Hughston

Health 6262 Veterans Parkway P.O. Box 9517 ColumbusAler GA 31908-9517 t Volume 12, Number 2 www.hughston.com SPRING, 2000

Stingers and Burners Fig. 1 A “stinger“ or “burner“ as seen in a gymnast who fell on top Few sports injuries are as eye- of her shoulder, causing her neck opening for the athlete as a “stinger” to bend toward the opposite side. or “burner.” This intense neurologic This motion stretched the nerves, (nerve) event occurs most commonly triggering an intense discharge of in football players. It also can electricity. occur in people who participate in wrestling, cycling, gymnastics (Fig. 1), snow skiing, martial arts (Fig. 2), or other sports. This article discusses the condition in football players and highlights several key points. Cervical spine What is a stinger or burner? A stinger or burner is an intensely painful nerve injury. The nerves that give feeling to the arms and hands originate from the cervical (neck) Collar spinal cord. As these nerves leave bone the neck, they form the brachial plexus (see Fig. 1). They weave together then branch as they pass Brachial plexus under the clavicle (collar bone) on the way to the shoulder. Nerve injury often happens when the athlete makes a hard hit using

his shoulder. The direct blow to the The Hughston Foundation, Inc. ©2000

top of the shoulder drives it down and After this intense electrical Inside This Issue: causes the neck to bend toward the discharge, the nerves’ motor fibers  Congenital Spinal Stenosis opposite side. This motion severely that allow movement in the arm do stretches or compresses the nerves not function well. The dysfunction is  Sport-Related Concussion and triggers an intense discharge of evident by weakness in the arm. The  The Marfan Syndrome electricity. For a few seconds, the weakness often involves the muscles electricity shoots down the nerves to that allow the athlete to lift the arm  Why Wear a Mouthpiece? the tip of the fingers. away from the body, to bend the Page 1 FOR A HEALTHIER LIFESTYLE When can the injured athlete go Fig. 2 back in the game? If the certified athletic trainer, physical therapist, or team doctor determines that the athlete’s sense of feeling, strength, neck motion, and reflexes have returned to normal, the athlete may be able to return to the game. All protective gear should be inspected to ensure it fits properly and is in good condition. Additional shoulder pads or a neck roll may be added. Do not attach restraining straps or other similar devises to the helmet because they can lead to more severe injuries. The athlete should be examined frequently during the game for further problems including recurrence of symptoms.

Martial arts is another sport How should the athlete be treated in which the athlete is at risk following the game? for a “stinger“ or “burner.“ The Hughston Foundation, Inc. ©2000 After the game, the athlete should be re-examined in the locker room elbow, and to grip. Symptoms also that can accompany a stinger include and, if necessary, at his doctor’s include sensations of tingling and of fractures, dislocations, or damage office. An athlete who has a stiff neck burning or stinging pain in the arm to the ligaments (tissue connecting following a stinger is more prone and hand. The extent of the damage two bones) of the cervical spine. to further, more serious injury and varies considerably. The pain usually Therefore, when treating an athlete needs a thorough evaluation of the lasts only a few minutes, but the who has a stinger, the doctor takes neck, shoulder, and nerves by an weakness can last weeks, months, or appropriate precautions to protect the orthopaedic doctor. An athlete who years. Rarely, the injury may cause spine. has had a stinger cannot return to play permanent damage. A spinal cord injury usually causes until the health care provider notes Treatment of a stinger or burner symptoms involving more than just that he has no pain or tenderness and usually begins as soon as the player one arm and possibly the legs. This that he exhibits full range of motion runs off the field with the limp arm injury must be treated as a medical and strength in the neck, shoulder, hanging by his side. The certified emergency. A contusion (bruise) to the and arm. athletic trainer, physical therapist, spinal cord in the neck during athletic or team doctor carefully examines competition can lead to temporary How do we prevent these injuries? the cervical spine, evaluates nerve quadriparesis, producing symptoms Preventing recurrent stingers is function in the neck and upper of pain and tingling in both arms and important. Subsequent injuries tend back, tests muscle strength, and tests both legs. Certain athletes may be to be increasingly severe and can reflexes. If the athletic trainer, physical more prone to this injury because the damage the nerve permanently. therapist, or doctor suspects that space in their necks through which Athletes, coaches, officials, athletic the athlete has a spinal cord injury, the spinal cord travels is narrow (see trainers, and parents need to ensure he or she treats the condition as a “Congenital Spinal Stenosis,” p. 3). that athletes follow these three medical emergency with full spinal Other injuries to the spinal cord can minimal guidelines. First, use proper precautions. cause lasting, serious nerve damage. technique in tackling as mandated The health care provider always treats by the 1979 football rule outlawing How do I know it’s a stinger and not neck injuries with full precautions spearing or head tackling. Second, something else? until serious injuries are ruled out. make sure that the shoulder pads and Stingers or burners produce neck roll, if used, fit properly and symptoms in only one arm. Injuries Page 2 FOR A HEALTHIER LIFESTYLE are in good condition. Third, before last one or two days. Bruising of the changes, fractures, and damage to the season begins, participate in an cervical spinal cord can result in the ligaments (tissue connecting exercise program to develop full range transient quadriplegia, producing two bones) that contribute to the of motion and protective strength of temporary pain and loss of movement symptoms. the neck and shoulder muscles. in both arms and both legs. Severe To treat your neck injury, the doctor bruising of the spinal cord can result prescribes medication and rest and Kurt E. Jacobson, M.D. in permanent quadriplegia (loss of immobilizes your neck with a cervical Columbus, Georgia movement and feeling in the arms collar. In certain cases, you need and legs). surgery to correct the problem and relieve the symptoms. Diagnosis and treatment A suspected spinal cord injury Can I still play sports? Congenital Stenosis should be treated as a medical Your health care provider decides emergency, with the health care whether you can return to contact of the Cervical Spinal provider taking full precautions to sports. You cannot return to play if Canal protect your spine and to transport you have temporary quadriplegia you by ambulance to the hospital. accompanied by cervical instability Congenital stenosis of the cervical X-rays of the cervical spine are (excessive motion between the spinal canal is the narrowing of the taken to find out what is causing vertebral bodies), a spinal fracture, spinal canal in the neck (Fig. 1). This the symptoms. If your spinal canal a recent disc herniation (disc condition, which exists at birth but is narrowing, the x-rays can expose bulging into the spinal canal), or is not hereditary, puts the affected the condition. Sometimes, they significant degenerative changes. If person at increased risk of injuring the reveal other problems including you have had repeated episodes of spinal cord. congenital fusion (permanent union temporary quadriplegia, you should The spinal canal lies within the of two vertebrae), degenerative not participate in contact sports. spine and encases the spinal cord. Side view The vertebral body (back bone) Normal cervical spinal canal forms the front and the lamina (bony covering) forms the back of this canal. The spinal cord travels from the brain through the canal to the lower back, giving feeling and movement to the entire body. Top view Am I at risk for injury? Spinal cord injury can occur when the neck is forced to bend too far forward or backward or is com- pressed through a blow to the top of the head. With these motions, the Side view Congenital spinal cord can be pinched within the cervical spinal stenosis narrow canal. Athletes who have cervical spinal stenosis and participate in contact sports (e.g., football, martial arts, basketball) are at risk for serious nerve injuries due to pinching within the spinal canal. Symptoms include Top view burning pain, tingling, or numbness in both arms and possibly both legs. The symptoms usually subside within a few minutes. Occasionally, they The Hughston Foundation, Inc. ©2000 Fig. 1 Page 3 FOR A HEALTHIER LIFESTYLE Returning to practice or competition Sport-Related with one of these conditions may result in severe, permanent damage to Concussion the nervous system. Researchers have found that certain Concussion is the most common athletes who have had one episode head injury that occurs during sport of temporary quadriplegia but no participation, with more than 250,000 accompanying injuries can return to injuries reported annually in football contact sports without an increased players alone. In fact, 20% of high risk of permanent nerve damage.1 If school football players experi-ence a the health care provider allows you to concussion each year. Sport-related return to contact sports, you first need concussions are usually witnessed, to regain maximum strength in your are generally mild, are usually not neck by stretching and strengthening associated with other injuries, and the muscles. If you play football, avoid sometimes are treated initially by using your head to tackle and modify nonmedical personnel. Athletes most your shoulder pads according to your at risk for a sport-related concussion health care provider’s directions. participate in football, boxing, hockey, lacrosse, rugby, equestrian events, and Long-term problems snow skiing. Degenerative disc disease (wearing down of shock-absorbing structures What is a concussion? between vertebrae), bone spurs A concussion is a temporary (overgrowth of bone), or vertebral alteration in consciousness that occurs subluxation (one vertebral body immediately after a blow to the head. The condition is the mildest form of slipping forward onto the next) further Fig. 2 narrows the spinal canal as the person The Hughston Foundation, Inc. ©2000 traumatic (sudden, forceful) brain with cervical spinal stenosis ages. injury. However, the cumulative effect These changes can lead to long-term determine the extent of the injury and of having more than one concussion spinal cord compression, resulting whether you can return to contact can be permanently damaging or in loss of nerve function such as sports. For long-term problems deadly. associated with the condition, your numbness, weakness, and loss of Symptoms health care provider has treatment fine motor control in the arms and Concussions range in severity. A options available to help relieve your hands and difficulty with walking. mild concussion disrupts function Sometimes, symptoms are so severe symptoms. but does not render the athlete that you need surgery to relieve unconscious. The athlete may them. Figure 2 shows the magnetic John D. Dorchak, M.D. describe a feeling of having his or resonance imaging scan of a person Columbus, Georgia her “bell rung” and may be confused with congenital stenosis of the cervical Further reading momentarily. The brain repairs itself spinal canal and accompanying 1. Torg JS. Cervical spinal stenosis with cord quickly and completely. A moderate degenerative disc disease that is neurapraxia and transient quadriplegia. In: Torg concussion results in longer lasting compressing the spinal cord. This JS, Shephard RJ, eds. Current Therapy in Sports confusion and amnesia in the person needed decompression Medicine, third ed. St. Louis, MO: Mosby-Year conscious athlete. For example, the Book, Inc., 1990; 57-60. (surgical relief of pressure on the 2. Torg JS. Risk factors in congenital stenosis athlete may not remember the events spinal cord and nerve roots) and of the cervical spinal canal. In: The Cervical leading up to the injury or what spinal fusion to relieve the symptoms. Spine Research Society, ed. The Cervical Spine, period of the game it is. The brain Congenital stenosis of the cervical second ed. Philadelphia, PA: JB Lippincott Co., has microscopic tissue damage that spinal canal puts athletes at risk for 1989;272-285. can take up to six months to repair 3. Watkins RG, Dillin WH, Maxwell J. Cervical nerve injuries. Symptoms of these spine injuries in football players. In: The Spine completely. A severe concussion injuries are usually temporary; in Sports. Hochschuler SH, ed. Philadelphia, results in loss of consciousness and is however, you must have a health PA: Hanley & Belfus, Inc., 1990;157-174. treated as an emergency. care provider examine your neck to One severe concussion or

Page 4 FOR A HEALTHIER LIFESTYLE successive mild or moderate (e.g., running in place) for at least 20 to contact sports one month after concussions can cause permanent minutes. Because another concussion injury only if no symptoms are present damage to the brain or can cause during the same game is more likely at rest and with exertion for at least postconcussive syndrome. The now and can cause further damage, two weeks. symptoms of postconcussive the doctor or ATC may consider After a second Grade 3 concussion, syndrome include headaches, barring the athlete from play that day. the athlete must stop participating dizziness, insomnia, poor After returning to play, the athlete for the season and must consider not concentration, memory difficulties, must be examined regularly by the returning to any contact sport. irritability, personality changes, same doctor or ATC throughout If the athlete continues to have anxiety, or depression. As many as competition. If symptoms appear, symptoms of postconcussive 30% of professional football players the athlete must stop competing that syndrome, he or she needs to see have symptoms of this disorder. day and have a magnetic resonance the doctor again. The doctor may A rare and usually deadly result imaging and a computed tomography prescribe mild analgesics to relieve of concussion is second impact (CT) scan to examine the brain. some of the symptoms and may syndrome. This syndrome develops If the athlete suffers a second Grade work with the athlete to rehabilitate when an athlete receives another 1 concussion in the same game, he brain function, thought processes, or concussion before fully recovering must stop playing that day. He or behavior. from the previous concussion. The she can return to play only when second concussion may occur after a symptoms have not been present for Prevention seemingly minor injury such as a blow at least one week. After a third Grade Wearing a good quality helmet, to the chest that is strong enough to 1 injury, competition ends for the wearing a mouthpiece, and jar the brain. After the injury, rapid, season. The athlete can participate strengthening the neck muscles can severe swelling of the brain leads to in contact sports (e.g., football, help prevent concussion. Although uncontrollably high pressure in the basketball) after three months only if athletes may be eager to return to skull. At first, the athlete appears symptoms are not present at rest and play, they need to be honest with the dazed, but, within a few seconds with exertion. examiner, telling him or her exactly or minutes, he or she collapses and An athlete with a Grade 2 how they feel. Remember, each develops rapid dilation of pupils, loss (moderate) concussion must stop successive concussion causes more of eye movement, and respiratory participating in competition that day brain damage, which can lead to (breathing) failure. and must be re-examined by a doctor severe discomfort, permanent brain the next day. He or she can return to damage, or death. Treatment contact sports only if nervous system Because a concussion damages the function is normal and no symptoms Marc Goldman, M.D. brain, an athlete must be examined are present at rest and with exertion Columbus, Georgia by a medical professional before for at least one week. returning to play. Several grading Further reading After a second Grade 2 concussion, 1. Youmans JR, ed. Neurological Surgery: systems have been devised to help the athlete cannot return to play for at A Comprehensive Reference Guide to the team doctors and certified athletic least one month and may be barred Diagnosis and Management of Neurosurgical trainers (ATCs) examine an athlete from play for the season. Suffering a Problems, fourth ed. Philadelphia, PA: W.B. with a sport-related concussion and Saunders Co., 1996;1533-1548, 1595-1617. third Grade 2 concussion ends play 2. Greenberg MS. Head trauma. In: Handbook prevent further, more serious brain for the season. of Neurosurgery, third ed. Lakeland, FL: Green- damage. One of the most frequently A Grade 3 (severe) concussion berg Graphics, Inc., 1994;521-569. used systems was developed by the is considered an emergency. The 3. Wojtys EM, Hovda D, Landry G, et al. Concussion in sports. Am J Sports Med 1999; Colorado Medical Society and is unconscious athlete must have the described here. 27(5):676-687. cervical (neck) spine immobilized as 4. Jacko J. Head injuries. In: Baker CL, ed. An athlete with a Grade 1 (mild) a precaution and must be transported The Hughston Clinic Sports Medicine Book. concussion must stop participating. by ambulance to a hospital for Philadelphia, PA: Williams & Wilkins, 1995; He or she can return to play only medical evaluation and a CT scan of 112-117. if the examiner determines that the head. The athlete can go home nervous system function is normal under the supervision of a family and if no symptoms (i.e., amnesia, member only when the results of the postconcussive syndrome) are nervous system evaluation and the CT displayed at rest and with exertion scan are normal. He or she can return Page 5 FOR A HEALTHIER LIFESTYLE Signs and symptoms person is taller than average for his or The Marfan Syndrome The number and severity of her age, is near-sighted, has an arm symptoms vary from person to person. span exceeding his or her height (Fig. The Marfan syndrome has been The lenses that enable the eyes to 1), is loose jointed (especially in the publicized in sport magazines focus on objects can be intact or knees, wrists, and fingers) (Fig. 2), because of the sudden, untimely dislocated (off center). The heart can is excessively flexible or limber, has deaths of Olympic volleyball player produce no symptoms until middle flat or “rocker bottom” feet, and has Flo Hyman and collegiate basketball age, or its aorta (large artery carrying kyphoscoliosis (an abnormal forward player Chris Patton who had this blood out of the heart) can develop and sideways curve of the back bone) condition. The Marfan syndrome is a life-threatening aneurysm (i.e., the (Fig. 3). an inherited, degenerative disorder thin wall of the aorta balloons out Because of the physical of the connective tissue, which gives under pressure) during adolescence. characteristics that can accompany shape and structure to tissues in The tubular long bones (e.g., arms, the Marfan syndrome, the term has the body and holds them in place. legs, and fingers) can grow until the been used loosely — and sometimes It affects several organ systems person is slightly taller than average incorrectly or without evidence — to including the ocular system (eyes), or until the person is much taller than describe any person who is tall and the cardiovascular system (heart and average. The breastbone can appear thin and has long arms and legs. An blood vessels), and the skeletal system normal or can point outward (pigeon unsuccessful proposal was made in (bones and joints). The condition is chest) or inward (funnel chest). In an the 1980s for athletes in the National considered a syndrome because the extreme case, the signs and symptoms Basketball Association to undergo physical symptoms occur together are obvious; the person is unusually testing for the Marfan syndrome. frequently enough for a pattern to be tall and thin, wears thick glasses, and Without conclusive evidence, recognized. More than 50,000 people tires out easily with moderate physical historians and medical professionals in the United States have the Marfan activity. In a typical case, the affected have debated whether Abraham syndrome. Lincoln had the Marfan syndrome.

Fig. 1 Diagnosis Diagnosing the Marfan syndrome is difficult because the number and severity of symptoms affecting each person varies. The doctor may first recognize that you demonstrate some symptoms of the disorder when treating you for a dislocated hip, kneecap, or jaw; groin pain due to a hernia; or spontaneous leakage of air from the lungs into the chest cavity. This person In addition to the physical exami- with the Marfan nation, the doctor records your syndrome is tall family’s medical history. He or she and thin and has even looks at photographs to find out an arm span that whether your family members have exceeds her height. any physical characteristics that could be related to the Marfan syndrome.

Treatment The Marfan syndrome cannot be cured. However, a treatment plan customized to your needs may help improve the quality and length of your life. Treatment includes annual The Hughston Foundation, Inc. ©2000 echocardiograms (sound wave picture

Page 6 FOR A HEALTHIER LIFESTYLE condition involve no contact and a low level of intensity. You may be able to walk briskly, play golf, bowl, and leisurely Aortic ride your bicycle. Your doctor arch can tell you about the benefits, risks, and expected outcome of participating in different types of sports from a high-intensity, contact sport like rugby to a low- intensity, non-contact sport like golf. Based on your condition and abilities, the doctor can help Aneurysm you find a sporting activity that is safe and fulfilling. Ascending John M. Henderson, D.O., FAAFP; aorta Bruce Getz, ATC; and Kelli Bowermeister Columbus, Georgia For more information, contact the National Marfan Foundation, 382 Main Street, Port Washington, NY 11050, Descending (516) 883-8712, (800) 8-MARFAN, aorta http://www.marfan.org. Fig. 2 The Hughston Foundation, Inc. ©2000 Fig. 4 The Hughston Foundation, Inc. ©2000 of the heart) and electrocardiograms Fig. 3 (recording of the heart’s electrical rhythms), periodic eye examinations by an ophthalmologist, evaluations Kyphoscoliosis of the skeletal system (especially for growing children and adolescents), medications, and lifestyle adaptations. Scoliosis Kyphosis

Participation in sports Talk with your doctor about the limits for safe participation in sports and pick your activities carefully. Avoid strenuous activities such as weight training, high-impact aerobics, and scuba diving that can aggravate an existing aortic aneurysm (Fig. 4). Avoid contact sports such as boxing, hockey, football, and rugby that put you at risk for fully dislocating an already loosened lens and for damaging the aorta. Avoid sports such as skiing, mountain climbing, gymnastics, and wrestling that put your loose joints at risk for injury. Sports better suited to your The Hughston Foundation, Inc. ©2000 Page 7 FOR A HEALTHIER LIFESTYLE Editor George M. McCluskey III, M.D. Why Wear a Mouthpiece? Managing Editor Elizabeth T. Harbison Blows to the jaw during sports participation can cause serious, costly Art Director Carolyn M. Capers, M.S.M.I., C.M.I. injuries to the mouth, teeth, jaw, and head. Studies from the National Editorial Board Youth Foundation for Safety show that an athlete involved in a contact Thomas N. Bernard, Jr., M.D. sport has a 10% chance each season and a 33% to 55% chance during an Douglas T. Cannon, M.D. athletic career of receiving these types of injuries. Clark H. Cobb, M.D. William C. Etchison, M.S. In the 1960s, Dr. Jack Hughston was instrumental in mandating that Bruce A. Getz, ATC all high school football players in the United States wear mouthpieces. Ashley S. Holloway, M.S. Charles H. Keaton, FACHE, CEO He and others involved in the care of athletes found that wearing Teri LaSalle, M.S., P.T., ATC mouthpieces helped prevent injuries, ranging from tooth loss to Leland C. McCluskey, M.D. concussion. Jill Yates, R.N., O.N.C. At less than $2, the cost of purchasing and wearing a mouthpiece is low compared with the cost of treating an injury. Replanting a tooth can Suggested readings and classic cost about $5000, and having a concussion carries a potential cost of references for articles contained brain damage (see “Sport-Related Concussions,” p. 4). Therefore, wearing in this issue can be found on www. mouthpieces while participating in contact sports is important. When hughston.com worn as designed, they offer inexpensive, simple prevention of injuries.

Bruce Getz, ATC Health Hint Columbus, Georgia Weeds, trees, and grasses are in full bloom, producing pollen. Your immune system may react to pollen with The Hughston Health Alert is a quarterly publication of the Hughston Sports Medicine Founda- tion, Inc. The Foundation’s mission is to help people of all ages attain the highest possible standards of sneezing, runny nose, and musculoskeletal health, fitness, and athletic prowess. Information in the Hughston Health Alert reflects itchy eyes. To reduce your the experience and training of physicians at The Hughston Clinic, P.C., of physical therapists and athletic exposure to this allergen, trainers at Rehabilitation Services of Columbus, Inc., of physicians who trained as residents and fellows under the auspices of the Hughston Sports Medicine Foundation, Inc., and of research scientists and wear a tight-fitting facemask other professional staff at the Foundation. The information in the Hughston Health Alert is intended to while mowing the lawn and supplement the advice of your personal physician and should not be relied on for the treatment of an individual’s specific medical problems. stay indoors with the windows Special written permission is required to reproduce, by any manner, in whole or in part, the mate- closed and air conditioning rial herein contained. Send inquiries to Medical Writing, Hughston Sports Medicine Foundation, Inc., on when the pollen counts P.O. Box 9517, 6262 Veterans Parkway, Columbus GA 31908-9517 USA. Copyright 2000, Hughston Sports Medicine Foundation, Inc. ISSN# 1070-7778 are high.

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