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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.

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

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.

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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.

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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.

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.

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.

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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

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

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:

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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.

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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

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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.

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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.

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.

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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

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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.

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

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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.

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.

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

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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.

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

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

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.

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