drive the rehab process.
Have to return to baseline for return to play.
Communication with the sports medicine team is crucial.

31. Thank you!

32. References
Vaccaro et al. Return to play criteria for the athlete with cervical spine injuries resulting in stinger and transient quadriplegia/paresis. Spine Journal Sep-Oct;2(5):351-6.
Castro, F. Stingers, cervical cord neurapraxia, and stenosis. Clin Sports Med22 (2003)
Concannon LG, et al. Radiating upper limb pain in the contact sport athlete: an update on transient quadriparesis and stingers. Curr Sports Med Rep Jan-Feb;11(1):28-34.
Coppieters MW, Butler DS. Do ‘sliders’ slide and ‘tensioners’ tension? An analysis of neurodynamic techniques and considerations regarding their application.
Coppieters MW, et al. The immediate effects of cervical lateral glide treatment technique in patients with neurogenic cervicobrachial pain. J Orthop Sports Phys Ther July;33(7):
Coppieters MW, et al. Different nerve-gliding exercises induce different magnitudes of median nerve longitudinal excursion: an in vivo study using dynamic ultrasound imaging. J Orthop Sports Phys Ther March;39(3):
Safran MR. Nerve injury about the shoulder in athletes, part 2. AJSM. 2004;32(4):
Editorial. Improving application of neurodynamic (neural tension) testing and treatments: A message to researchers and clinicians. Manual Therapy. 2005;10:
Weinstein, SM. Assessment and rehabilitation of the athlete with a stinger. Clinics in Sports Medicine. 1998;(17)1:
Jellad, A, et al. The value of intermittent cervical traction in recent cervical radiculopathy. Annals of Physical and Rehabilitative Medicine. 2009;(52)
Schenk, R, et al. Inclusion of mechanical diagnosis and therapy (MDT) in the management of cervical radiculopathy: a case report. The Journal of Manual & Manipulative Therapy. 2008;16(1):E2-E8.

33. Rihn, JA, et al. Cervical spine injuries in American football
Rihn, JA, et al. Cervical spine injuries in American football. Sports Med. 2009;39(9):
Cantu RV and Canut RC. Current thinking: return to play and transient quadriplegia. Current Sports Medicine Reports. 2005, 4:27-32.
Abdulwahab, SS and Sabbahi, M. Neck retractions, cervical root decompression, and radicular pain. JOSPT. 2000;30(1):4-12.
Gross, AR, et al. Knowledge to action: A challenge for neck pain treatment. JOSPT. 2009;39(5):
O’Leary, S, et al. Muscle dysfunction in cervical spine pain: implications for assessment and management. JOSPT. 2009;39(5):
Ghiselli, G, et al. On-the-field evaluation of an athlete with a head or neck injury. Clin Sports Med. 2003;22:
Olson, DE, et al. Unilateral cervical nerve injuries: brachial plexopathies. Current Sports Medicine Reports. 2007,6:43-49.
Charbonneau, RM, et al. Brachial neuropraxia in Canadian Atlantic University Sport Football Players: What is the incidence of “stingers”? Clin J Sport Med. 2012; 22(6):
Weinberg, J, et al. Etiology, treatment, and prevention of athletic “stingers”. Clin Sports Med. 2003,21:
Standaert CJ and Herring SA. Expert opinion and controversies in musculoskeletal and sports medinice: stingers. Arch Phys Med Rehabil. 2009,90:
Stracciolini A. Cervical burners in the athlete. Pediatr Case Rev ,3:
Sterling M. (2003) Development of motor dysfunction following whiplash injury. Pain, 103, 65–73.
Jull, G. (2002) A randomized controlled trial of exercise and manipulative therapy for cervicogenic headache. Spine 27(17), 1835–43.