Burner / Stinger Injury

Upper Limb

Overview

A burner or stinger is a transient brachial plexus injury causing acute nerve irritation, typically resulting from shoulder depression with cervical lateral flexion or direct trauma to the shoulder girdle. This common sports injury presents with acute burning pain, paresthesia, and weakness in the upper limb that usually resolves within minutes to hours. While most cases are benign and self-limiting, recurrent episodes warrant thorough assessment to exclude structural pathology.

Pathophysiology

The injury mechanism involves stretch or compression of the brachial plexus nerve roots (C5-T1), most commonly at the level of the shoulder girdle during forced shoulder depression combined with cervical contralateral flexion or rotation. The plexus becomes traction-loaded or compressed against surrounding structures (scalene muscles, clavicle, first rib), causing acute neuropraxia with demyelination of nerve fibers without structural interruption. This results in transient loss of conduction velocity, manifesting as acute burning dysesthesia, paresthesia, and muscle weakness in the distribution of affected nerve roots.

Patient Education

A burner or stinger is a temporary nerve irritation that usually recovers quickly, but recurrent episodes or persistent symptoms require medical evaluation to rule out structural neck problems and establish preventive strategies including proper neck strengthening and technique modification.

Typical Presentation

Site

Lateral shoulder, upper arm, and forearm; often unilateral following impact; symptoms may follow dermatomal or specific nerve distribution (C5-C6 most common)

Quality

Burning, sharp, tingling, electric shock-like sensation; described as 'burner' or 'stinger' due to characteristic burning dysesthesia

Intensity

Acute onset severe pain/paresthesia (8-10/10) with rapid onset but typically brief duration; intensity decreases within minutes to hours

Aggravating

Shoulder depression with cervical lateral flexion, direct blow to shoulder area, contact sports maneuvers, rapid overhead arm movements, continued activity after initial injury

Relieving

Cessation of activity, gentle shoulder shrug/elevation, rest, removal from aggravating position, ice application, typically resolves spontaneously within minutes

Associated

Acute weakness in shoulder abductors (supraspinatus, deltoid) or arm flexors/extensors depending on nerve root involvement, transient muscle weakness lasting minutes to hours, possible mild cervical pain at time of injury, shoulder girdle muscle tightness

Orthopaedic Tests

Test descriptions are written with AI assistance from standard clinical texts. Where a test lists Sources, its description has been checked against them; those sources are independent and do not endorse OsteoKit. Accuracy figures and grades (A–D) appear only when checked against the published study; tests without one are marked “No accuracy study”.

Further reading: full test procedures are described in standard clinical examination texts, e.g. Magee & Manske, Orthopedic Physical Assessment (7th ed.), and Cook & Hegedus, Orthopedic Physical Examination Tests: An Evidence-Based Approach (2nd ed.).

Grade B
A+ABCDGood clinical value: meaningfully changes the diagnosis in one direction (LR 5–10 or 0.1–0.2)
best for ruling OUT (screening).

Upper Limb Tension Test (ULTT) – Median Nerve Bias

Procedure

Patient supine. With the shoulder girdle held down, abduct and externally rotate the shoulder, supinate the forearm, extend the wrist and fingers and then the elbow. Add neck side-flexion away from and towards the test side.

Positive Finding

Reproduction of the familiar arm symptoms that changes with neck side-flexion and differs from the other side.

Sensitivity / Specificity

97%/22%

Reference: Wainner RS et al., Spine 2003; PMID 12544957

Interpretation

Shows that the nerves of the arm are irritable. After a stinger, a positive test supports ongoing nerve irritation; a negative test makes cervical radiculopathy less likely. Note: these figures derive from cervical radiculopathy populations (Wainner 2003); not validated specifically for burner/stinger injury.

Sources

Grade C
A+ABCDModest value: a small but usable shift in probability (LR 2–5 or 0.2–0.5)
modest, supportive value.

Spurling's Test (Cervical Compression Test)

Procedure

Once serious injury has been excluded, with the patient seated: extend the neck and side-bend it towards the symptomatic side, then apply gentle downward pressure through the head. Do not perform on the field if there is neck pain, bony tenderness or bilateral symptoms.

Positive Finding

Reproduction of the familiar burning or electric pain into the arm on the tested side.

Sensitivity / Specificity

50%/86%

Reference: Wainner RS et al., Spine 2003; PMID 12544957

Interpretation

Supports nerve-root compression in the foramen, a mechanism more common in older or recurrent 'stingers'. Symptoms in both arms, persisting weakness or neck pain need medical assessment and imaging before return to play. Note: these figures derive from cervical radiculopathy populations (Wainner 2003); not validated specifically for burner/stinger injury.

Sources

Grade C
A+ABCDModest value: a small but usable shift in probability (LR 2–5 or 0.2–0.5)
modest, supportive value.

Neck Distraction Test

Procedure

Patient supine, once serious injury has been excluded. Cradle the occiput and chin and apply a gentle, gradually increasing lift along the line of the spine.

Positive Finding

Relief or reduction of the familiar arm pain or tingling while the neck is lifted.

Sensitivity / Specificity

44%/90%

Reference: Wainner RS et al., Spine 2003; PMID 12544957

Interpretation

Relief supports nerve-root compression in the foramen. Return to play needs full pain-free neck movement, normal strength and no symptoms. Note: these figures derive from cervical radiculopathy populations (Wainner 2003); not validated specifically for burner/stinger injury.

Sources

No accuracy study

Shoulder Abduction Relief Test (SAT)

Procedure

Patient seated. Ask the patient to rest the hand of the symptomatic arm on top of the head.

Positive Finding

The arm pain or tingling eases in this position.

Interpretation

Relief supports cervical nerve-root compression (usually C4–C6) because the position slackens the nerve root. It helps tell nerve-root pain from shoulder pain.

Sources

No accuracy study

Cervical Rotation Lateral Flexion (CRLF) Test

Procedure

Patient seated. Rotate the head fully away from the tested side, then gently flex the neck forwards, bringing the ear towards the chest.

Positive Finding

Forward flexion in this rotated position is clearly blocked compared with the other side.

Interpretation

Assesses first-rib movement. A block suggests an elevated, stiff first rib, which has been linked to thoracic outlet and arm symptoms. It does not test the nerve root. This entry previously described a different manoeuvre.

Sources

No accuracy study

Tinel's Sign (Supraclavicular Brachial Plexus)

Procedure

Tap gently over the brachial plexus above the clavicle (Erb's point), on both sides.

Positive Finding

Tingling spreading into the arm on the tapped side.

Interpretation

Suggests irritation of the upper trunk of the plexus, which fits a traction-type stinger. The cervical nerve roots themselves lie deep in the foramina and cannot be tapped.

Sources

⚠ Red Flags

  • •Recurrent episodes suggesting underlying structural cervical pathology requiring imaging
  • •Neurological deficits persisting beyond 48 hours suggesting possible nerve root avulsion or serious plexus injury
  • •Bilateral symptoms suggesting possible myelopathy or serious CNS pathology
  • •Progressive neurological deterioration contraindicating continued play
  • •Bowel or bladder dysfunction or lower limb involvement suggesting spinal cord involvement
  • •History of significant trauma with severe ongoing pain suggesting possible serious structural injury

⚡ Yellow Flags

  • •Athlete anxiety or catastrophic thinking about recurrence impacting performance
  • •Fear-avoidance behaviors limiting rehabilitation or sport participation
  • •Emotional distress from repeated injury episodes affecting psychological resilience
  • •Pending return-to-sport decision creating time pressure on recovery
  • •Poor social support from coaching staff or team regarding injury management
  • •History of recurrent burners without structured return-to-sport protocol or cervical strengthening program

Osteopathic Techniques

Refer first

This condition needs medical assessment and management first. Do not use neck-directed manual techniques. Any osteopathic care is supportive, away from the injured area, and only once the treating team has cleared it. Recurrent stingers need medical review: they are more common with structural changes in the cervical spine.

Rehabilitation Exercises

Cervical Lateral Flexion with Contralateral Shoulder Shrug

Range of MotionBeginner

Upper Trapezius Stretch (Ear-to-Shoulder)

StretchingBeginner

Scalene Muscle Stretch (Seated, Contralateral Rotation and Flexion)

StretchingBeginner

Shoulder Shrug Hold with Isometric Contraction

StrengtheningBeginner

Cervical Isometric Lateral Flexion Resistance

StrengtheningBeginner

Chin Tucks with Shoulder Blade Retractions

PosturalBeginner

Prone Shoulder Blade Squeeze (Rhomboid Activation)

StrengtheningIntermediate

Lateral Shoulder Raise with Scapular Stability

StrengtheningIntermediate

Wall Slides with Cervical Neutral Spine

PosturalIntermediate

Proprioceptive Neck Stabilization Exercise (Eyes Closed, Gentle Head Movements)

BalanceIntermediate

Quadruped Row with Cervical Stabilization

StrengtheningAdvanced

Sport-Specific Technique Training with Neck Brace (Graduated Return-to-Sport)

StrengtheningAdvanced

Referral Criteria

  • •Recurrent episodes (≥2 burners in single season) warrant neurology or spine specialist evaluation and imaging to exclude cervical myelopathy or structural pathology
  • •Neurological deficits persisting beyond 48 hours require urgent neurological assessment and possible EMG/NCS studies
  • •Bilateral symptoms or lower limb involvement require immediate medical evaluation to exclude myelopathy
  • •Progressive weakness or functional deterioration warrant urgent specialist referral
  • •First episode with significant ongoing pain or high-impact mechanism warrant imaging referral to exclude structural injury
  • •History of cervical spine pathology (spondylosis, stenosis) should be referred for baseline imaging if not recently obtained
  • •Return-to-sport clearance decision requires input from sports medicine physician or appropriate team medical staff
  • •Athlete with multiple recurrent episodes may benefit from sports psychologist consultation to address anxiety or fear-avoidance behaviors