SPINE CONDITIONS
Radiating Upper Limb Pain in the Contact Sport
Athlete: An Update on Transient Quadriparesis
and Stingers
Leah G. Concannon, MD1; Mark A. Harrast, MD1,2; and Stanley A. Herring, MD, FACSM1,2,3,4
Athletic Association (NCAA) football
players in the 1984 season found an
incidence of TQ of 7.3 per 10,000,
with 6 per 10,000 with sensory symptoms only and 1.3 per 10,000 with
motor and sensory symptoms (29). A
more recent study from 1989 to 2002
found a significantly lower incidence,
with a rate of 0.17 per 100,000 for
high school and 2.05 per 100,000 for
college athletes, with a combined rate
of 0.9 per 100,000 (2). It is unclear
how much of this difference is due to
insufficient reporting of transient symptoms versus a true
decrease in the incidence.
TQ can be divided into three types: plegia (complete loss
of motor function), paresis (motor weakness), and paresthesia (sensory symptoms only). Three grades also have
been described. Grade 1 involves symptoms lasting less than
15 min, grade 2 symptoms last 15 min to 24 hours, and
grade 3 symptoms last longer than 24 h. Symptoms also can
be described by their anatomical distribution: quad (all four
limbs), upper (both arms), lower (both legs), and hemi (one
arm and one leg) (32). TQ is most commonly seen in contact
sports such as American football, wrestling, and ice hockey,
but it can occur in any sport where collisions occur. It is
important for athletes, coaches, and medical personnel to
distinguish between TQ and stingers, which are discussed in
detail below. Any time an athlete complains of neurological
symptoms in more than one extremity, an injury to the
cervical spine must be considered first.
Abstract
Participation in contact sports exposes the athlete to a risk of cervical
spine injury. Temporary neurological injuries manifesting as radiating
arm pain or paresthesias, such as transient quadriparesis and stingers,
present unique challenges for the sports medicine physician and will
be reviewed in detail. The initial management of these conditions must
recognize signs and symptoms of spinal cord injury and prevent further
neurological sequelae. Evaluation will often include advanced imaging of
the cervical spine in addition to serial neurological examinations. This
review concludes with rational return-to-play guidelines for contact sport
athletes.
Introduction
Participation in contact sports exposes the athlete to a
risk of cervical spine injury. These can range from simple
cervical sprains to permanent spinal cord injury. Temporary
neurological injuries, such as those seen in transient quadriparesis (TQ) and stingers, present unique challenges for
the sports medicine physician in terms of initial management, evaluation, and eventual return to play.
Transient Quadriparesis
In the United States, 10% of spinal cord injuries occur
during participation in sports (17). TQ has been known by
many other names, including cervical cord neurapraxia,
burning hands syndrome, commotio spinalis, and spinal
cord concussion. TQ, by definition, is a transient neurological episode encompassing sensory symptoms with or
without motor changes. A survey of National Collegiate
1
Department of Rehabilitation Medicine, University of Washington, Seattle,
WA; 2Department of Orthopaedics and Sports Medicine, University of
Washington, Seattle, WA; 3Spine, Sports and Musculoskeletal Medicine,
University of Washington, Seattle, WA; and 4Seattle Sports Concussion
Program, University of Washington, Seattle, WA
Address for correspondence: Leah Concannon, MD, Department of
Rehabilitation Medicine, University of Washington, Box 359721, 325 Ninth
Avenue, Seattle, WA 98014 (E-mail: lgconcan@uw.edu).
1537-890X/1101/28Y34
Current Sports Medicine Reports
Copyright * 2012 by the American College of Sports Medicine
28
Volume 11 & Number 1 & January/February 2012
Mechanism of Injury
There are three primary mechanisms for cervical spine
injury. These include hyperextension, hyperflexion, and
axial loading. Hyperextension of the neck creates a functional spinal stenosis due to infolding of the ligamentum
flavum into the spinal canal. The sagittal diameter of the
spinal canal is decreased by up to 30% in this position.
Penning (24) described the pincer mechanism of injury in
hyperextension in which the cord is compressed by the
inferior portion of the superior vertebral body anteriorly
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and the spinolaminar line of the inferior vertebral body
posteriorly. In flexion, the reverse occurs, with the lamina of
the superior vertebral body and the posterior superior
aspect of the inferior vertebral body approximating each
other, again resulting in compression of the spinal cord.
Thus, a narrow spinal canal, whether congenital or secondary to disc herniation or other causes, can potentially predispose to injury in either of these positions (6).
An axial load to the head when the neck is either
straightened or slightly flexed also can put one at risk for
injury. When the normal cervical lordosis is lost, the cervical spine functions as a segmented column and is less able
to tolerate axial loads. In this position, the spine will fail
in flexion. Oftentimes a fracture-dislocation results, and
there is some degree of permanent spinal cord injury (11).
When a fracture does not occur, the presence of spinal
stenosis, either congenitally or from a disc herniation or discosteophyte complex, can still lead to transient compression
of the cord, though with potentially less devastating results.
Spear tackler’s spine is defined by the development of
stenosis of the cervical canal, with loss or reversal of the
normal cervical lordosis, and prior evidence of posttraumatic changes on radiographs. There is a prior history of
using a spear tackling technique. The classification of ‘‘spear
tackler’s spine’’ originated from a report of 15 cases during
a 4-year period (30). Eleven of these athletes had transient
symptoms and four developed permanent neurological deficits. Contact sport athletes with spear tackler’s spine are
at increased risk for both transient and permanent spinal
cord injury. In 1976, a football rule change was implemented, banning spear tackling or using the helmet as the
initial point of contact, which causes axial compression of
a straight or slightly flexed cervical spine. This led to an
immediate decrease in the incidence of cervical spinal injuries
in 1977 (34). In 2007 and 2008, both the National Federation of State High School Associations and the NCAA,
respectively, tightened their rules against spear tackling even
further. More recent studies have demonstrated stability at
this lower rate of spinal cord injury for both high school and
collegiate athletes (Table 1).
A recent case of a Canadian professional hockey player
who developed TQ after being struck in the back of the neck
Table 1.
Incidencea of cervical spinal cord injury in football.
Year
High School
College
1976b
2.24
10.66
1977c
1.3
2.66
1989 to 2002
d
0.5
0.82
2006 to 2010
e
0.48
1.33
A rule change in 1976 banning spear tackling led to an immediate
and sustained drop in the rates of cervical spinal cord injury in football.
a
Incidence is per 100,000 participants.
b
Torg et al. (28).
Torg et al. (34).
c
d
Boden et al. (2).
e
Mueller and Cantu (20).
www.acsm-csmr.org
by a puck indicates that an additional mechanism may be
involved in the development of TQ. It may be that an indirect force was imparted to the cord via a transfer of kinetic
energy from the puck, causing symptoms in the absence of
underlying stenosis and without a hyperflexion, extension,
or axial loading moment (39).
Presentation and Initial Management
An athlete with TQ may complain of symptoms in two to
four limbs. The most common complaint is the so-called
burning hands syndrome, with painful paresthesias in both
hands, which is suggestive of a central cord syndrome.
Sensory changes include burning, tingling, and diminished
or absent sensation. Motor changes may or may not be
present and can range from mild weakness to full paralysis.
There may be dysethesias in the neck area, but typically,
there is no other neck pain at the time of injury. Symptoms
generally last less than 10 to 15 min but may last as long as
36 to 48 hours. Athletes should be treated with full cervical
spine precautions to prevent progression of the injury (37).
Establishment and maintenance of an airway may be necessary. In cases of more severe spinal cord injury, neurogenic
shock may occur and should be appropriately managed.
Evaluation
Diagnostic imaging should begin with cervical spine
radiographs, potentially including flexion and extension
views if the patient is neurologically stable. Advanced
imaging with computed tomography (CT) can more readily
diagnose a cervical fracture or dislocation, but in cases of
TQ, there is generally no bony injury. Further imaging with
magnetic resonance imaging (MRI) should then be performed to evaluate for intrinsic spinal cord abnormalities or
ongoing spinal cord or nerve root compression. MRI may
occasionally show spinal cord edema, but this is not generally seen in TQ. MRI may, however, identify a disc herniation or disc-osteophyte complex causing a functional
spinal stenosis. Dynamic MRI in flexion and extension can
also be used to further evaluate for any functional stenosis,
although its clinical utility has not yet been proven. Somatosensory evoked potentials (SSEPs) may be considered to
evaluate for myelopathy and, more specifically, dorsal column dysfunction. SSEPs are an electrodiagnostic study that
consists of repetitive stimulation of a peripheral nerve,
generally the tibial nerve, with cutaneous recording of the
ascending sensory potentials in the limb, spinal cord, and
over the sensory cortex. These potentials ascend through the
dorsal columns of the spinal cord, so a lesion that spares the
dorsal columns will result in a normal SSEP. Latencies of the
responses can be compared to known normal values to
identify a site of dysfunction along the pathway. The SSEP is
a test of nerve function that can be used as an extension of
the physical examination and imaging findings.
Prior to the advent of more advanced imaging, radiographs were used to evaluate for spinal stenosis. This was
done by simply measuring the anteroposterior diameter of
the spinal canal from the posterior aspect of the vertebral
body to the most anterior point on the spinolaminar line.
Values greater than 15 mm are considered normal, while
13 mm or less is considered consistent with stenosis (6).
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29
An alternative measurement, mainly of historical interest,
is the ratio method, also commonly referred to as the Torg
ratio or the Torg-Pavlov ratio. This method was developed
before MRI was in common use. By using a ratio, this
method is independent of variations in the technique used in
obtaining plain radiographs. The Torg ratio is measured at
the C3-C6 levels and is the ratio between the sagittal
diameter of the spinal canal measured from the mid height
of the posterior aspect of the vertebral body to the spinolaminar line divided by the anterior-to-posterior diameter of
the corresponding vertebral body. A normal ratio is 1.0, and
values less than 0.8 are consistent with stenosis (29). This
ratio is very sensitive for identifying what Torg described as
‘‘significant spinal stenosis.’’ He found that the sensitivity
was 93% for transient neurapraxia; however, its low positive predictive value of 0.2% for identifying athletes at risk
of transient neurapraxia or cervical spinal cord injury led
him to conclude that the ratio itself should not be used as
a screening method to exclude athletes from participation
in contact sports (31). Another difficulty with the ratio
method is the larger size of the vertebral body in professional football players. This will skew the denominator
and decrease the ratio even if the true diameter of the spinal
canal is normal (21).
A more useful measurement is the amount of ‘‘functional’’
spinal stenosis seen on MRI. The ‘‘functional reserve’’ of
the spinal canal refers to cerebrospinal fluid (CSF) that is
able to flow freely around the cord in the absence of stenosis. Factors that can lead to stenosis include a congenitally
narrow canal, disc herniation or disc-osteophyte complexes,
other degenerative changes, and posttraumatic instability.
When there is a loss of CSF around the cord or, in more
severe cases, indentation of the cord, this represents more
significant stenosis. This functional reserve cannot be evaluated on plain radiographs and requires the use of MRI or
CT myelogram. It has been determined that the ratio method
described above has a low positive predictive value, ranging
from 12% to 33%, for identifying patients who truly have
functional spinal stenosis on MRI (14,21). Thus, any highrisk athlete with neurological symptoms in more than one
limb, no matter how transient, should be evaluated with a
cervical spine MRI to determine a potential source of the
transient symptoms and measure the functional reserve. Lateral flexion and extension plain radiographs are necessary for
evaluation as well before returning an athlete to play.
Treatment
High-dose methylprednisolone has been used for the initial management of acute traumatic spinal cord injury,
although its use remains somewhat controversial (23,36). It
may work by decreasing inflammatory mediators and
inhibiting lipid peroxidation that can lead to secondary
neurological injury. It has been associated with increased
infections (4). There is no role for steroids in the athlete
with TQ who shows resolution of symptoms. Depending
on policies of the treating hospital, it may be considered
in cases where neurological signs persist. The Bracken, or
National Acute Spinal Cord Injury Study II, protocol is
often followed, continued for either 24 or 48 hours (3,4).
Moderate systemic hypothermia also has been used in
the treatment of TQ, although its use is still considered
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Volume 11 & Number 1 & January/February 2012
experimental and is not recommended for routine care.
Hypothermia is thought to decrease tissue metabolism and
limit secondary hypoxic injury. However, it can be complicated by hypotension, cardiac arrhythmias, coagulopathy,
infections, and sepsis. Therapeutic hypothermia gained
media attention after its use in a professional football player
(9). A recent retrospective review of 14 patients with complete spinal cord injury demonstrated similar complication
rates at 1 year to matched controls, but continued studies
are needed to determine efficacy before its widespread use
can be endorsed (15).
Return to Play
Controversy continues to exist over return-to-play guidelines for athletes who have suffered an episode of TQ. Part
of the controversy stems from the relative lack of long-term
data. With such a small incidence of both TQ and SCI in
athletes, it would take a study of enormous proportions
to truly determine the risk of catastrophic spinal cord injury
after an episode of TQ. Torg et al. (32) in 1997 reported on
110 athletes who had suffered an episode of TQ. In this
survey, 57% of the athletes returned to contact sports, and
of these, 56% later developed a second episode of TQ. None
of them sustained a permanent neurological injury, although
no physical examination data were presented. Narrowing
of the spinal canal as determined by MRI was the only predictive factor in identifying those athletes who suffered a
second episode of TQ, although MRI was not performed
on more than half of the athletes. In a separate study,
they surveyed 117 athletes with permanent quadriplegia and
found that none of them recalled a prior episode of TQ.
Conversely, none of the athletes with TQ in this study went
on to develop permanent neurological injury. In addition,
none of the athletes with permanent spinal cord injury had
evidence of spinal stenosis on imaging (29).
There are two reports in the literature of an athlete with
transient neurological symptoms who subsequently developed permanent neurological injury. Cantu (7) reports on a
case of a young football player with an episode of TQ and
stenosis based on x-rays but did not undergo further imaging. He later went on to develop Brown-Sequard syndrome
and permanent spastic tetraplegia after a tackle, with
imaging demonstrating a C3-C4 disc herniation with cord
displacement and edema.
Brigham and Adamson (5) reported a case of a young
football player with a complaint of tingling in all four
extremities when he performed neck flexion, without a
prior history of injury. He was evaluated and allowed to
continue playing, although imaging did reveal the presence
of functional spinal stenosis. Two years later, he suffered
an axial load while tackling and developed bilateral C6
paresthesias, with cord signal changes at C5. Symptoms
remained 2 years after the incident, with continued dysethesias and weakness of elbow flexion and wrist extensors
bilaterally.
There are differing opinions regarding return-to-play
criteria after TQ. On the conservative end, Castro (10)
recommends that a single episode of TQ is an absolute
contraindication for return to contact sports; however,
this view is not generally accepted. More widely agreed
upon absolute contraindications include cervical fracture or
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ligamentous injury, any persistent neurological signs or
symptoms, and cord signal changes or edema, although it is
known that there are some professional athletes who return
to play with persistent cord signal changes without obvious
neurological deficit. Any incidentally discovered congenital
abnormality that would normally preclude contact sports,
such as os odontoideum, Klippel-Feil fusion greater than
two levels, any atlanto-occipital fusion, or brain stem signs
to include Arnold-Chiari malformation or basilar invagination, is an absolute contraindication. Cervical spine segmental instability, including C1-C2 hypermobility (anterior
dens interval Q4 mm) and more caudal vertebral segments
(93.5 mm of translatory displacement on dynamic flexion
or extension plain radiographs or 911 degrees of kyphotic
deformity) is also an absolute contraindication. Cantu (6)
also argues that functional spinal stenosis seen on MRI or
CT myelogram is an absolute contraindication for return to
contact sports. Studies with the National Center for Catastrophic Sports Injury Research have demonstrated that in
those athletes who suffer a spinal cord injury, those who
have underlying spinal stenosis have a poorer prognosis for
recovery of function than in those without cervical stenosis
(6). A second episode of TQ requires a repeat complete
evaluation and is considered either an absolute or relative
contraindication for return (8,35). Spear tackler’s spine also
is considered either an absolute or a relative contraindication
(8,35). A well-healed single-level fusion is not a contraindication for return to play. Maroon et al. (18) reported on
five professional football players who underwent cervical
surgery and advocated that a fusion in and of itself should
not represent a contraindication but that any level of fusion
with loss of functional reserve should be considered a contraindication. Multilevel fusions are generally considered a
contraindication for return to contact sports (33). Absolute
and relative contraindications for return to play are summarized in Tables 2 and 3, respectively.
With a lack of a consensus, any return-to-play decisions
must obviously include a lengthy discussion with the athlete,
Table 2.
Absolute contraindications for return to play after an episode of TQ.
Persistent neurological findings, cervical pain, or loss of ROM
MRI evidence of spinal cord defect or edema
Functional spinal stenosis on MRI
Acute cervical fracture or ligamentous disruption
Acute or chronic cervical disc herniation
Cervical spine segmental instabilitya
Arnold-Chiari malformation
Basilar invagination
Os odontoideum
Atlanto-occipital fusion or instability
Klippel-Feil fusion greater than two levels
Multi level surgical fusion
a
Segmental instability was defined as anterior dens interval Q4 mm
(C1-C2 hypermobility) or 93.5 mm of displacement or 911 degrees of
kyphotic deformity on flexion or extension radiographs.
www.acsm-csmr.org
Table 3.
Relative contraindications for return to play after an episode of TQ.
Healed cervical fracture
Single level Klippel-Feil fusion
Spear tackler’s spine
Second episode of TQ
Healed single-level cervical decompression and fusion without
functional stenosis
Small cervical disc herniation or spondylosis without any signs
or symptoms or functional stenosis
parents, and coach on the potential risks and must be made
on a case-by-case basis.
Stingers
Stingers, or burners, are a common but often under
reported peripheral nerve injury. As mentioned above,
stingers should not be confused with burning hands syndrome, which is indicative of a central cord injury. Simultaneous bilateral stingers are quite rare, and any athlete
with symptoms in more than one extremity should be
evaluated for a spinal cord injury. Stingers are a unilateral
peripheral nerve injury occurring at a point from the cervical nerve root to the brachial plexus. Up to 50% to 65%
of collegiate football players report at least one prior episode of a stinger, and recurrences have been reported to be
as high as 87% (16,25).
Mechanism of Injury
Controversy exists over the exact mechanism of injury
involved in stingers, as well as the exact location of the
lesion. It may well be that different mechanisms and locations of the injury are present in different age groups. The
three commonly reported mechanisms include traction or
tensile stretch injury, compressive injury, and direct trauma.
Traction results from ipsilateral shoulder depression with
flexion of the neck to the contralateral side, which leads to
stretch on the nerve roots and the brachial plexus. This
more commonly occurs in younger athletes with less experience and weak neck and shoulder musculature, who lack
radiographic evidence of cervical spondylosis (26). Compression stems from extension and lateral bending to the
ipsilateral side, with compression often occurring within a
narrowed neural foramina and is more common in older
players (16,19). Direct compression can occur at Erb’s point
and stems from improper padding. The brachial plexus is
most superficial at this point and vulnerable to direct compressive forces.
The cervical nerve roots are at higher risk than the brachial plexus for both tensile and compressive injury for
several reasons. The linear, as opposed to plexiform, orientation of the cervical nerve roots and their relative lack of
perineurium and epineurium increase their susceptibility to
injury. The C5 nerve root is the shortest and is in direct
alignment with the brachial plexus and is therefore the most
vulnerable. In addition, the ventral motor root lacks the
dampening effect of the dorsal root ganglion, which may
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31
help explain why motor symptoms may be more persistent
than sensory symptoms (38).
Despite these anatomic factors, the literature slightly
favors brachial plexus stretch injury over nerve root stretch,
nerve root compression, and direct compressive forces. As
mentioned above, this may relate to the age and experience
of the player (13).
Presentation
Stingers are a transient episode of unilateral pain and/or
paresthesias in an upper extremity. They may or may not
present with weakness. Symptoms are most commonly in
the C5 or C6 distribution. However, sensory symptoms may
be present in a circumferential, rather than a dermatomal
pattern. The athlete generally has full, pain-free cervical
neck range of motion (ROM), without tenderness to palpation. They may have a positive Spurling maneuver on
examination, particularly if the mechanism of injury was
one of compression. As mentioned, there is a preponderance
for C5 or C6 and upper trunk symptoms. Shoulder abduction, external rotation, and elbow flexion strength should
be given special attention during the examination of the
athlete to evaluate carefully for weakness in this distribution. Serial assessments are necessary because the duration
of symptoms can be quite variable, generally lasting seconds
to minutes, but may persist for days or longer.
Evaluation
The first step in evaluation of the athlete is to rule out
the presence of symptoms in more than one extremity, no
matter how transient, because this raises concern for a cervical spine injury.
After a first stinger, cervical radiographs and MRI may
be recommended to evaluate for potential etiologies. This
is particularly important if symptoms last for more than
1 hour, if there is concomitant neck pain, or if neurological
symptoms and signs are in a particular nerve root distribution (6). Stingers that resolve within minutes without
any residual signs or symptoms may not require further
evaluation. X-ray can identify bony foraminal stenosis or
instability on flexion or extension. MRI can be used to
identify disc herniation or disc-osteophyte complexes that
may be contributing to any neural foraminal narrowing that
is present and is recommended in the evaluation of any
athlete with persistent weakness. Chronic stingers are often
associated with foraminal narrowing or cervical disc disease
(16). Imaging of the brachial plexus with MRI also can be
considered to evaluate for a more peripheral injury.
Electrodiagnostic testing can be considered in the athlete
with persistent symptoms and, in general, is more helpful
for evaluating motor weakness rather than sensory changes
only. Electrodiagnostics can help to differentiate a cervical
nerve root injury from a brachial plexus injury. They may
also help to differentiate a neurapraxic versus an axonal
injury, helping to predict prognosis and time frame for
recovery. It often takes up to 3 wk for signs of denervation
to be seen on an electrodiagnostic study; however, reduced
recruitment may be seen immediately. In addition, findings on electrodiagnostics can remain abnormal even after
full clinical recovery of strength and should not necessarily
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Volume 11 & Number 1 & January/February 2012
preclude a return to competition, particularly if the examination demonstrates evidence of reinnervation (38).
Treatment
Initial treatment consists of rest and pain control. A
comprehensive rehabilitation program focused on ROM,
posture, muscular imbalances, and other predisposing factors should follow to decrease the risk of recurrent injury.
Because stingers are generally self-limited, further treatment
would be unusual but could include fluoroscopically guided
epidural steroid injections for pain relief or even surgical
decompression of a narrowed foramen or fusion for continued or progressive weakness (13).
Cervical collars are sometimes used in an effort to
decrease the risk of recurrent injury. They are intended to
decrease extension and lateral flexion, although research to
demonstrate their effectiveness is lacking (12). In addition,
limiting extension may have the unwanted effect of placing
the player’s head in a more flexed position, thereby potentially increasing the risk of severe cervical spine injury.
Reducing cervical ROM also may affect a player’s abilities
on the field. The Cowboy collar has added padding over
Erb’s point and may be used to prevent recurrent direct
trauma to the brachial plexus.
B vitamins are occasionally used in the treatment of
stingers and other nerve injuries. While vitamin B deficiencies have been linked to the development of peripheral
neuropathies, the literature does not clearly support their
use in peripheral neuropathies that do not have an underlying vitamin B deficiency. There is not sufficient evidence
Table 4.
Return-to-play guidelines for stingers.
All athletes require further diagnostic evaluation, with the
exception of a first stinger with rapid resolution of
symptoms.
Athletes must have resolution of all symptoms with full,
pain-free cervical ROM and full strength, along with an
absence of any underlying risk factors for further injury,
before they are allowed to return to play.
May return in the same game:
First stinger with rapid resolution of symptoms and normal
neurological examination
Second stinger in separate seasons with rapid resolution and
normal neurological examination
Requires evaluation before return to play:
Either a first or a second stinger with persisting neurological
symptoms or signs
Third stinger in separate seasons with rapid resolution and
normal neurological examination
Out for the season, consider restricting from contact sports:
Third stinger in the same season, with or without persisting
symptoms or signs
Third stinger in separate seasons, with persisting
neurological symptoms or signs
[Adapted from Standaert CJ, Herring SA. Expert opinion and controversies in musculoskeletal and sports medicine: stingers. Arch. Phys.
Med. Rehabil. 2009; 90:402Y406. Copyright * 2009 W.B. Saunders.]
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to support its use in alcoholic and diabetic neuropathy (1)
and it is no better than placebo in the treatment of carpal
tunnel syndrome (22). Practitioners who elect to prescribe B
vitamins should be careful not to exceed the recommended
daily upper limit because pyridoxine (B6) toxicity also can
present with peripheral neuropathy and excess of either
thiamine (B1) or pyridoxine can deplete other B vitamins.
Return to Play
Athletes should not return until they have full, pain-free
cervical neck ROM, no neck tenderness to palpation, no
residual symptoms, and no suspicion of underlying cervical
injury (7). If symptoms resolve rapidly and the athlete has a
normal neurological examination with full, pain-free cervical ROM, he or she may be considered for return to play
in the same game if this is his or her first stinger. Recurrent
stingers in the same game or season, or any evidence of neck
pain or neurological changes require the player to undergo
further workup before returning to competition (27).
Absolute contraindications for return to play include
persisting weakness, cervical anomalies identified on imaging, persisting electrodiagnostic abnormalities (with the exception of reinnervation), evidence of myelopathy, continued
pain, and reduced cervical ROM (Table 4) (27).
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12. Gorden JA, Straub SJ, Swanik CB, Swanik KA. Effects of football collars on
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Conclusions
Evaluation and management of any suspected cervical
spine injury require a well-managed team of medical professionals. In the case of TQ, the first priority is prevention
of further neurological injury. Only after symptoms have
resolved and a complete evaluation has been performed can
the focus shift to questions of return to play. When evaluating a stinger, the first priority is identifying those athletes
who may actually have an injury to the spinal cord. Any
athlete with bilateral symptoms, no matter how transient,
should be treated as a suspected spinal cord injury. They
should be placed in a cervical collar, on a backboard, and
taken to the emergency department for full evaluation.
Athletes with persistent unilateral symptoms also require a
more detailed evaluation before considering return to play.
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evaluation and surgical treatment. Report of five cases. J. Neurosurg. Spine.
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The authors declare no conflicts of interest and do not
have any financial disclosures.
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Radiating Upper Limb Pain in the Athlete
Copyright © 2012 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.