Burner’s (Stingers) Syndrome 

Burner’s Syndrome, also known as a stinger or transient brachial plexopathy, is a brief but potentially recurrent neurological injury affecting the brachial plexus or cervical nerve roots. It is characterized by a sudden onset of burning pain, numbness, and temporary motor weakness in one upper extremity, typically caused by traction or compression during high-impact trauma, most commonly in contact sports. Although symptoms often resolve within minutes, recurrent episodes or delayed motor weakness may occur, necessitating careful clinical monitoring.

 

Pathophysiology

Burner’s syndrome typically results from an overstretching or compressive force to the upper brachial plexus (C5–C6) or cervical nerve roots, often during high-velocity collisions. The injury usually manifests as a neuropraxia (Grade I) but may occasionally involve axonotmesis (Grade II).

Classification of Peripheral Nerve Injuries in Burner's Syndrome

 

Mechanisms of Injury in Burner's Syndrome

The injury mechanisms can be classified into three primary types, each involving either traction, compression, or direct trauma to the nerves.

1. Traction Injury

Occurs when the shoulder is forcefully depressed while the neck bends to the opposite side, stretching the upper trunk of the brachial plexus (C5–C6). Common in tackles or illegal moves like clotheslines. Most frequent cause of stingers.

2. Compression Injury

Caused by narrowing of the neural foramina due to axial loading, neck hyperextension, and lateral flexion. Seen in players with cervical stenosis or disc issues, especially after head-first impacts or chin blows.

3. Direct Blow (Erb’s Point Contusion)

A direct hit to the supraclavicular fossa (Erb’s Point) can bruise the superficial C5–C6 nerves. Occurs in shoulder collisions or contact with helmets/pads. Nerves are vulnerable due to their superficial location.

 

Epidemiology

Burner’s syndrome is highly prevalent in contact sports such as:

1. Football
2. Rugby
3. Ice Hockey

Studies report up to 50–65% incidence in collegiate football players. Linebackers, defensive backs, and linemen are especially at risk. Unfortunately, it is frequently underreported, as many athletes may not disclose symptoms.

 

Clinical Presentation of Burner's Syndrome (Stingers)

Typical Features

1. Onset:

Sudden onset of symptoms following forceful impact or traction or compression of the brachial plexus during contact sports.

2. Primary Symptoms:

• Unilateral burning pain starting in the supraclavicular region
• Radiation of pain down the arm in a dermatomal or non-dermatomal pattern
• Paresthesia (pins and needles)
• Numbness

3. Muscle weakness, especially in:

• Shoulder abduction (C5)
• Elbow flexion (C6)
• External rotation
• Sensation of a "dead arm"

4. Symptom Duration:

• Varies from seconds to several days depending on severity
• Most recover within minutes (Grade I), but persistent weakness or sensory loss may indicate more serious injury (Grade II/III)

 

Diagnosing Burner’s Syndrome

Differential Diagnosis

Serious Conditions

• Cervical spine fracture or dislocation
• Spinal cord injury
• Transient quadriplegia
• Concussion

Other Considerations

• Shoulder dislocation or AC joint sprain
• Clavicle fracture
• Thoracic outlet syndrome
• Brachial neuritis (insidious onset, non-traumatic)
• Muscle strain (no neurological signs)

 

Physiotherapy Management and Rehabilitation of Burner's Syndrome (Stingers)

Burner’s Syndrome is managed based on the severity of nerve injury (Grades I–III) and focuses on:

1. Symptom control
2. Functional restoration
3. Prevention of recurrence
4. Safe return to sport

  

Early Management: Pain & Inflammation Control

• Rest and activity modification
• Analgesics / NSAIDs
• Cervical collars (short-term use)
• Epidural steroid injections (in select cases with foraminal narrowing - used cautiously)

 

Physical Therapy Goals

Postural Correction

• Restore cervical lordosis
• Address the following - thoracic kyphosis, scapular protraction, glenohumeral internal rotation and segmental hypermobility

Flexibility & Muscle Balance

Stretch Tight Muscles:

• SCM, upper traps, levator scapulae
• Pectoralis major/minor, subscapularis, serratus anterior

Strengthen Weak Muscles:

• Deep neck flexors
• Middle/lower traps, rhomboids
• Thoracic extensors, latissimus dorsi

Week Rehabilitation Protocol (Sample)

Week 1 - Restore ROM & Neural Mobility

• Manual Therapy: Cervical traction, UPA mobilizations
• Neural Gliders: Supine median nerve sliders → HEP
• Therapeutic Exercises: Rows, I-T-Ys (light resistance)
• Outcomes: Improved ULTT, ROM, and reduced paresthesia

Week 2 - Achieve Full ROM & Strength

• Manual Therapy: Minimal (Grade IV UPA, side glides)
• Strengthening exercises using resistance bands/dumbbells along with neck isometrics

Weeks 3–5 - Plyometrics & Sport-Specific Drills

• Plyometrics: Med ball drops, plyo push-ups
• Closed Chain Stability: UE rocker board
• Sport Drills: 3-point stance, sled pushes, swim/rip moves
• Advanced Strength: Push-ups plus, shoulder IR/ER at 90°
• Outcome: Full sport participation by Week 3–5, no symptoms

Return-to-Sport Criteria

• Full pain-free ROM and strength
• No neurological deficits
• Tolerance to contact drills
• Individualized decision - no formal guidelines

Prevention Strategies

• Pre-season screening:

          > History of previous stingers

          > Limited ROM/strength

          > Cervical imaging if indicated

• Posture and technique training
• Protective gear - cowboy collars, shoulder pads
• Emphasize neck strengthening and safe tackling

Weinstein’s Rehabilitation Principle

Weinstein’s approach provides a structured and progressive framework for rehabilitating athletes recovering from stingers, with a focus on restoring neuromuscular control, postural stability, and functional strength.

Stabilization Hierarchy

Progressive stabilization from central to peripheral segments:

Head/Neck → Shoulder → Thoracic Spine → Upper Extremity

Stabilizing the proximal segments first (especially the neck and scapular region) provides a foundation for coordinated movement and reduces stress on the recovering nerve structures.

• Begin: Isometric → isotonic in neutral positions
• Progress: Concentric loading + balanced posterior/anterior strength
• End phase: Multiplanar functional tasks with increasing resistance

Surgical Management (For Grade III Injuries)

Indications:

1. No functional return
2. Persistent deficits >3–6 months
3. Confirmed neurotmesis or root avulsion

Options:

1. Nerve repair or grafting
2. Nerve transfers (e.g., to restore shoulder abduction/elbow flexion)
3. Muscle transfer (if motor endplates are no longer viable)