Stingers

“Stingers” or “Burners” are relatively common in rugby and should be differentiated from spinal injuries.

Definition

An intense painful, unilateral, neurological event due to an acute traumatic nerve injury affecting the upper roots or trunks of the brachial plexus.

Pathology

The injury may result in any of the following:

• Neuropraxia
• Axonotmesis
• Neurontmesis

Presentation

The following are characteristic of a stinger:

• The mechanism of injury is usually:
• Lateral flexion of neck causing compression of the nerve
• Lateral flexion of the neck causing traction of the nerve
• Depression of shoulder causing traction of the nerve
• Usually affects C5/6 nerve roots or the upper trunks of the brachial plexus. C5/6 myotomes can be assessed by resisted testing of:
• Shoulder abduction
• Shoulder external rotation
• Elbow flexion
• Sensory symptoms usually resolve within seconds
• Motor symptoms may persist

On-field – ‘Red Flags’

The following signs and symptoms should be considered ‘red flags’:

• Bilateral signs or symptoms
• Midline neck pain
• Painful neck movement
• Blocked neck movement
• Persistent sensory symptoms – pain or dysaesthesia
• Significant persistent weakness

In a first presentation or in players with recurrent stingers (when the presentation is different from their usual signs or symptoms), there should be a high index of suspicion for cervical spinal injury and particular care must be taken. In these cases, the player should treated as a potential spinal injury and managed appropriately.