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Stingers On and Off the Field: What To Do and When To Do It

Posted on: 03/18/2009
Athletes participating in collision or contact sports are at risk for stingers. Usually it's a temporary injury but it can put a player out permanently. In this article, doctors from the University of Washington (Seattle) review the controversies around this injury. Decisions about diagnosis, treatment, and return-to-play are discussed. The need for equipment modifications to prevent stingers has been questioned and debated. The pros and cons of such a move are also presented.

Stingers refer to the burning, electrical, or shooting sensation a player feels after forceful contact to the head and/or shoulder by another player. The injured player's neck is bent away from the side of the injury. At the same time, the shoulder on the injured side is depressed forcefully. The combination of rapid, forceful movement and direct pressure pulls and presses the nerves in the neck area.

The symptoms are brought on by trauma to the nerves in the neck and don't usually last long. Cervical nerve root(s) in the neck or the brachial plexus further down between the neck and the shoulder are affected. The exact site of the problem remains a hotly debated topic. Is it really the cervical nerve roots that are affected? Or is it the brachial plexus? Maybe it's both. Maybe some players have one type and others have a different type. There's some evidence that younger players are more likely to end up with a brachial plexus stinger. Older players seem to be at greater risk for nerve root compression.

No matter which area of nerve supply is affected, most players are able to get back into play during the same game. In some cases, a stinger (or more often, repeated stingers) causes permanent nerve damage. That's a problem, and one we don't really know how to predict or prevent. Despite the fact that this is a fairly common injury (up to 65 per cent of college players have at least one sometime), there are no clinical guidelines for how to evaluate and treat players.

That's where these authors hope to help sports medicine doctors figure out what to do on and off the field. Obviously X-rays aren't available on the field. Imaging studies may be done later if the symptoms persist or if the player reports muscle weakness of the neck or arm.

Players who have had two or more stingers should consider having an X-ray to check for instability. There could be a narrowing of the spinal canal or the space where the nerve root exits. This narrowing is called stenosis. There could be a protruding or herniated disc pressing on the nerve root. Such findings would change the entire picture. Any of these problems can put the player at increased risk for significant nerve injury. A more thorough diagnostic evaluation will be needed to decide if the player is safe to return-to-play. And as you can imagine, this is a big decision for most players whose life is sports.

Even with diagnostic X-rays, CT scans, or MRIs, the findings aren't always very clear or helpful. Further assessment may be needed with electrodiagnostic studies (EDX). These tests can help identify which nerves are affected and check the function and integrity of the nerves. They are ordered two to four weeks after the injury when the symptoms of a stinger have not gone away. The hope is that the tests will be normal indicating a good prognosis for recovery. If the tests show abnormal nerve function, they can be repeated again later to look for signs of improvement indicating slow recovery.

In the meantime, what should the athlete be told? Can he return-to-play while waiting for nerve function to return? Is it safe to do so? The authors say this isn't a cut-and-dried decision. Many factors must be taken into consideration. They provide a table of return-to-play criteria to use when making recommendations for the season. For example, one stinger with rapid return to normal is easy: no diagnostic tests are needed and the player is safe to return to the game as soon as the symptoms are gone.

Two stingers in the same season should be checked by X-ray and in some cases, an MRI should be done. Persisting pain, numbness, weakness, and/or loss of motion are signs that electrodiagnostic tests are needed. The athlete is held out of the game until it is safe to play again. Two or more stingers in different seasons are assessed first by symptom resolution, then by X-rays, MRIs, or electrodiagnostic testing if symptoms persist.

Three or more stingers in the same season or in different seasons put the player at risk for being benched and out for the season (if not permanently). These are the cases where it is clearly in the best interest of the individual to be protected from any further injuries. When is it safe to return to the practice field? When the player has full, painfree neck motion and strength to perform all the sport-specific skills needed to play without any symptoms.

Players who take a long time to recover (even after only one stinger) or who have anatomical deformities such as stenosis or disc herniation should be advised to stop playing (permanently) in sports that involve potential collisions or contact.

Some experts have asked if wearing a special collar would help prevent these injuries from occurring in the first place. There are cervical collars that limit how much the neck can be pushed into extension (backwards) or into lateral flexion (bent to the side). There have even been a couple of studies in the lab with different types of cervical collars to start looking at this issue. The studies were fairly limited -- for example, they were not tested during live play.

Even so, early results showed that the collars restricted some motion needed to play safely without really limiting motions that result in stingers. It doesn't appear that adding a cervical collar to the standard football uniform and equipment is the answer. There isn't a good solution yet to preventing stingers. For now, quick action at the time of the injury to protect the player from further injury may be the best that can be offered. Careful assessment is needed when making the out-of-the-game virus return-to-play decision.

Christopher J. Standaert, MD, and Stanley A. Herring, MD. Expert Opinion and Controversies in Musculoskeletal and Sports Medicine: Stingers. In Archives of Physical Medicine and Rehabilitation. March 2009. Vol. 90. No. 3. Pp. 402-406.

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