Cervical Stinger / Brachial Plexus Neuropraxia

The classic stinger is unilateral, immediate, and self-limiting. The athlete reports burning, electric, lancinating pain shooting from neck into shoulder and down the arm, often shaking out a "dead arm." Paraesthesia and weakness in the C5-C6 distribution (deltoid, biceps, shoulder external rotators) are typical. Symptoms usually resolve within seconds to minutes and almost always within hours.

Examination off the pitch:

• •Cervical range (full and pain-free in pure stinger)
• •Midline cervical tenderness (absent in stinger)
• •Full upper-limb neurological assessment (power, sensation, reflexes)
• •Spurling test as a foraminal compression screen
• •Contralateral limb assessment

Every athlete with a stinger should undergo a concurrent concussion screen (SCAT or equivalent) - the mechanism overlaps and concomitant concussion is common and easily missed.

A "dead arm" after a tackle must also be distinguished from acute anterior shoulder subluxation or dislocation, which produces apprehension, altered shoulder contour, and focal shoulder pain rather than shooting neck pain (axillary nerve neuropraxia can co-occur).

A single, classical, fully-resolved unilateral stinger with a normal examination requires no imaging - the diagnosis is clinical. Document mechanism, side, distribution, duration, neurological findings, lower-limb assessment, recurrence history, red flag exclusion, and the clinician making the return-to-play decision.

Imaging is indicated for bilateral or four-limb symptoms (urgent imaging to exclude cord injury or cord neuropraxia), persistent symptoms, recurrent stingers, neurological deficit on examination, midline cervical tenderness, reduced cervical range, altered consciousness, or significant mechanism.

For adults aged 16 or over with suspected traumatic cervical spine injury, NICE NG41 recommends CT cervical spine when imaging is indicated by the Canadian C-spine rule, with MRI added where neurological abnormality could be attributable to spinal cord injury or where cord, root, disc, or ligamentous injury is suspected. In children under 16, MRI is favoured when there is strong suspicion of cervical cord or column injury.

In recurrent stingers, MRI assesses foraminal stenosis, disc-osteophyte complex, congenital canal stenosis, cord signal change, and instability. The Torg-Pavlov ratio (sagittal canal diameter divided by vertebral body diameter; under 0.8 indicates relative stenosis) is a recognised exam marker but has limited predictive value because athletes often have larger vertebral bodies. Modern specialist assessment uses absolute sagittal canal diameter (under 13 mm relative, under 10 mm absolute) and MRI evidence of CSF effacement around the cord.

Nerve conduction studies and EMG have no acute role. They may be considered beyond 2-3 weeks for persistent weakness or suspected axonal injury.

Pitchside, the priority is to exclude cervical spine injury and concussion.

Same-day return to play may be considered ONLY after a first, single, fully-resolved unilateral stinger, with all of the following:

• •Complete symptom resolution
• •Full pain-free cervical range of motion
• •Normal upper-limb neurology and full strength
• •No neck pain or midline tenderness
• •No lower-limb or bilateral symptoms
• •No recurrence during sport-specific testing
• •Normal concussion screen
• •Assessment by an appropriately trained clinician

There is no UK-specific stinger return-to-play guideline; same-day return is supported by sports medicine consensus.

For any bilateral symptoms, lower-limb symptoms, persistent neurological deficit, midline cervical pain or tenderness, reduced range, altered consciousness, intoxication, distracting injury, high-risk mechanism, or unreliable examination, manage as suspected cervical spine or spinal cord injury per NICE NG41 and BOASt: spinal precautions, avoid unnecessary movement, trained pitchside spinal protocols, and emergency transfer with appropriate trauma imaging.

Pharmacological management is supportive (paracetamol, short-course NSAIDs per BNF / NICE CKS). Persistent neuropathic pain is not a typical stinger and should trigger reassessment rather than empirical neuropathic agents.

Specialist referral (spinal surgery or sports medicine) is indicated for recurrent stingers (multiple episodes in one season, short-interval recurrence, increasing severity, prolonged symptoms, persistent weakness), persistent neurology, imaging showing structural abnormality, or any concern about return-to-collision-sport safety. Decisions about continued contact play are shared and multidisciplinary, integrating symptoms, recurrence pattern, examination, imaging, instability, sport demands, and risk tolerance rather than relying on any single number.

Rehabilitation has three pillars: cervical and scapular strength, technique correction, and graded return.

Phase 1 (24-48 hours): ice, simple analgesia, gentle pain-free range, early restoration of cervical proprioception and neutral head positioning. Proprioceptive deficits are common after neck trauma and contribute to poor tackling technique on return.

Phase 2 (1-2 weeks): deep cervical flexor strengthening (chin-tuck progression), scapular stabiliser work (lower trapezius, rhomboids, serratus anterior), thoracic mobility, posterior chain strengthening.

Phase 3 (return to contact): full pain-free cervical range, normalised neurological examination, full strength symmetry, integration of sport-specific tackling or contact technique training. Coach involvement on tackle technique (head up, shoulder square, no leading-shoulder dip into the traction position) is essential to recurrence prevention. Protective collar or roll equipment evidence is sport-specific (American football) and is not a routine rugby recommendation.

Return to full contact is criteria-based, not time-based. A first single stinger may return within hours to days; recurrent or more severe injury may require weeks to months.

• •NICE NG41 Spinal injury assessment and initial management (2016): UK framework for cervical spine clearance and imaging triage in trauma. Specifies CT first in adults and MRI-first in children when criteria are met.
• •BOASt - Assessment of the Spine in the Trauma Patient: BOA standards for pitchside and ED spinal trauma assessment.
• •Canadian C-spine Rule (Stiell et al., JAMA 2001): clinical decision rule for cervical imaging with sensitivity approaching 100% for clinically important injury.
• •Torg and Pavlov sagittal canal ratio (1986): historical marker of relative cervical canal stenosis (under 0.8 = stenotic); limited predictive value in athletes because of larger vertebral body size.
• •Castro et al. transient quadriparesis series and subsequent contact-sport return guidance: contributed to modern specialist criteria for cord neuropraxia and recurrent stingers.
• •Sunderland nerve injury classification (1951): UK and international framework for grading neuropraxia (Grade I focal demyelination), axonotmesis (Grade II-IV), and neurotmesis (Grade V).

• •UNILATERAL upper-limb burning that resolves quickly = stinger. BILATERAL upper-limb or four-limb symptoms = cord neuropraxia (immobilise and image urgently). MIDLINE neck tenderness = potential fracture, follow NICE NG41 imaging.
• •Upper trunk C5/C6 distribution. Three mechanisms: traction (lateral flexion AWAY + shoulder depression), compression (ipsilateral flexion + extension, older athlete), and direct blow to Erb's point.
• •Torg-Pavlov ratio under 0.8 is the exam-relevant marker of relative canal stenosis but has limited predictive value (athletic vertebral body size) and cannot be used in isolation.
• •Always screen for concomitant concussion in any athlete with a stinger - the mechanisms overlap and concussion is easily missed.
• •Same-day RTP requires ALL criteria met: full symptom resolution, normal neurology, no neck pain or midline tenderness, normal concussion screen. There is no UK-specific RTP guideline.
• •Recurrent stingers warrant specialist referral and MRI. Decisions are shared and multidisciplinary, integrating recurrence pattern, imaging, and sport demands.