What is a stinger (cervical nerve injury)?

What is a Stinger (Cervical Nerve Injury)

A stinger is an episodic unilateral peripheral nervous system dysfunction caused by compressive or traction injury to the nerve root or brachial plexus, characterized by burning, stinging pain, weakness, and dysesthesia in one upper extremity, with symptoms typically lasting minutes to hours before full resolution. 1

Clinical Presentation

• Acute lancinating pain radiating from the neck down one arm to the fingertips
• Sensory symptoms: Burning, stinging, numbness, dysesthesia
• Motor symptoms: Weakness or paralysis in the affected limb (variable)
• Duration: Usually transient, resolving within minutes to hours
• Distribution: Unilateral upper extremity involvement
• Associated findings: May occur with or without neck pain

Mechanism of Injury

Stingers typically occur through two primary mechanisms:

1. Compression mechanism: Direct impact to the supraclavicular region causing compression of the brachial plexus
2. Traction mechanism: Forceful lateral neck flexion away from the affected side with shoulder depression, stretching the brachial plexus

These injuries are most common in contact sports, particularly among:

• Running backs (69% prevalence)
• Defensive linemen (60% prevalence)
• Linebackers (55% prevalence)
• Defensive secondary players (54% prevalence) 2

Evaluation

When a stinger occurs, proper assessment is critical:

1. On-field evaluation:

   • Rule out more serious cervical spine injuries
   • Assess neurological function (strength, sensation)
   • Evaluate range of motion

2. Off-field evaluation:

   • Complete neurological examination
   • Cervical spine and shoulder examination
   • Assessment for biomechanical and postural faults 3

3. Imaging considerations:

   • First-time stinger with rapid symptom resolution: No imaging required
   • MRI should be obtained after a second stinger event 1
   • MRI brachial plexus is the gold standard imaging modality (sensitivity 84%, specificity 91%) 4
   • Imaging should be delayed approximately 1 month after trauma to allow resolution of hemorrhage and edema 4

Return to Play Guidelines

The consensus among experts provides clear guidelines for return to play:

1. For athletes with symptoms lasting <5 minutes:

   • May return to play once symptoms completely resolve
   • Normal neurological examination required
   • Full active range of motion must be present 1

2. For athletes with symptoms lasting >5 minutes:

   • Return to play decisions should be made on a case-by-case basis
   • More thorough evaluation is warranted 1

3. For recurrent stingers:

   • MRI should be obtained after a second stinger event
   • Evaluate for underlying cervical spine pathology 1

Management

Management depends on severity and frequency:

1. Acute management:

   • Rest and activity modification
   • Pain control measures
   • Gentle range of motion exercises within pain-free range

2. Rehabilitation:

   • Progressive strengthening of rotator cuff, scapular stabilizers, and core muscles
   • Address biomechanical issues and muscle imbalances
   • Gradual return to activity with systematic progression 4

3. Prevention strategies:

   • Neck strengthening programs (though evidence for effectiveness is limited) 2
   • Proper tackling technique in contact sports
   • Addressing shoulder laxity if present 5

Important Considerations

• Recurrent stingers require thorough evaluation as they may indicate underlying cervical spine pathology
• Persistent symptoms (pain, weakness, sensory changes) beyond the expected resolution time warrant further investigation
• Children and adolescents can experience stingers even with relatively low-force trauma 6
• Shoulder laxity may predispose individuals to stinger syndrome 5

When to Consider Permanent Removal from Contact Sports

In some circumstances, athletes may need to be permanently restricted from contact sports:

• Multiple recurrent stingers
• Persistent neurological deficits
• Evidence of structural cervical spine abnormalities
• Stinger symptoms that fail to resolve completely 7

Remember that while most stingers resolve completely without long-term sequelae, proper evaluation and management are essential to prevent recurrence and identify potentially more serious underlying conditions.