Author(s): David Pilkington, DO, Albert Chang, MD, Katie Smolinski, DO, Jami Montagnino, MD, Christopher McMullen, MD
Originally published: September 20, 2013 Last updated: April 14, 2022
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Disease/ Disorder

Definition

A stinger/burner is usually an athletic injury from traction, compression, or direct trauma to the upper brachial plexus or cervical nerve roots.1

Etiology

There are three generally accepted mechanisms of injury for stingers/burners.

  1. Traction injuries occur when there is contralateral lateral neck flexion and/or ipsilateral shoulder depression.
  2. Compression injuries occur when the neck is forced into ipsilateral lateral flexion and/or oblique extension.
  3. Direct blow injuries occur when there is a blow, often by an opponent’s helmet or shoulder, directly over the supraclavicular fossa or lower lateral neck.
  4. Injuries that result in foraminal narrowing with mechanical compression of exiting brachial plexus nerves are thought to be the most common and result in more severe symptoms.2

Epidemiology including risk factors and primary prevention

Stingers/burners are commonly reported in collision sports, most notably football, but also including hockey, lacrosse, rugby, gymnastics, and weightlifting.3 Early literature reported the annual incidence of stingers/burners in contact sports at 49-65%, with recurrence estimated at 87%.1,4 More recent data from 2012 showed an incidence of 26% and lifetime prevalence of 62% in Canadian college football players.5 Approximately 50-65% of football players and 30-40% of rugby players have reported at least one stinger in their career.8,9 The true prevalence is unknown as symptoms are often under-reported by athletes for fear of being removed from play. Stingers are the most common cervical spine injury in American college football athletes.7 However, in one study, 70% of American college football players reporting a stinger/burner did not report this to medical personnel. Stingers most often resulted from direct contact, were more common in those with previous history of cervical injury or congenital cervical stenosis, more often occurred during regular season games, and in the following football positions: linebackers, offensive linemen, and wide receivers.2,7,9

Primary prevention efforts should focus on proper play techniques, protective equipment, and preventive rehabilitation. A more upright tackling position can prevent a blow to the top of the head causing excessive axial loading of the cervical spine. Higher riding padding and the use of a cervical collar can also help absorb the energy from a blow.7,10

Patho-anatomy/physiology

Stingers/burners typically affect the C5 +/- C6 nerve roots or the upper trunk of the brachial plexus. Mild injury may result in neurapraxia and conduction block, leading to temporary sensory deficits and weakness that may last from minutes to weeks. More severe injury may result in axonotmesis or neurotmesis, which can lead to long-term sensorimotor deficits.11

The role of intrinsic anatomical abnormalities is controversial. The neuroforamina and the central canal are narrowed when the neck is in extension and rotation.9,10 Cervical canal stenosis, measured by a Torg ratio < 0.8, has been correlated with increased risk of stingers/burners in collegiate athletes. A 1994 study found that college athletes with a Torg ratio < 0.8 had a threefold increase in sustaining burners.9 Similarly, increased risk of burners has been reported high school athletes with central canal or neuroforaminal stenosis.10 More recently, a mean subaxial cervical space available for the cord (MSCSAC) < 5mm has also been shown to have a high sensitivity and specificity for chronic stingers/burners, and may have some predictive value.12,13 However, given the high prevalence of similar anatomy in asymptomatic individuals and the high rates of stingers/burners in those without these anatomic features, the exact role of abnormal cervical vertebral anatomy is controversial.14 Even if these anatomic features are correlated with the development of a stinger/burner, they are most likely only predictive for compression type injuries, and not for those due to traction or direct trauma.

Disease progression including natural history, disease phases or stages, disease trajectory (clinical features and presentation over time)

  1. New-onset: Acute stingers/burners are characterized by the first occurrence of unilateral, intense burning pain in the shoulder with radiation down the arm and possible weakness in the C5 and C6 myotomes. The vast majority of symptoms generally resolve within minutes to hours, but can last for up to two days, with pain typically resolving prior to weakness.2
  2. Chronic: Chronic stingers/burners are characterized by the presence of prolonged pain, sensory deficits, or weakness with possible muscle atrophy lasting longer than a few days. This can result in time lost from practice or competition. When stingers/burners are chronic, recovery is typically slow.15
  3. Terminal: Terminal stingers/burners are characterized by severe neurotmetic injuries, where incomplete reinnervation may lead to permanent weakness and atrophy.

Essentials of Assessment

History

Stingers/burners are usually associated with traumatic events, such as collisions, direct impacts, or falls. In collision sports, improper technique or improper equipment may be responsible. If possible, the mechanism of injury should be noted. Patients will complain of immediate onset of severe, unilateral burning pain radiating down the arm, often with paresthesia and motor weakness.

Physical examination

Physical examination should first focus on ruling out other, more severe injuries. Given the high energy impact involved, immediate assessment of airway, breathing, circulation, cervical spine injuries, or other acute shoulder fractures/dislocations is paramount.  If bilateral upper extremity or concurrent lower extremity symptoms are present, the athlete should be treated for potential cervical spinal cord injury, including immediate cervical spine immobilization, spinal precautions, and transport by EMS to a trauma center for further evaluation and care. Once emergent medical diagnoses are ruled out, further assessment of the cervical spine, shoulder, and neurovascular structures should be completed.

The diagnosis of stingers/burners is typically made by the history and physical examination. The involved extremity is often braced against the body for comfort, held up by the uninvolved limb to relieve tension, or set in a depressed position due to weakness. Close inspection should be performed as ecchymosis, swelling, deformity, or asymmetry of the neck, shoulders, clavicles, and scapulae suggests other causes of injury. Focal tenderness to palpation is also atypical and should alert the clinician to suspect other etiologies. Neck and upper extremity range of motion is generally not helpful in the acute stage of injury due to protective spasms. A baseline neuromuscular exam should be established, including myotomal strength, dermatomal sensory, reflexes, and neural root tension testing. Transient, unilateral weakness or sensory abnormalities are often identified on neurologic examination.  Serial exams should be performed to assess for resolution of symptoms or identify late-onset symptoms. Testing should focus on C5 and C6 myotomes (deltoid, biceps, and infraspinatus) and dermatomes. Biceps, brachioradialis, and Hoffman’s reflexes should be checked but are often normal. Spurling’s maneuver may be positive; it has high specificity but low sensitivity.16 A negative Spurling test and the absence of neck pain may indicate a brachial plexus etiology.3 While weakness is common, atrophy of the neck, shoulder, or arm is suggestive of a more chronic process, such as a chronic stinger/burner or cervical radiculopathy.

Functional assessment

Functional assessments should involve cervical and shoulder range of motion, neuromuscular exam, and sport-specific activities.

Imaging

Imaging should be obtained in the following instances:

  • Recurrence of stinger/burner
  • Bilateral pain, weakness, or numbness
  • Pain, weakness, or numbness lasting more than 24 hours
  • Any concern for C-spine injuries

Imaging studies are generally not indicated in the following conditions:

  • First incidence of pain
  • Unilateral pain
  • Symptoms that resolve within 24 hours
  • Benign physical examination (without concern for C-spine or shoulder injury)

Imaging should initially consist of: A-P, lateral, and odontoid C-spine films. Flexion/extension views can be helpful in demonstrating spinal instability but should only be done in the hospital setting for acute injuries. If symptoms are bilateral, or there is concern for cervical spine pathology, a C-spine MRI should be obtained to evaluate for spinal cord edema, nerve root integrity, disc herniation, pars interarticularis fractures, ligamentous injury, or foraminal stenosis. If unable to perform MRI, CT cervical spine can also evaluate for central/foraminal stenosis and detect an occult spine fracture.

Supplemental assessment tools

Electrodiagnostic examinations (EDX) can help confirm the diagnosis, define and locate the site and nature of the lesion (axonal, demyelinating), and guide prognosis. EDX can help distinguish between cervical radiculopathy and brachial plexopathy. Decreased conduction velocities, prolonged latencies and proximal conduction blocks on nerve conduction studies are consistent with neurapraxia. If sensory studies are abnormal, this is suggestive of a brachial plexus injury, rather than a radiculopathy, and may suggest a longer recovery process. The presence of positive sharp waves and fibrillation potentials on needle electromyography represents active denervation and axonal injury, which also suggests a longer recovery period; this may take up to four weeks to develop post-injury.17 Involvement of the cervical paraspinal muscles suggests a nerve root injury rather than plexopathy. While serial EDX can be helpful in case of axonotmesis and neurotmesis to monitor recovery, it is not recommended to base return-to-play decisions on resolution of EDX abnormalities, as functional strength may return prior to the resolution of EDX abnormalities.18 However, ongoing acute denervation (spontaneous potentials) without evidence of reinnervation (polyphasicity with appropriate recruitment) may suggest that the athlete is not yet ready to return to play.

Early predictions of outcomes

Given the relatively high incidence of stingers/burners and the rare incidence of permanent disability, the general prognosis appears good. While return to play time can be variable, one report estimated that more than 85% of players did not miss a game or practice after a stinger.4  Lack of prior stingers/burners and rapid resolution of symptoms are considered favorable prognostic factors.15 In contrast, prior history of a stinger has been shown to strongly correlate with recurrent stingers by more than 50% in some studies.9 However, there is no current evidence to suggest that the risk of permanent nerve injury is associated with the number of recurrence.

Environmental

Clear return to play guidelines are lacking, though absolute contraindications include persistent weakness, bilateral symptoms, and suspicion of a cervical spine injury (continued neck pain or lack of full ROM).3 If a player has their first stinger and symptoms resolve rapidly, they have a normal neurologic exam, and pain-free cervical ROM, they may be considered to return to play in the same game.3 A second stinger in the same game would be an absolute contraindication to return to the same game, pending radiologic workup. The patient’s sport, position, and form should also be considered when determining return to play, especially for those with recurrent stingers/burners.

Social role and social support system

Coaches and parents should be educated on injury mechanism and proper sporting technique and equipment. Tackling mechanics should be assessed in defensive football players with recurrent injuries.

Professional Issues

If cervical spine injury is considered, spine precautions should be initiated, and the patient should be emergently transported to the hospital for more extensive evaluation. The physician must also be aware of the possibility of concurrent or separate shoulder dislocations that can be caused by the same trauma and may present in a similar manner. It would be inappropriate to return athletes to play if they are in need of advanced medical work-up or have any continued neurologic deficits. Such actions could be a deviation of standard of care and may be considered medical negligence.

Rehabilitation Management and Treatments

Available or current treatment guidelines

While there is variability among these review guidelines for returning to play following stingers/burners,20-24 all agree that athletes should not return to play until all symptoms have resolved, including full, pain-free cervical ROM, full strength, no tenderness to palpation, and normal neurologic examination. Neck pain with decreased ROM, persistent neurologic deficits, or evidence of instability are absolute contraindications to return to play. Additional recommendations should consider symptom recurrence and duration:

  • First stinger/burner in a season: An athlete may return to play in the same game once they are pain free with full cervical range of motion, full, symmetric strength in bilateral upper extremities, and no neurological symptoms.
  • Second stinger/burner in the same game: An athlete should not return to play that game, even if symptoms completely resolve.3
  • Second stinger/burner in a season: An athlete should not return to play in the same game. Formal medical evaluation should be considered. If all symptoms resolve quickly and fully, the athlete may return to subsequent games.
  • Second stinger/burner in a separate season: An athlete with rapid resolution of symptoms and normal physical examination including full symmetric strength and pain free cervical ROM can return to play the same game.3
  • Third stinger/burner in a season: An athlete should have imaging evaluation before returning to play. Medical personnel should consider having the athlete sit out for the remainder of the season and/or avoiding future contact sports. Three or more stingers, particularly in rapid succession, are often cited as a relative contraindication to return to play. 19, 21 The athlete should undergo cervical spine imaging to rule out anatomical risk factors for future spinal injuries.
  • Any stinger/burner with persistent symptoms requires advanced imaging, medical evaluation, and consideration of EMG testing. Return to play should occur only with complete symptom resolution and appropriate medical clearance.

At different disease stages

Initial management consists of rest and pain control. Since stingers/burners are generally self-limiting, most patients will quickly return to full participation without any need for pain medications. Ongoing management includes a rehabilitation program that focuses on correcting biomechanical or technical deficits to prevent recurrence. Rehabilitation programs should emphasize postural correction, normalization of cervical ROM and flexibility, shoulder strengthening and stabilization, and correction of muscular imbalances in cervical, thoracic, scapular, and core stabilizers. A structured muscle-strengthening program can help to prevent recurrent stingers. Proper sporting technique should be reinforced. Protective equipment should be re-evaluated with a focus on improving shoulder padding. The use of cervical collars and neck rolls in sport to reduce risk of re-injury in athletes with recurrent stingers remains controversial. The decision to use a football collar should be case specific, based on the mechanism of injury, as placing the athlete in a more flexed cervical spine position could increase risk of severe spinal cord injury.3

For chronic or recurrent pain, anti-inflammatory or neuropathic pain medications may be helpful but their effects on disease progression are unknown. The role of corticosteroids is controversial.  Physical therapy and a home exercise program may be beneficial and should focus on cervical and shoulder stabilization, ROM, and strengthening affected muscles. If the pain continues to be refractory, a multidisciplinary pain management program may be helpful. Persistent neurological deficits are a contraindication of return to play. If these are noted, athletes should consider termination from further participation in collision sports.

Primary management of stingers is non-operative; however, for cases where permanent or residual strength deficits are present due to suspected nerve root damage, operative intervention should be considered and early consultation with a specialist is advised for most effective treatment.3

Coordination of care

Coordination among the physician, athlete, athletic trainers, coaching staff, and physical therapists can help establish the understanding of the pathophysiology of the condition, and reinforce the importance of proper training, techniques, protective equipment, and direct rehabilitation efforts.

Patient & family education

Education should focus on the importance of proper sporting technique to prevent recurrence. In sports with tackling, athletes should be advised against any spearing-type tackling or leading with the head and neck. Athletes and coaches should not hesitate to report any incidence of stingers/burners to the training staff or a physician familiar with stingers/burners.

Emerging/unique interventions

Treatment outcome is largely based on the resolution of symptoms and return to pre-morbid level of physical activity. Complete recovery is expected in the majority of stingers/burners; however, in chronic cases there may be residual symptoms which usually manifest as myotomal weakness.  There has been one case report demonstrating cervical transforaminal epidural steroid injection as a successful treatment modality in a collegiate football play with recurrent stingers with persistent upper extremity symptoms despite conservative management.25 However, cervical injections are not without risk, and further investigation is needed to support the benefits of this treatment approach.

Translation into practice: practice “pearls”/performance improvement in practice (PIPs)/changes in clinical practice behaviors and skills

In sports with tackling, athletes should be advised against any “spearing”-type tackling, as this has been shown to correlate with a higher incidence of stingers/burners.

Return to play decisions are contingent upon complete symptom resolution, a normal physical exam, and in the case of recurrent stingers, normal imaging findings.

Cutting Edge/ Emerging and Unique Concepts and Practice

NA

Gaps in the Evidence-Based Knowledge

The exact role of cervical anatomy in the pathophysiology and prognosis is uncertain at this time. The ideal protective padding for primary prevention of this injury in high-risk sports is also unclear. Equipment modifications such as thermoplastic total contact shoulder-chest orthosis, shoulder pad lifts, or a U-shaped neck roll may provide additional support against neck extension, but they have yet to show reduction in risk of nerve injury. 4

References

  1. Clancy JR, William G., Robert L. Brand, and John A. Bergfield. “Upper trunk brachial plexus injuries in contact sports.” The American journal of sports medicine 5.5 (1977): 209-216.
  2. Kepler CK, Vaccaro AR. Injuries and abnormalities of the cervical spine and return to play criteria. Clin Sports Med. 2012 Jul;31(3):499-508. doi: 10.1016/j.csm.2012.03.005. Epub 2012 Apr 5. PMID: 22657998.
  3. Bowles DR, Canseco JA, Alexander TD, Schroeder GD, Hecht AC, Vaccaro AR. The Prevalence and Management of Stingers in College and Professional Collision Athletes. Curr Rev Musculoskelet Med. 2020 Dec;13(6):651-662. doi: 10.1007/s12178-020-09665-5. PMID: 32691363; PMCID: PMC7661678.
  4. Sallis, R. E., K. Jones, and W. Knopp. “Burners: offensive strategy for an underreported injury.” Physician and sports medicine 20.11 (1992): 47-55.
  5. Charbonneau, Rebecca ME, Sonja A. McVeigh, and Kara Thompson. “Brachial neuropraxia in Canadian Atlantic University sport football players: what is the incidence of “stingers”?.” Clinical journal of sport medicine 22.6 (2012): 472-477.
  6. Tosti, Rick, et al. “Burners, Stingers, and Other Brachial Plexus Injuries in the Contact Athlete.” Operative Techniques in Sports Medicine 24.4 (2016): 273-277.
  7. Chung AS, Makovicka JL, Hassebrock JD, Patel KA, Tummala SV, Deckey DG, Hydrick TC, Rubel NC, Chhabra A. Epidemiology of Cervical Injuries in NCAA Football Players. Spine (Phila Pa 1976). 2019 Jun 15;44(12):848-854. doi: 10.1097/BRS.0000000000003008. PMID: 30830045.
  8. Qureshi, Sheeraz A., and Andrew C. Hecht. “Burner syndrome and cervical cord neuropraxia.” Seminars in Spine Surgery. Vol. 22. No. 4. WB Saunders, 2010.
  9. Meyer, Scott A., et al. “Cervical spinal stenosis and stingers in collegiate football players.” The American journal of sports medicine 22.2 (1994): 158-166.
  10. Kelly, John D., et al. “Association of burners with cervical canal and foraminal stenosis.” The American journal of sports medicine 28.2 (2000): 214-217.
  11. Chao, Simon, Marisa J. Pacella, and Joseph S. Torg. “The pathomechanics, pathophysiology and prevention of cervical spinal cord and brachial plexus injuries in athletics.” Sports medicine 40.1 (2010): 59-75.
  12. Presciutti, Steven M., et al. “Mean subaxial space available for the cord index as a novel method of measuring cervical spine geometry to predict the chronic stinger syndrome in American football players.” Journal of Neurosurgery: Spine 11.3 (2009): 264-271.
  13. Greenberg, Jared, Dan Leung, and Jenny Kendall. “Predicting chronic stinger syndrome using the mean subaxial space available for the cord index.” Sports health 3.3 (2011): 264-267.
  14. Boden, SCOTT D., et al. “Abnormal magnetic-resonance scans of the cervical spine in asymptomatic subjects. A prospective investigation.” JBJS 72.8 (1990): 1178-1184.
  15. Levitz, Craig L., Philip J. Reilly, and Joseph S. Torg. “The pathomechanics of chronic, recurrent cervical nerve root neurapraxia: the chronic burner syndrome.” The American journal of sports medicine 25.1 (1997): 73-76.
  16. Viikari-Juntura, E., M. Porras, and E. M. Laasonen. “Validity of clinical tests in the diagnosis of root compression in cervical disc disease.” Spine 14.3 (1989): 253-257.
  17. Standaert, Christopher J., and Stanley A. Herring. “Expert opinion and controversies in musculoskeletal and sports medicine: stingers.” Archives of physical medicine and rehabilitation 90.3 (2009): 402-406.
  18. Speer, Kevin P., and Frank H. Bassett III. “The prolonged burner syndrome.” The American journal of sports medicine 18.6 (1990): 591-594.
  19. Concannon, Leah G. MD1; Harrast, Mark A. MD1,2; Herring, Stanley A. MD, FACSM1,2,3,4 Radiating Upper Limb Pain in the Contact Sport Athlete, Current Sports Medicine Reports: January/February 2012 – Volume 11 – Issue 1 – p 28-34. doi: 10.1249/JSR.0b013e318240dc3f
  20. R.C. Cantu. Stingers, transient quadriplegia, and cervical spinal stenosis: return to play criteria. Med Sci Sports Exerc, 29 (7 Suppl) (1997), pp. S233-S235
  21. Huang P, Anissipour A, McGee W, Lemak L. Return-to-Play Recommendations After Cervical, Thoracic, and Lumbar Spine Injuries. Sports Health. 2016 Jan; 8(1): 19–25.
  22. S. Paulus, D.J. Kennedy. Return to play considerations for cervical spine injuries in athletes. Phys Med Rehabil Clin N Am, 25 (4) (2014), pp. 723-733
  23. A.R. Vaccaro, B. Watkins, T.J. Albert, et al.. Cervical spine injuries in athletes: current return-to-play criteria. Orthopedics, 24 (7) (2001), pp. 699-703
  24. Weinstein SM. Assessment and rehabilitation of the athlete with a “stinger”: a model for the management of noncatastrophic athletic cervical spine injury. Clin Sports Med 1998;17(1):127–35.
  25. Leung, Daniel, et al. “Cervical transforaminal epidural injection in the management of a stinger.” PM&R 4.1 (2012): 73-77.

Original Version of the Topic

Yin-Ting Chen, MD, D.J. Kennedy, MD. Stingers and Burners. 9/20/2013.

Previous Revision(s) of the Topic

Alexa Royston, MD, Lindsay Ramey, MD. Stingers and Burners. 2/14/2018.

Author Disclosures

David Pilkington, DO
Nothing to Disclose

Albert Chang, MD
Nothing to Disclose

Katie Smolinski, DO
Nothing to Disclose

Jami Montagnino, MD
Nothing to Disclose

Christopher McMullen, MD
Nothing to Disclose