What is a Stinger?
A stinger is a sports related injury to the nerves about the neck
or shoulder. It is sometimes called a burner or nerve pinch injury,
but the term stinger is most descriptive of the symptoms that the
athlete experiences including painful electrical sensations radiating
through one of the arms. While the stinger is usually a spine
injury, it is never a spinal cord injury. The stinger occurs
most commonly in contact and collision sports, but is not as catastrophic
as a spinal cord injury and does not result in paralysis in the
arms and legs. A stinger is often not reported by the athlete to
the coaches or the athletic trainers since the symptoms can spontaneously
resolve within a short period of time. However, stingers tend to
recur and if not properly diagnosed and treated can lead to persistent
pain or even arm weakness, which can eventually result in extended
lost playing time.
Athletes competing in various sports (most common in football and
wrestling), playing specific positions (such as defensive back,
linebacker or offensive line) or performing certain athletic maneuvers
(such as tackling, blocking or executing a take down maneuver) are
at greatest risk of sustaining a stinger. The injury occurs in 1
of 2 ways: either 1 of the nerves off the spinal cord in the neck
is compressed as the head is forced backward and toward that side;
or the nerves in the neck and shoulder are over-stretched as the
head is forced sideways away from the shoulder. The athlete will
experience sudden and severe painful, stinging sensations in 1 of
his arms frequently lasting from seconds to minutes, occasionally
hours and less frequently days or longer. There is often associated
weakness of the muscles in the shoulder and arm that are supplied
by the injured nerve. The arm symptoms are usually more severe than
neck pain. First time stingers will usually recover quickly even
without treatment, but there is a greater risk of recurrent injury
if left untreated. Each additional stinger will likely result in
continued neurologic impairment including muscle weakness. Stingers
do not affect both arms at the same time, although each arm can
be affected with different injuries. If both arms are symptomatic
at the same time after a neck injury, a spinal cord injury is likely
to have occurred which leads to a much different treatment plan.
How is It Diagnosed? The diagnosis of the stinger requires the expertise of a medical professional.
Ideally, the first evaluation of the athlete occurs at the time
of injury at the game or match. Since these injuries are not catastrophic,
the athlete often exits the field of play without assistance.
A sideline evaluation will be conducted by the athletic trainer,
physical therapist and/or team physician that will include: a determination
of the mechanism of the injury, the symptoms experienced by the
athlete, and the physical examination findings including assessment
of muscle strength. A decision will be made whether or not the athlete
is medically cleared to return to that contest. Persistence of symptoms,
stiffness or loss of full range of neck motion, muscle spasm and
weakness would usually keep the athlete out of competition.
Careful medical follow-up evaluations are important and necessary.
These examinations should take place regularly until the athletes
condition has normalized. If the symptoms and/or neurologic findings
worsen during the first few days after the injury or continue beyond
2 weeks, then further medical assessment is necessary. The physician
may order specific tests such as X-ray examinations, magnetic resonance
imaging (MRI), and an electromyogram (or EMG) which is designed
to evaluate for nerve damage. Occasionally a stinger can result
from a disk herniation in the neck. If so, this should be confirmed
on the MRI.
No matter how trivial the injury may appear, in order for the physician
to make the correct diagnosis and prescribe the appropriate treatment
it is very important for the athlete not to withhold information.
If the injury was not witnessed by the medical personnel covering
the event, then it is the responsibility of the athlete to report
the injury even if the symptoms disappear quickly. In some situations,
the effects of the stinger can lead to permanent nerve damage if
left undiagnosed and untreated.
What Treatments Are Available?
The goals of treatment are to reduce the pain and abnormal sensations in the
arm, regain the strength of weakened shoulder and arm muscles, and
prevent further injuries.
There are several nonoperative options for the treatment of an
acute stinger. The order in which these treatments are utilized
depends largely on whether the primary complaint is pain or weakness.
Treatment for acute pain usually includes activity restriction,
ice or heat, antiinflammatory and pain medications, a cervical collar
and cervical traction. Following an acute injury, the athlete is
not allowed to return to competition to allow time for recovery.
Modalities such as ice and heat can be used both for comfort and
to reduce inflammation. Ice is usually applied about the neck and
shoulder region up to 48 hours post injury after which time heat
is substituted.
Nonsteroidal antiinflammatory medications are frequently prescribed
for both reduction of swelling and inflammation as well as pain
relief. Stronger analgesics (pain medications) are not usually necessary,
but muscle relaxants may be utilized for a short period of time
to treat muscle spasm.
A cervical collar may also be used for a short period of time to
prevent further nerve root injury or irritation. Cervical traction
helps to reduce pressure on the nerve root. It can be applied manually
or mechanically under the guidance of a physical therapist. Often,
trunk strengthening and chest-out posture correction exercises are
started.
For persistent pain, cortisone injection around the injured nerve
root (nerve root block) performed with X-ray guidance
can be helpful to reduce inflammation of the nerve. If weakness
is the main problem, then the acute treatment includes modified
activities, ice or heat and antiinflammatory medication.
The majority of stingers are treated successfully without surgery.
Surgery is only considered if the injured nerve root is found to
be severely compressed by either a disc herniation or bone spur
and there is severe persisting pain or worsening weakness. The 2
surgical options are removal of the disc (discectomy) or bone spur,
or discectomy followed by a fusion. In each case, the surgical decision
is individualized to the athletes symptoms and signs and the
results of additional diagnostic tests.
Prevention
Many athletes who sustain a stinger are found to have substantial postural
deviations which may interfere with full recovery. Some of these
abnormal postures include the head jutting out too far forward from
the neck and the shoulders too rounded. These postures will cause
more pressure to be placed on some of the nerve roots in the neck
making them more likely to be injured and to recover slower after
injury.
A comprehensive physical therapy treatment program will be of value
to correct the various areas of muscular and soft tissue tightness
and weakness throughout the neck, upper back and shoulder region.
Trunk stabilization and chest-out posture correction exercises are
usually the basis of the treatment program.
Physical therapy may also include manual therapy treatments in
which the therapist provides deep tissue massage to release tight
soft tissues and joint mobilization to loosen stiff spinal joints.
Forceful spinal manipulation should be avoided so as not to further
injure the cervical nerve root. Therapy includes specific exercises
to strengthen the weak muscles of the neck, upper back and arms.
Athletes who undergo surgery must also complete a full rehabilitation
program.
Return to Play
Before the athlete can return to regular athletic competition, several goals
must be met. First, the athlete must be completely free of pain
and weakness and must regain full range of motion of the neck. Second,
the diagnostic tests such as the EMG and/or MRI should not reveal
any active nerve damage or severe nerve compression. Third, the
athlete must be reconditioned for the sport especially if he has
not competed for awhile. Fourth, improvement in the athletes
playing technique (such as blocking and tackling) and equipment
modifications should be made to protect the athlete from further
injury.
In football, special pads and neck rolls can be fitted to the helmet
or shoulder pads, which can help prevent re-injury. However, this
type of equipment change does not replace the most important part
of prevention, which is building strength and endurance of the neck
and shoulder muscles. That is why athletes who have had surgery
will usually take longer to return to play.
Finally, in some cases the decision to return to play must be delayed
especially if the athlete has suffered several stingers in the same
season. Healing is usually slower after multiple injuries. The key
concern is to avoid permanent nerve damage, which could cause problems
in the young athletes personal as well as athletic life. Rarely
does a history of multiple stingers signal the end of an athletic
career. The sports medicine physician, working together with the
athletic trainers, should provide counseling regarding how serious
the injury is and discuss early or delayed return to play.
Disclaimer: This information is for general information
and understanding only and is not intended to represent official
policy of the North American Spine Society. Please consult your
physician for specific information about your condition.
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