Rehabilitation Following Brachial
Plexopathy
“Stingers”
Scott Kaylor, PT, DPT, SCS
Proaxis Therapy
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Acknowledgements
➔ Timothy
McHenry III, MD
➔ Whitney Wiles, ATC
➔ Matthew Baird, MD
➔ Tom Denninger, PT, DPT, OCS, FAAOMPT
➔ Chuck Thigpen, PhD, PT, ATC
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Objectives
➔ To
identify the prevalence of brachial
plexopathy.
➔ To identify the anatomy involved with brachial
plexopathy injury.
➔ To describe an evidence-based return-to-play
progression that is criteria driven.
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Prevalence and Incidence
➔ Common
in contact and collision sports.
➔ Reported annual incidence of a stinger is
between 49-65% in collegiate-level football
players over a 4-year career
➔ Recurrence rate 57%
➔ 5-10% of players have more serious injuries
with prolonged neurological deficits
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Signs and Symptoms
➔
➔
➔
➔
➔
Common
Unilateral UE involvement
A traumatic event
Painful sensation that
radiates from their neck to
their finger tips
Lancinating, burning pain,
and dysesthesia usually in a
dermatomal pattern.
Weakness/”dead arm”
Red Flags
➔
➔
Bilateral symptoms or symptoms
into more than one limb.
o Suspect spinal cord
involvement
If the player remains on the “field
of play” the possibility of a spinal
cord injury must be considered
and ruled out before he is
allowed to walk.
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Symptom Duration
➔ Pain
o
typically seconds to hours.
Rarely beyond 24-hours
➔ May
experience weakness in deltoid and
supra/infraspinatus that typically resolves in
24-hours to 6 weeks.
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Injury Grading
➔ Grade
o
neurapraxia
➔ Grade
o
II
axonotmesis
➔ Grade
o
I
III
neurotmesis
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Management
Phase I
Pain control
Restore ROM
Muscle
facilitation
Phase 2
Improve
muscular
endurance
Improve
shoulder
mobility as
needed
Incorporate
extremity
movements
with
stabilization
Phase 3
Phase 4
Improve
muscle
strength
Initiate
contact
drills
Implement
sport specific
activities
without
contact
Return to
play
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Phase I Rehabilitation
➔ Pain
control
➔ Restore cervical ROM
➔ Initial muscle facilitation
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Phase I Rehabilitation
➔ Manual
Therapy
Traction
o Joint mobilization
o Soft tissue mobilization
o
➔ Modalities
Traction
o E-stim
o
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Phase I Rehabilitation
➔ 1st
Rib Mobilization
Elevated 1st rib due to scalene spasm
o Assess with cervical rotation lateral
flexion test
o
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Phase I Exercise Examples
➔ Supported
o
chin tucks
With biofeedback
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Phase I Rehabilitation
➔ Neural
Dynamics
Sliders vs. tensioners to
increase excursion
o Do NOT want to increase
strain during healing
o
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Phase I Rehabilitation
➔ Cervical
o
ROM
Adjust and progress positioning
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Criteria to Begin Phase II
➔ Full
cervical ROM
➔ Resolution of upper extremity symptoms
o
Not necessarily full resolution of strength
➔ Be
able to maintain a supine chin tuck for 30
seconds
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Phase II Rehabilitation
➔ Improve
shoulder mobility as needed
➔ Improve muscular endurance
➔ Incorporate extremity movements with
stabilization.
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Phase II Rehabilitation
➔ Shoulder
mobility
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Phase II Exercise Examples
➔ Quadruped
and prone chin tucks
➔ Cervical stabilization with extremity movements
o
o
“No Money”
Dying bug
➔ Half
kneel chop and lift
➔ Upper extremity exercises
o
o
o
Bands
PNF
Isotonics
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Phase II Exercise Examples
➔ Shoulder
Strengthening
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Phase II Exercise Examples
➔ Half
Kneel Chop and Lift
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Criteria to Begin Phase III
➔ Be
able to hold chin tuck with head lift
(without helmet) for 30 seconds
➔ > 4/5 upper extremity strength to be able to
perform light-to-moderate upper extremity
strengthening without symptoms
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Phase III Rehabilitation
➔ Improve
muscular strength
➔ Implement sport specific activities without
contact
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Phase III Exercise Examples
➔ Cervical
Strengthening
➔ Participation in weight lifting with team
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Phase IV Rehabilitation
➔ Criteria
to begin phase IV
Be able to maintain a chin tuck with head lift
wearing a helmet > 30 seconds
o No symptoms
o Full upper extremity strength
o
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Phase IV Rehabilitation
➔ Phase
o
IV
Initiate contact drills
• Percussion to Erb’s Point
• Spurling’s Test
o
Return-to-play
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Return to Play Criteria
➔
General RTP Criteria:
o
o
o
o
o
o
o
➔
Adequate time to heal from primary injury
Absence of underlying conditions that pose undue risk of
further injury
Resolution of all symptoms
Full, pain-free ROM
Appropriate cardiovascular fitness
Normal strength
Ability to perform sport-specific skills without symptoms
Same game if complete resolution of symptoms,
return-to-baseline ROM and strength profile.
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Slow-to-No Symptom Resolution
➔ Communication
with and referral to team
physician
➔ Further imaging
o Radiographs
o MRI
o CT scan or SPECT scan
➔ EMG study
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Prevention
➔ Identifying
o
Post-season questionnaire
➔ Proper
o
o
those at risk
tackling techniques
Avoid dropping shoulder
Continued eye contact with opposing player should
allow for more upright position
➔ High
riding shoulder pads to absorb impact
➔ Protective neck rolls
o
o
Prevent excessive lateral flexion & extension of neck
NEVER connect straps from helmet to shoulder pads
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➔ Brachial
Neuropraxia Postseason
Questionnaire
o
Clin J Sport Med. 2012; (22)6
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Key Points
➔ Stingers
are common and history of stinger
increases likelihood of sustaining subsequent
stinger.
➔ Use criteria to drive rehabilitation progressions.
➔ Do not return to play if have not returned to
baseline.
➔ Communication with sports medicine team is
important, particularly in the presence of slowly
resolving symptoms.
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Thank you!
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