What is the management and treatment for a stinger (brachial plexus injury)?

Management and Treatment for Stingers (Brachial Plexus Injury)

For stingers (brachial plexus injuries), immediate rest and removal from activity until symptoms resolve completely is the primary treatment approach, followed by a gradual return to activity only after normal neurological examination and full range of motion are documented.

Initial Assessment and Management

• Stingers are episodic unilateral peripheral nervous system dysfunction, secondary to compressive or traction-type nerve root or brachial plexus trauma, causing burning, stinging, weakness and pain that typically lasts minutes to hours 1
• Athletes should not return to competition until all abnormal neurologic signs disappear 2
• Most guidelines allow return to play (RTP) only after symptoms completely resolve and there is documented normal neurologic examination with full active range of motion 1
• If symptoms persist for more than 5 minutes, further medical evaluation is warranted before return to play 1

Immediate Treatment

• Rest and removal from activity until symptoms resolve 3
• Ice application can be useful for local pain relief 1
• Over-the-counter acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) can be used to alleviate pain 1
• If the skin is intact, topical lidocaine can help relieve local pain 1

Return to Play Guidelines

• Symptomatic stingers lasting less than 5 minutes may allow return to play after symptoms resolve and normal examination is documented 1
• Episodes lasting greater than 5 minutes warrant further medical consideration before return to play 1
• Advanced imaging (MRI) is recommended after a second stinger event, even if the initial event had rapid symptom resolution 1
• Athletes with a history of cervical spine pathology warrant a screening MRI prior to collision sports participation 1

Diagnostic Considerations

• Electromyography (EMG) and nerve root stimulation studies may be necessary to delineate the lesion in recurrent or persistent cases 4
• Many stingers initially diagnosed as lateral stretch of brachial plexus are actually C6 radiculopathies 2
• The most common mechanism of injury is compression of the fixed brachial plexus between the shoulder pad and superior medial scapula, rather than traction from lateral neck flexion 4

Rehabilitation Approach

• Rehabilitation should focus on:
  • Range of motion exercises 5
  • Strengthening of affected muscles 5
  • Sensory training if sensory deficits are present 5
  • Neuromuscular electrical stimulation may be beneficial in some cases 5

Prevention Strategies

• Appropriate counseling on tackling technique modification 3
• Addition of protective gear or orthoses designed to protect the brachial plexus from compressive forces 4, 3
• Complete rehabilitation before return to full activity 3

When to Seek Advanced Medical Care

• Emergency services should be called if symptoms extend beyond the affected arm or include difficulty breathing, dizziness, or confusion 1
• Medical care should be sought if:
  • Pain extends beyond the site of injury 1
  • Pain becomes severe and is not controlled by over-the-counter medications 1
  • Symptoms persist beyond 24 hours 3
  • Multiple stinger episodes occur 1

Common Pitfalls to Avoid

• Allowing return to play before complete symptom resolution 2
• Failing to recognize that recurrent stingers may indicate underlying cervical spine pathology 1
• Delaying advanced imaging after multiple stinger episodes 1
• Underestimating the potential for long-term nerve damage with repeated injuries 3

Special Considerations

• Cervical canal stenosis with concurrent degenerative disc disease may predispose athletes to stinger injuries 3
• The athlete, family, and coaches need to understand that recurrence remains unpredictable 3
• Long-term outcomes are generally favorable with proper management, but repeated injuries may lead to chronic symptoms 6