Brachial plexus injuries in the contact athlete: a narrative review

Abstract

Background and objective: Brachial plexus injuries (BPIs) are a rare but potentially devastating injury among contact athletes. More common injuries, such as "burners" or "stingers", indicate a temporary and less severe insult to either the nerve roots or plexus. The aim of this review is to discuss this spectrum of injuries in their epidemiology, mechanism in contact sports, diagnosis, and treatment.

Methods: This literature review utilized key terms to search manuscripts available in English from inception to October 2024 within three research databases.

Key content and findings: BPIs among contact athletes occur on a spectrum from neuropraxia to neurotmesis. Neuropraxia is very common among contact athletes with approximately a 49-65% incidence among career football players with the most common mechanism being a traction injury. Most of these resolve within minutes to hours. Axonotmesis and neurotmesis can be far more severe injuries and require further investigation if not resolved by 2-3 weeks. The majority of athletes who suffer neuropraxic injuries will return to sport with minimal to no time missed, however, more severe injuries portend variable outcomes.

Conclusions: BPIs are common among contact athletes and involve a spectrum of nerve damage, of which most are self-limiting. However, further evaluation is warranted when symptoms last beyond 2-3 weeks. Future studies should focus on treatment algorithms and long-term outcomes, including return to sport.

Keywords: Brachial plexus injury (BPI); burner; contact athletes; sports; stinger.

Figure 1

Erb’s point is the confluence of the C5 and C6 roots to form the upper trunk. It is a common site of traction with the forced depression of the ipsilateral shoulder and lateral flexion of the neck (arrows). It also is a notable point of contact in injuries resulting from direct compression of the nerve.

Figure 2

The brachial plexus as it originates from the cervical spinal roots C5–C8 and T1. The upper, middle, and lower trunks, the anterior and posterior divisions, lateral, medial, and posterior cords, and the terminal branches. Erb’s point as the point of confluence of C5 and C6 spinal roots.

Figure 3

The neuronal axon is surrounded by the collection of Schwann cells that make up the myelin sheath. These axons are surrounded by the endoneurium and then bundled together by the perineurium into fascicles. These fascicles are organized and contained by the epineurium. The blood supply to the nerve (vasa nervorum) is contained in the epineurium layer.

Figure 4

Brachial plexus on field evaluation and management. Cervical spine injury is critical for safe player evaluation prior to exiting the field. Return to play should only occur in the patient with full resolution of any neurologic symptoms, pain, a negative concussion evaluation, and no indication for spinal imaging by NEXUS criteria (33). CT, computed tomography; EMG, electromyography; MRI, magnetic resonance imaging; NEXUS, National Emergency X-Radiography Utilization Study.