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UCSF 11th Annual Primary Care Sports Medicine Conference:

Upper Extremity

Stingers, Burners, and Winging:

Nerve Injuries of the Upper Extremity

Cindy J. Chang, M.D.

Associate Professor Primary Care Sports Medicine

December 9, 2016

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Disclosures

I have nothing to disclose

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Objectives

• Review common upper extremity nerve injuries seen in athletes

• Discuss return to play issues concerning specific upper extremity nerve issues

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Exam Room Tips• Stock gowns/sheets and paper shorts in the room

• Be able to get to both sides of the exam table

• Have a step stool handy

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Case #1

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Case #1

• 1994 AFC Championship Game

• San Diego Charger upset the favored Pittsburgh Steelers 17-13

• Junior Seau recorded 16 tackles and a forced fumble despite:

– Not being able to lift his arm above his shoulder

– Playing with a bad left shoulder

– Having a pinched nerve in his neck

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“Arm not fine? First Clear the Spine!”

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Taking a Really Good History

• Chief complaint -- eg, pain, numbness, weakness, location of symptoms?

• Use a visual analogue scale -- patient's perceived level of pain

• Anatomic pain drawings -- quick review of pain pattern.

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Taking a Really Good History• Onset, mechanism, what was done at that time?

• How do activities and head positions affect symptoms? In what position does patient sleep? Ever wake up with pain?

• Social history: sport/position, occupation, field of study, amount of computer use, ergonomic set-up, alcohol and tobacco use

• What previous treatments (prescribed or self-selected) has the patient tried?

– ice and/or heat

– Medications (eg, acetaminophen, aspirin, nonsteroidalanti-inflammatory drugs [NSAIDs])

– Physical therapy, traction, manipulation, acupuncture

– Injections, surgical treatments

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Taking a Really Good History• Has the patient experienced previous episodes of

similar symptoms or localized neck pain? When and for how long? What helped? Other spine pain?

• Any symptoms suggestive of a cervical myelopathy, e.g., changes in gait, bowel or bladder dysfunction , or sensory changes or weakness of the legs?

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OLDCARTS

•Onset

•Location

•Duration

•Character

•Aggravating/Alleviating

•Radiation

•Timing/Treatments

•Severitywww.fammedref.org/mnemonic/pain-hx-old-carts-p

MS OLDCARTSMechanism of Injury

Symptoms

Onset

Location

Duration

Character

Aggravating/Alleviating

Radiation

Timing/Treatments

Severitywww.fammedref.org/mnemonic/pain-hx-old-carts-p

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Typical Hx of Cervical Radiculopathy • Presents with neck

and/or arm discomfort of insidious onset

– range from a dull ache to a severe burning pain

• Initially, pain referred to medial border of scapula

– chief complaint may be shoulder pain

• As radiculopathy progresses, pain radiates to upper or lower arm and into the hand

– along sensory distribution of the involved nerve root

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Typical Hx of Cervical Radiculopathy • Acute disc herniations and sudden narrowing of

the neural foramen can occur in injuries involving cervical extension, lateral bending, or rotation and axial loading

• Increased pain with these neck positions that cause foraminal narrowing

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Cervical Radiculopathy

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If you think it’s Cervical Radiculopathy…

• MRI most useful imaging choice

• C-spine xrays including oblique views (“5 views”) may show degenerative changes

– Order “7 views” if h/o trauma to neck

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Eubanks JD, AFP 2010

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If you think it’s Cervical Radiculopathy…

• Most patients <35 will do well with a trial of conservative management (time, meds, rehab/modalities).

• Emphasize time. Emphasize activity. Emphasize posture. Emphasize restful sleep. Emphasize time.

The art of medicine consists of amusing the patient while nature

cures the disease.”

-Voltaire

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Eubanks JD, AFP 2010

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Emphasize Posture

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Case #1

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Case #1After making a tackle, the football player jogs off without assistance, but is carrying his left arm wi th his right. You question him on the sideline. Whic h of the following symptoms do NOT make you think this is a stinger?

A. He describes a burning type of painB. He describes weakness in only his

wrist extensorsC. He feels numbness in both armsD. He is having neck pain

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3%

17%

47%

33%

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““““Burners/Stingers ””””

• Definition: – Nerve injuries resulting from

trauma to neck or shoulder area

– Cause a traction or compression along brachial plexus or cervical neck roots.

• Diagnosis– Immediate onset of burning pain

down the arm unilaterally

– Can be associated with numbness or weakness

• Lasts seconds to hours

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Safran MR, AJSM 2004

““““Burners/Stingers ””””

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““““Burners/Stingers ””””

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““““Burners/Stingers ””””

• Risk factors

– Contact sports

– Spinal stenosis

• Symptoms

– Usually last seconds to minutes

– In 5-10%, can last hours to days or longer

– Burn, electric shock, warmth, tingly

– Numbness, weakness

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““““Burners/Stingers ””””

• Work-up if:

– Weakness lasts several days

– Recurrent burners/stingers

– Neck pain

– Atypical symptoms, e.g. bilat UE

• Tests

– Radiographs to include flexion/extension views, obliques

– MRI C-Spine

– EMG/NCS if > 3 weeks post injury and weakness

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Case #235 yo dragon boat racer walks into clinic to reques t a prescription for physical therapy for her “rotator c uff tendinitis”. You do a very quick exam and she is weak when testing all of her rotator cuff muscles. What should you do next?

A. Order an XrayB. Check her sensation over her deltoid

regionC. Visually inspect her shoulder girdleD. Write the prescription but limit to 3

wks with strict follow-up

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6% 5%

50%

39%

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Scapular Winging

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The Role of the Scapula

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• Scapula serves as the attachment site for 17 muscles

• function to stabilize scapula to thorax, provide power to the upper limb, and synchronize glenohumeral motion.

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Scapular Motion• Elevation and upward rotation : trapezius

• Scapular protraction (anterior and lateral motion): serratus anterior, pectoralis major and minor muscle

• Scapular retraction (medial motion) : rhomboid major and minor muscles

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Scapular Stabilizer

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Scapular Winging• Long Thoracic Nerve

(LTN) is branch of brachial plexus C5, 6, 7

• Seen in pectoral region on surface of serratus anterior, just behind mid-axillary line

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Scapular Winging

• Observe active forward flexion and abduction from behind patient

• Watch for scapular winging on descent

• Dysfunction also common with rotator cuff tears and instability

• Wall push up – for more pronounced winging seen with Long thoracic Nerve injury

– serratus anterior palsy

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Scapular Winging - LTN

• Mechanisms of injury to long thoracic nerve

– iatrogenic from anesthesia

• 10% had prior surgery

– repetitive stretch injury (most common)

• increased risk with head tilted away during overhead arm activity

– compression injury

• direct compression of nerve at any site

– scapula fracture

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Nawa S, J Brach Plex Periph Nerve Inj 2015

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Scapular Winging – LTN - Treatment• Nonoperative

– observation, bracing, and strengthening

• observation minimum 6 months for nerve to recover

• Operative

– pectoralis transfer; decompression, neurolysis, and tetanic electrical stimulation

• failure of spontaneous resolution after 1-2 years

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Nath RK et al, BMC Musculoskeletal Disorders 2007

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Case #3

22 yo RHD woman presents with increasing right shoulder pain despite doing rehab exercises diligently every day. This is what you see on observation:

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Case #3She plays outside hitter on a volleyball team which increased practices to 5x/wk a month ago preparing for nationals. You suspect what pathology?

A. Suprascapular nerve entrapment at the suprascapular notch resulting in atrophy of the supraspinatus

B. Suprascapular nerve entrapment at the spinoglenoid notch resulting in atrophy of the infraspinatus and teres minor

C. Suprascapular nerve entrapment at the suprascapular notch resulting in atrophy of the supraspinatus and infraspinatus

D. Suprascapular nerve entrapment at the spinoglenoid notch resulting in atrophy of the infraspinatus

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8%

26%31%

35%

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Suprascapular Neuropathy

• If atrophy of both infraspinatus and supraspinatus

– Compressed at suprascapular notch

• Only atrophy of infraspinatus

– Compressed at spinoglenoid notch

– Traction injury

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Suprascapular Neuropathy• Atrophy of both

– Surgical decompression

– Release of transverse scapular ligament at suprascapular notch

• Atrophy of infraspinatus

– Decompress ganglion, paralabral cyst at spinoglenoid notch

– Release spinoglenoid ligament

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Suprascapular Neuropathy• Non-operative Treatment

– Activity modification, formal shoulder rehab program

– Rehab performed for a minimum of 6 months

– EMG/NCS

• Operative

– Structural lesion seen on MRI (cyst, labral tear)

– Nerve decompression if failure of extended nonoperative management (~ 1 year)

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Safran MR, AJSM 2004

Burners/Stingers, Winging and other Nerve Injuries of the Upper Extremity

• Return to Play– Pain resolved

– Full pain-free neck and upper extremity ROM

– Normal strength

• preferably compared with preseason baseline

– Normal reflexes

– Negative Spurling’s test

– Negative imaging studies

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Huang P et al, Sports Health 2015

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Burners/Stingers, Winging and other Nerve Injuries of the Upper Extremity• Absolute contraindication to RTP

– Symptomatic disc herniation

• Relative contraindication to RTP– Prolonged symptomatic burner/stinger lasting >24°

– ≥ 3 stingers; must have full return of ROM, normal strength, and no baseline discomfort

• No contraindication to RTP– Degenerative disc disease; only occasional neck

stiffness and pain and no changes in baseline neurological status

– < 3 episodes of a stinger lasting <24° with full ROM and no neurological deficit

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Cantu RC et al, CSMR 2013

Burners/Stingers, Winging and other Nerve Injuries of the Upper Extremity

• Return to Play – no universally accepted criteria– Can the athlete protect

themself from further injury?

– Can the athlete successfully play their sport?

– Long term and short term risks vs. benefits?

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Creighton DW et al, CJSM 2010

Burners/Stingers, Winging and other Nerve Injuries of the Upper Extremity

• Prevention– Proper technique

– Neck and shoulder girdle strengthening

– Balance (core) training

– Additional protective padding

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“You don't stop exercising because you grow old.

You grow old because you stop exercising.”- Anonymo us

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