Burners and Stingers – Causes, Classifications and Treatment

Definition

Burners and stingers are a term commonly used in sports, particularly contact sports like American football, rugby, and wrestling. It refers to a temporary and usually intense burning or stinging sensation that athletes experience after a forceful impact or collision, typically involving the head, neck, or shoulder region. The sensation is often described as a sharp pain that radiates down the arm, and it is caused by compression or stretching of the brachial plexus, a network of nerves that control the muscles of the arm and hand. This nerve compression or stretch occurs when the head and neck are forcefully tilted to one side, leading to a sudden and transient injury. Burners and stingers are generally not considered serious injuries, and athletes typically recover fully with time. However, recurrent incidents may warrant further medical evaluation to ensure the long-term health and well-being of the athlete.

Epidemiology of burners and stingers

Stingers are most commonly seen in football players, but can also be seen in hockey, lacrosse, and rugby players. This is because the mechanism of injury is usually forced rapid lateral neck flexion, which can occur during tackling and can cause traction or compression injuries to the brachial plexus. It is estimated that over 50% of football players have reported at least one stinger during their career. The true prevalence of this condition is not known, mainly due to its transient nature and the tendency of players to not report or underreport their symptoms.

Mechanism of Injury

Stingers and burners typically result from contralateral flexion of the neck with depression of the ipsilateral arm (brachial plexus type of stretch injury) but may also be caused by extension compression of a nerve root at the cervical foramen, ipsilateral flexion with simultaneous extension of the neck, compression of an existing nerve root at the neural foramen, or a direct blow to the brachial plexus. For example, a football player’s shoulder pad may pinch the brachial plexus and may press the nerves against the superior medial scapula in a point where they are vulnerable (Erb’s point).

The blow from an opponent’s helmet or shoulder pad may injure the nerve tissue between the player’s scapula and his own shoulder pads. In hockey or lacrosse, this may happen as well if a player is hit on the shoulder with someone else’s stick. Compression has been found to be the most common mechanism among college-age subjects. Because younger players have yet to develop predisposing spinal conditions, they tend to have stretch stingers rather than compression stingers.

Pathophysiology of burners and stingers

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. The role of intrinsic anatomical abnormalities is controversial. The neuroforamina and the central canal are narrowed when the neck is in extension and rotation. 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. Similarly, increased risk of burners has been reported high school athletes with central canal or neuroforaminal stenosis.

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. 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. 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.

Classifications of stingers and burners 

Regardless of the classification of the injury, the athlete will experience similar type of symptoms including “sudden, severe burning pain that radiates” down the arm and may have associated “degrees of numbness, weakness, and neck pain”. There are three classifications of brachial plexus stingers beginning with the mildest classification as a Grade I injury and progressing in severity through to a Grade III injury.

Grade 1

Grade one injury is called a neuropraxia injury and results in a temporary loss of sensation and/or loss of motor function (ability to use muscles). This is thought to occur due to a localized conduction block in the nerve bundle that prevents the flow of information from the spinal cord to the innervated areas. Because this is only a “block”, the symptoms are transient and may only last from several minutes to several days.

Grade 2

Grade two injuries are more significant injuries because there may be actual damage to the nerves known as axonotmesis. Axonotmesis is defined as damage to the axon of the nerve without severing the nerve. These types of injuries may produce significant motor and/or sensory deficits that last at least two weeks. Because growth of an injured axon is a very slow process (a rate of 1 to 2 mm per day), it takes several weeks for the regrowth to occur. However, once the regrowth has occurred, full function of the athlete’s motor and sensory functions are restored.

Grade 3

The most severe plexus injury is a grade three injury. Athletes with these types of injuries may not have a full recovery and may be considered to have sustained a catastrophic injury because the neurological symptoms may last up to one year. A Grade III is known as a neurotmesis injury and is defined as a complete severance of the nerve. Athletes who have sustained this type of injury have a poor prognosis and may need surgical intervention.

Symptoms of burners and stingers

Burners and stingers share similar symptoms since they are both types of brachial plexus injuries. The primary symptoms include:

• Intense Pain: The hallmark symptom is a sudden and severe shooting pain that runs from the neck and travels down the arm. This pain is often described as burning, electric shocks, or tingling sensations.
• Numbness and Tingling: The affected arm may experience numbness and tingling sensations, making it feel weak or “asleep.”
• Weakness: There may be a noticeable weakness in the affected arm, making it challenging to perform tasks that require grip strength or arm movement.
• Loss of Sensation: Some individuals may experience a loss of sensation in parts of the arm or hand.
• Shoulder and Neck Pain: In addition to arm symptoms, there may be accompanying pain in the shoulder and neck region.
• Transient Symptoms: Symptoms of burners and stingers are often temporary and last for a few seconds to several minutes. However, in severe cases, the symptoms may persist for an extended period.

Causes of burners and stingers

Burners and stingers are primarily caused by trauma or injury to the brachial plexus, a network of nerves that originate from the spinal cord in the neck and control the muscles of the shoulder, arm, and hand. The most common causes include:

Forceful Tackling or Collision:

In contact sports such as American football, rugby, or wrestling, a forceful impact or collision can result in the head and neck being suddenly and forcefully tilted to one side. This movement can lead to compression, stretching, or pinching of the brachial plexus nerves, causing the characteristic burning or stinging sensation.

Neck Extension or Lateral Flexion:

The brachial plexus can be affected when the head is forcibly extended backward or tilted to the side, causing a stretching or compressive force on the nerves. This can occur during tackles, falls, or other athletic maneuvers where the head and neck are subjected to sudden and forceful movements.

Direct Trauma to the Shoulder:

Impact or trauma directly to the shoulder region, such as a blow or collision, can also contribute to burners and stingers. The force transmitted to the shoulder can affect the brachial plexus nerves, leading to symptoms.

Repetitive Overhead Movements:

In some cases, athletes who engage in repetitive overhead movements, such as throwing in sports like baseball or swimming, may be at an increased risk of developing burners and stingers due to chronic stress on the brachial plexus.

Abnormal Anatomy or Nerve Entrapment:

Some individuals may have variations in the anatomy of the neck or shoulder that predispose them to nerve compression or entrapment, increasing the likelihood of experiencing burners and stingers.

While burners and stingers are often transient and resolve without long-term consequences, recurrent episodes or persistent symptoms may necessitate further evaluation to rule out underlying issues and ensure appropriate management.

Complications of burners and stingers

While burners and stingers are often temporary and resolve without long-term consequences, recurrent or severe episodes can lead to complications. Here are some potential complications associated with burners and stingers:

Nerve Damage: Severe or repeated burners/stingers can harm nerves, leading to lasting weakness or numbness in the affected arm.

Chronic Pain: Ongoing pain may persist in the arm or shoulder, impacting daily life and sports activities.

Decreased Range of Motion: Long-term or frequent burners/stingers might result in reduced neck, shoulder, or arm movement.

Functional Impairment: Serious injuries may limit daily activities and sports performance, requiring therapy for functional recovery.

Psychological Impact: The experience of chronic or severe injuries can cause anxiety, fear of reinjury, or reduced confidence in physical activities.

Recurrence: Without proper care, there’s a higher chance of burners/stingers happening again, potentially causing more damage.

Risk factors of burners and stingers

Several factors can increase the risk of experiencing burners and stingers, especially in the context of sports and physical activities. Common risk factors include:

• Playing Contact Sports: Engaging in sports like football, rugby, or wrestling, where there’s frequent physical contact, increases the risk.
• Position and Style of Play: Certain playing positions or aggressive styles may raise the chances of experiencing burners and stingers.
• Poor Conditioning: Not having strong neck and shoulder muscles increases vulnerability to these injuries.
• Previous History: Having experienced burners and stingers before may increase the risk of recurrence.
• Neck Structure: Specific neck or shoulder structures may make individuals more prone to nerve compression.
• Repetitive Movements: Sports involving repeated overhead movements, like throwing, may heighten the risk.
• Lack of Protection: Inadequate or incorrectly used protective gear, such as helmets, may contribute to increased risk.
• Poor Technique: Incorrect tackling or collision techniques can raise the likelihood of head and neck injuries.
• Age and Gender: Younger athletes, especially males, may be more susceptible, as their bodies are still developing.

Understanding these factors helps in taking steps to prevent burners and stingers, including targeted exercises, proper training, and the use of protective gear.

Diagnosis

The diagnosis of burners and stingers typically involves a combination of clinical evaluation, medical history assessment, and, if necessary, diagnostic tests. Here’s how the diagnosis is typically approached:

Clinical Evaluation

A healthcare professional, such as an orthopedic specialist or a sports medicine physician, will conduct a thorough examination. The examination includes assessing the individual’s symptoms, such as the nature and location of pain, weakness, or numbness, and any specific events or activities that trigger the symptoms.

Medical History

Gathering information about the individual’s medical history is crucial. This includes details about previous burners and stingers, overall health, and any relevant pre-existing conditions.

Neurological Examination

The healthcare provider will perform a neurological examination to assess the function of the nerves in the affected area. This may involve testing muscle strength, sensation, and reflexes in the neck, shoulder, arm, and hand.

Imaging Studies

In most cases, burners and stingers do not require imaging studies. However, if symptoms are severe, prolonged, or recurrent, the healthcare provider may order imaging studies, such as magnetic resonance imaging (MRI). MRI can provide detailed images of the spinal cord, nerve roots, and surrounding structures, helping to identify any compression or damage to the brachial plexus.

Electrodiagnostic Tests

Electromyography (EMG) and nerve conduction studies may be conducted to assess the electrical activity of muscles and nerves. These tests can help determine the extent of nerve involvement and identify any areas of nerve compression or dysfunction.

X-rays

X-rays are typically not very helpful in diagnosing burners and stingers, but they may be performed to rule out other potential causes of symptoms, such as fractures or dislocations.

It’s essential for individuals experiencing symptoms of burners and stingers to seek medical attention for a proper diagnosis.

Treatment

The treatment for burners and stingers varies based on the severity of the symptoms. In most cases, conservative approaches are effective, but more severe or persistent cases may require additional interventions. Here are common treatments for burners and stingers:

Rest and Activity Modification

Immediate rest is often recommended to allow the nerves to recover. Avoidance of activities or movements that triggered the symptoms is crucial during the initial phase of recovery.

Ice Application

Applying ice to the affected area can help reduce inflammation and alleviate pain. Ice can be applied for about 15-20 minutes every 2-3 hours during the first 48 hours after the injury.

Pain Medications

Over-the-counter pain relievers, such as nonsteroidal anti-inflammatory drugs (NSAIDs), may be used to manage pain and inflammation. Always follow recommended dosages and consult with a healthcare professional if there are any concerns.

Physical Therapy

A physical therapist may prescribe specific exercises to improve strength, flexibility, and range of motion in the affected area. Physical therapy can help in the rehabilitation process and reduce the risk of recurrence.

Gradual Return to Activity

Once symptoms have significantly improved, a gradual return to sports or activities is typically recommended. This should be done under the guidance of a healthcare professional to ensure a safe and gradual reintroduction of physical activity.

Protective Equipment

In some cases, wearing protective equipment, such as neck rolls or collars, may be advised to reduce the risk of recurrent burners and stingers.

Cervical Collar

A soft cervical collar may be recommended in some cases to limit neck movement and provide support during the initial recovery period.

Corticosteroid Injections

In cases where there is significant inflammation and pain, a healthcare provider may consider corticosteroid injections to reduce inflammation around the affected nerves.

Surgery (Rare)

Surgery is rarely needed for burners and stingers and is typically reserved for severe cases with persistent symptoms and evidence of structural issues compressing the nerves.

It’s important for individuals experiencing burners and stingers to consult with a healthcare professional for personalized advice and treatment. Early intervention and appropriate care can contribute to a faster and more complete recovery.

Prevention of burners and stingers

You can help prevent a sports injury in your child by:

• Having your child be in good physical shape for playing sports. They should have a preseason physical. You may want to ask your child’s healthcare provider about the sports physical exam called the preparticipation physical evaluation.
• Having your child wear sport-appropriate protective padding and gear for every practice and game.
• Checking that protective padding and gear is in good condition before every practice and game.
• Having your child do warm-up and cool down exercises before and after practice or a game.
• Teaching your child to know and pay attention to signs of injury. This will help them take a break before pain gets worse.
• Putting emphasis on good sportsmanship so that athletes don’t get hurt because of personal conflicts.