[PPT] - 12/9/2016 CHANG CJ Disclosures I have nothing to disclose UCSF 11 PowerPoint Presentation

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UCSF 11th Annual Primary Care Sports Medicine Conference: Upper Extremity

Stingers, Burners, and Winging: Nerve Injuries of the Upper Extremity

Cindy J. Chang, M.D.

Associate Professor Primary Care Sports Medicine December 9, 2016

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Disclosures

I have nothing to disclose

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Objectives

Review common upper extremity nerve injuries

seen in athletes

Discuss return to play issues concerning

specific upper extremity nerve issues

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Exam Room Tips

Stock gowns/sheets and paper shorts in the room
Be able to get to both sides of the exam table
Have a step stool handy

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Case #1

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Case #1

1994 AFC Championship Game
San Diego Charger upset the favored Pittsburgh

Steelers 17-13

Junior Seau recorded 16 tackles and a forced

fumble despite:

– Not being able to lift his arm above his shoulder – Playing with a bad left shoulder – Having a pinched nerve in his neck

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“Arm not fine? First Clear the Spine!”

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Taking a Really Good History

Chief complaint -- eg, pain, numbness,

weakness, location of symptoms?

Use a visual analogue scale -- patient's

perceived level of pain

Anatomic pain drawings -- quick review of

pain pattern.

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12/9/2016 3 Taking a Really Good History

Onset, mechanism, what was done at that time?
How do activities and head positions affect

symptoms? In what position does patient sleep? Ever wake up with pain?

Social history: sport/position, occupation, field
f study, amount of computer use, ergonomic

set-up, alcohol and tobacco use

What previous treatments (prescribed or self-

selected) has the patient tried?

– ice and/or heat – Medications (eg, acetaminophen, aspirin, nonsteroidal anti-inflammatory drugs [NSAIDs]) – Physical therapy, traction, manipulation, acupuncture – Injections, surgical treatments

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Taking a Really Good History

Has the patient experienced previous episodes of

similar symptoms or localized neck pain? When and for how long? What helped? Other spine pain?

Any symptoms suggestive of a cervical myelopathy,

e.g., changes in gait, bowel or bladder dysfunction, or sensory changes or weakness of the legs?

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OLDCARTS

Onset
Location
Duration
Character
Aggravating/Alleviating
Radiation
Timing/Treatments
Severity

www.fammedref.org/mnemonic/pain- hx-old-carts-p

MS OLDCARTS

Mechanism of Injury Symptoms Onset Location Duration Character Aggravating/Alleviating Radiation Timing/Treatments Severity

www.fammedref.org/mnemonic/pain- hx-old-carts-p

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Typical Hx of Cervical Radiculopathy

Presents with neck

and/or arm discomfort

f insidious onset

– range from a dull ache to a severe burning pain

Initially, pain referred to

medial border of scapula

– chief complaint may be shoulder pain

As radiculopathy

progresses, pain radiates to upper or lower arm and into the hand

– along sensory distribution

f the involved nerve root

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Typical Hx of Cervical Radiculopathy

Acute disc herniations and sudden narrowing of

the neural foramen can occur in injuries involving cervical extension, lateral bending, or rotation and axial loading

Increased pain with these neck positions that

cause foraminal narrowing

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Cervical Radiculopathy

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If you think it’s Cervical Radiculopathy…

MRI most useful imaging choice
C-spine xrays including oblique views (“5

views”) may show degenerative changes – Order “7 views” if h/o trauma to neck

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Eubanks JD, AFP 2010

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If you think it’s Cervical Radiculopathy…

Most patients <35 will do well with a trial of

conservative management (time, meds, rehab/modalities).

Emphasize time. Emphasize activity.

Emphasize posture. Emphasize restful

sleep. Emphasize time.

The art of medicine consists of amusing the patient while nature cures the disease.”

Voltaire

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Eubanks JD, AFP 2010

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Emphasize Posture

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Case #1

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Case #1

After making a tackle, the football player jogs off without assistance, but is carrying his left arm with his right. You question him on the sideline. Which

f the following symptoms do NOT make you think

this is a stinger?

A. He describes a burning type of pain
B. He describes weakness in only his

wrist extensors

C. He feels numbness in both arms
D. He is having neck pain

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3% 17% 47% 33%

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12/9/2016 6 “ “ “ “Burners/Stingers” ” ” ”

Definition:

– Nerve injuries resulting from trauma to neck or shoulder area – Cause a traction or compression along brachial plexus or cervical neck roots.

Diagnosis

– Immediate onset of burning pain down the arm unilaterally – Can be associated with numbness

r weakness
Lasts seconds to hours

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Safran MR, AJSM 2004

“ “ “ “Burners/Stingers” ” ” ”

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“ “ “ “Burners/Stingers” ” ” ”

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“ “ “ “Burners/Stingers” ” ” ”

Risk factors

– Contact sports – Spinal stenosis

Symptoms

– Usually last seconds to minutes – In 5-10%, can last hours to days or longer – Burn, electric shock, warmth, tingly – Numbness, weakness

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“ “ “ “Burners/Stingers” ” ” ”

Work-up if:

– Weakness lasts several days – Recurrent burners/stingers – Neck pain – Atypical symptoms, e.g. bilat UE

Tests

– Radiographs to include flexion/extension views,

bliques

– MRI C-Spine – EMG/NCS if > 3 weeks post injury and weakness

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Case #2

35 yo dragon boat racer walks into clinic to request a prescription for physical therapy for her “rotator cuff tendinitis”. You do a very quick exam and she is weak when testing all of her rotator cuff muscles. What should you do next?

A. Order an Xray
B. Check her sensation over her deltoid

region

C. Visually inspect her shoulder girdle
D. Write the prescription but limit to 3

wks with strict follow-up

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6% 5% 50% 39%

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Scapular Winging

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The Role of the Scapula

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Scapula serves as the attachment site for 17

muscles

function to stabilize scapula to thorax, provide

power to the upper limb, and synchronize glenohumeral motion.

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Scapular Motion

Elevation and upward rotation: trapezius
Scapular protraction (anterior and lateral motion):

serratus anterior, pectoralis major and minor muscle

Scapular retraction (medial motion): rhomboid major

and minor muscles

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Scapular Stabilizer

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Scapular Winging

Long Thoracic Nerve

(LTN) is branch of brachial plexus C5, 6, 7

Seen in pectoral region
n surface of serratus

anterior, just behind mid-axillary line

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Scapular Winging

Observe active forward

flexion and abduction from behind patient

Watch for scapular winging
n descent
Dysfunction also common

with rotator cuff tears and instability

Wall push up – for more

pronounced winging seen with Long thoracic Nerve injury

– serratus anterior palsy

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Scapular Winging - LTN

Mechanisms of injury to long thoracic nerve

– iatrogenic from anesthesia

10% had prior surgery

– repetitive stretch injury (most common)

increased risk with head tilted away during
verhead arm activity

– compression injury

direct compression of nerve at any site

– scapula fracture

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Nawa S, J Brach Plex Periph Nerve Inj 2015

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Scapular Winging – LTN - Treatment

Nonoperative

– observation, bracing, and strengthening

observation minimum 6 months for nerve to recover
Operative

– pectoralis transfer; decompression, neurolysis, and tetanic electrical stimulation

failure of spontaneous resolution after 1-2 years

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Nath RK et al, BMC Musculoskeletal Disorders 2007

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Case #3

22 yo RHD woman presents with increasing right shoulder pain despite doing rehab exercises diligently every day. This is what you see on

bservation:

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Case #3

She plays outside hitter on a volleyball team which increased practices to 5x/wk a month ago preparing for nationals. You suspect what pathology?

A. Suprascapular nerve entrapment at the suprascapular notch resulting in atrophy of the supraspinatus B. Suprascapular nerve entrapment at the spinoglenoid notch resulting in atrophy of the infraspinatus and teres minor C. Suprascapular nerve entrapment at the suprascapular notch resulting in atrophy of the supraspinatus and infraspinatus D. Suprascapular nerve entrapment at the spinoglenoid notch resulting in atrophy of the infraspinatus

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8% 26% 31% 35%

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Suprascapular Neuropathy

If atrophy of both

infraspinatus and supraspinatus

– Compressed at suprascapular notch

Only atrophy of

infraspinatus

– Compressed at spinoglenoid notch – Traction injury

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Suprascapular Neuropathy

Atrophy of both

– Surgical decompression – Release of transverse scapular ligament at suprascapular notch

Atrophy of

infraspinatus

– Decompress ganglion, paralabral cyst at spinoglenoid notch – Release spinoglenoid ligament

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Suprascapular Neuropathy

Non-operative Treatment

– Activity modification, formal shoulder rehab program – Rehab performed for a minimum of 6 months – EMG/NCS

Operative

– Structural lesion seen on MRI (cyst, labral tear) – Nerve decompression if failure of extended nonoperative management (~ 1 year)

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Safran MR, AJSM 2004

Burners/Stingers, Winging and other Nerve Injuries of the Upper Extremity

Return to Play

– Pain resolved – Full pain-free neck and upper extremity ROM – Normal strength

preferably compared with

preseason baseline

– Normal reflexes – Negative Spurling’s test – Negative imaging studies

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Huang P et al, Sports Health 2015

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Burners/Stingers, Winging and other Nerve Injuries of the Upper Extremity

Absolute contraindication to RTP

– Symptomatic disc herniation

Relative contraindication to RTP

– Prolonged symptomatic burner/stinger lasting >24° – ≥ 3 stingers; must have full return of ROM, normal strength, and no baseline discomfort

No contraindication to RTP

– Degenerative disc disease; only occasional neck stiffness and pain and no changes in baseline neurological status – < 3 episodes of a stinger lasting <24° with full ROM and no neurological deficit

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Cantu RC et al, CSMR 2013

Burners/Stingers, Winging and other Nerve Injuries of the Upper Extremity

Return to Play – no

universally accepted criteria

– Can the athlete protect themself from further injury? – Can the athlete successfully play their sport? – Long term and short term risks vs. benefits?

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Creighton DW et al, CJSM 2010

Burners/Stingers, Winging and other Nerve Injuries of the Upper Extremity

Prevention

– Proper technique – Neck and shoulder girdle strengthening – Balance (core) training – Additional protective padding

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“You don't stop exercising because you grow old. You grow old because you stop exercising.”

Anonymous

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