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Hi, my name is Jo Gibson, an upper limb rehabilitation specialist, specialised in treating patients with shoulder problems, pain, or instability since 1995. Those of you who've joined me before will know that I like to talk about all things shoulders, some interesting case studies, new evidence, clinical conundrums, all sorts of different things.

Tonight's case study is a request to talk about a particular condition and a patient that I saw regularly that brought this up. And just really some interesting bits from the literature and some pointers to think about when you're treating this particular condition.

So if I tell you about my patient, first of all essentially this was a young student. I'd actually seen this girl when she was about 16 or 17. She'd had a background of instability. She was somebody who did it through the shot put. She was very good. She was doing that at county level. But when she started at university she thought that she'd have a go at rugby. Now it turned out she was very good at rugby and she was a tough girl and she was right involved in the scrum. Definitely wanting to play in a kind of prop forward row. But apparently it had a couple of injuries that what sounded like stingers.

So essentially when she came to see me, the reason she came is she had some AC joint pain, but she'd had three stingers in her first season of playing, she wasn't even at the end of that season when she came to see me. Now, three stingers is not good news for many reasons that we'll talk about. This girl that had a background of laxity, she'd had previous instability in her shoulder, but came to see me because she felt she just hadn't entirely got back the strength in her arm. She did have some AC joint pain and some symptoms in her little finger.

When we talk about stingers or burners, what do we mean?

So they're basically referred to as both in the literature, which is important to know if you're trying to find anything useful about them. Now, essentially they're named according to the symptoms that patients experience. So generally transient burning or stinging pain, funny enough often with some paraesthesia, and they may also have some weakness.

Now typically involves C5, C6, but it can involve the lower nerve roots as well, depending on the mechanism of injury. But typically, if there is any transient weakness, it tends to be an abduction external rotation, and also elbow flexion weakness. And we'll talk about why that might be in just a moment.

Now, as I say, typically patients get these temporary sensory and motor deficits in the extremity, but they can literally last for a few seconds, a few minutes, a few hours, and it can actually last a little bit longer. But the majority, don't miss any games or practice, and that's important to say. A very positive message is 85% of people getting a stinger or burner, actually, it'll go very quickly. They do have a slight increased risk of having a second one, and that's an important thing to consider when we look at the mechanisms, but fundamentally, most of them will do well quickly.

When they present, obviously they have the pain and the paraesthesia that I talked about, and clearly movement loss, but again, very transiently, and a kind of feeling of weakness. The pain can be associated with some initial cervical spine symptoms, but again, they go very quickly.

Typically, it doesn't just fit one dermatome. Typically, the pain's circumferential, it's non dermatomal radiating down the arm, and as I say, about a third have weakness and associated paraesthesia.

It's important to know that in a true burner or stinger, it's unilateral, and that's really important, it only involves one arm. Why is that important? Well, you can imagine in terms of Spinal cord injury, cervical fractures, cervical injuries, anything involving the cord, then you're going to get bilateral symptoms. So that unilateral presentation is really important.

No great surprise, when you look at the typical sports that are involved and where we see these injuries reported most commonly, contact sports, rugby, American football, are probably the two sports that we have the most literature for.

But we also see case studies in boxing, people in the gym, certainly those that are doing heavy lifting with things across their shoulders and also hockey. So, weightlifting, hockey, all those kind of things. If you look at something like American football, it is in fact the most common neck injury that we see.

When you look at the instance in rugby and American football, an interesting fact is, that the prevalence is actually twice as common in pre-season as it is actually during the season. Now, you might think, well, maybe they're just not fit enough. Maybe they've just not had as much tackling exposure. But there's also this query in some of the reporting that athletes aren't as good as reporting it in season because actually they don't wanna risk missing a game.

There's some really nice big studies actually following up patients in American football and in rugby, and in American football, about 77% have that common description of pain associated with tingling. About 61% get some numbness, 44% get some weakness, 17% have some associated neck pain, and about a third have some muscle weakness, which can take five to six days to resolve. As I say, 80% of the stingers described in American football are reported in that pre-season period, which is really interesting. But another important message is to say that despite those symptoms, 64% have less than 24 hours lost to play or training. So it's important to know that generally this is a positive condition. It's annoying, it goes away, but we just need to have a bit of vigilance in some key situations.

In rugby, again, there was a really nice follow up study looking at 569 rugby players. 21% of whom reported having had a stinger, 34% had more than one, so they'd had a prior history, but 76%, so three quarters of all stinger injuries resulted from a tackling injury. So we're gonna talk about mechanism in just a moment. So that's something important to bear in mind and it's particularly relevant with this young girl that I'm talking to you about. In rugby exactly the same in terms of return to play. Again, around 64% are back to play in 24 hours. But importantly, between 80 and 85% don't miss a competitive game.

Thinking about my patient, there's some key things that we need to consider when we look at stinger and burner injuries, there's three key mechanisms. The first is a direct compression. That's where basically somebody's helmet, somebody's head, it could be a weight bar, a blunt trauma, it hits the brachial plexus at the Erb's point. Now, Erb's point is, two to three centimeters superior to the clavicle where C5 and C6 join a kind of upper trunk of the brachial plexus and where it's most superficial. Obviously, this is gonna impact the axillary nerve, the musculocutaneous nerve, the suprascapular nerve. This is where it's particularly vulnerable and actually you can almost palpate it if you go those two to three centimeters, the posterior border of your sternocleidomastoid, it's pretty uncomfortable if you start prodding around there. That's the first mechanism.

The second mechanism is traction of the brachial plexus, and that's generally due to an increased angle between the shoulder and the neck. So the shoulder gets depressed, the neck gets laterally flexed away all very quickly.

And again, we get this massive overstretch. You can see in that situation, that was very much the mechanism that related to the lady I was treating. And so that would make sense that perhaps she had some more lower nerve root involvement.

And the third mechanism is basically nerve root compression. Either because of extreme flexion, extension or side flexion. So three quite different mechanisms.

If you look at direct compression, that's very common in American football. Usually from direct player contact, generally over the Erb's point where the brachial plexus is more vulnerable.

Just because that's where it's most superficial, helmet or the shoulder hits or the scapula gets squashed because somebody's on top of it. But again, commonly that's gonna take out C5 and C6, however, transiently with deltoid, supraspinatus and biceps are a very clear pattern. So again, knowing that mechanism or the point at which they felt those transient symptoms can be very helpful in working out.

In the traction injuries, that's probably what accounts for a lot of our tackling related injuries where the shoulder gets depressed and then we have lateral flexion of the cervical spine. Theoretically, that should have been significantly improved by some of the changes in terms of tackle rules and people going in with their shoulder rather than their head to make the neck less vulnerable.

But again, often with novice rugby players, sometimes, they'll still go in with their head too high. And again, that can make them very vulnerable. So clearly it's a coaching issue, but in somebody new who perhaps hasn't had the exposure, it's something just to be aware of.

Similarly, if you look at the flexion extension injuries, what's really interesting about those is there's some evidence to suggest that actually they're more common in your aging athletes who's been playing for a long time. And there does seem to be some association with restriction of range of movement in the cervical spine as a precursor, but also foraminal narrowing and also cervical disc degeneration.

So there's actually some studies that would look at measuring the index in terms of the width of the spinal canal and actually seeing that as a potential risk factor. Now, I think we have to be a little bit careful when we saw all the evidence, challenging the relevance of imaging and knowing that it's very dependent on an individual's physiology.

However, it's important to let you know that there are papers out there where they've measured an index and seen that specifically an older athlete who's getting recurrent stingers who's got some significant cervical stenosis or cervical disease. That may be a factor that's taken into account in decision making in terms of whether they should keep playing.

So I'll post some links to a couple of those papers because they're worth a read. But again, important that when we look at evidence and stuff, we probably haven't got robust studies that follow that up over time.

Some papers postulate that having hypertrophic scaleni might be a risk factor, but you could probably argue that both ways. One of the biggies as say, is how old the athlete is and also, their tackling technique.

With my girl, what was the key issue? Well, probably the clues in her history. She's had three, which is not good news. If you look at most return to play things. They'll say if somebody's had two in the same season, then essentially they need a period of time out to do stuff. And actually this girl them in three subsequent weeks, which is clearly not very good. And she just about recovered each time. So again, it wasn't something that was just coming and going quickly. She's getting a really good overstretch, getting some real neural irritation. And then just about recovering by the time she played her next match.

With these sorts of athletes, again, I know her, I know she's had a background of instability. I'm gonna ask her if she's still been doing any sort of shoulder rehab or any strengthening and what she's been doing in the gym. But also, one of the other things that I hadn't done with her specifically was any specific neck strengthening.

And clearly for anybody who's gonna be in the scrum, that's a really important thing. Now, the other thing is this girl had some AC joint irritation, but again, if somebody's had some neck pain, if they've got some ongoing neck stiffness or neck symptoms, we know that can have a facilitative effect on upper trapezius and it might alter some of the mechanics around the AC joint just because of those protective patterns. So again, it's just working out what's the chicken and what's the egg.

When we look at these situations, we talked about tackling ability, the studies looking at modifying tackling technique, and some of the rule changes have certainly helped that. There was a really nice study that showed that before the rule changes, if you looked at having that high head where the head's almost ahead of the ball carrier, then the bottom line is 69 per thousand stinger injuries compared to after modifying the technique and actually much more that shoulder loading, it went down to 2.7 per thousand. So that's a change. So clearly what we need that drop shoulder, but what's really important is not getting the head on a massive stretch and taking a hit either on that Erb's point or getting that massive overstretch. And when I spoke to this girl's physiotherapist, who luckily was a colleague of mine who was doing the physio for the university team, he basically pointed out that she always had her head too high and that he was working with the coaches in the club to try and address that.

Clearly, in somebody's learning, what's really important is to limit her tackling exposure or arguably take her out of play for a period of time until we know she's got adequate neck strength that we've really addressed any issues around her shoulder, and I'll come back to those in just a moment because clearly she's not gonna go back until she's got full range of movement, no pain in her neck, no neurological symptoms, but the very fact that she's had three in quick succession, we need a period of time out. Address all the potential things that are contributing.

Once she's got that strength, she ticks all those boxes in terms of return to play, and we are happy we've ruled out anything else concerning. Then the bottom line is then that doing the tackling training is definitely gonna be part of her return to play. Now, as I said, If you get somebody who's had a stinger injury, there are some key things that you might want to think about.

Bilateral symptoms, you're going to need to start looking, and particularly with associated neurology, we're going to be very vigilant in terms of some of our fractures, our spinal cord injuries. Similarly, remember, we've talked before on these Facebook Lives about vascular presentations, the importance of screening for vertebrobasilar insufficiently, our headaches, our dizziness, our nausea and vomiting, dysarthria, visual disturbance.

Again, just be very clear about those, and we've talked again about how we'd look at perfusion, how we'd look at blood pressure index, et cetera, if there was any indication of any vascular element in presentation. Of course, what's really important is we need to consider in terms of our differential diagnosis, whether there's any evidence that might make us worry about a fracture and further investigation, whether it is discogenic or nerve root compression.

Again, we've talked about cervical spine differentiation before. But really it's all about a thorough assessment. Often these patients won't have a positive Spurling. Generally,

if you look at Guidelines for the management of these stinger and burner injuries say that essentially if patients have had symptoms for longer than an hour than they might be merit in doing some simple radiographs, particularly if they have neck pain with movement. And particularly if it's their second episode in quick succession. However, what they also say is that you don't need to go on to do MRI and up to 70% of patients if symptoms still resolve relatively quickly.

EMG might be useful, but again, it often can take up to three weeks before you see any changes in terms of an axonal transport, but they can still pick up some conduction abnormalities and distinguish between pre and post ganglionic brachial plexus injuries if we use EMG. So there might be merit in doing those things if somebody's had repeated episodes and has some subtle weaknesses or signs that you are picking up and those things aren't going away, but as I say, remember the majority, it's a quick injury that goes away very quickly.

With my patient, what are the things that are relevant? Well, I treated her for instability before. Again, if you've joined us on these Facebook Lives, you'll know obsession with the scapular is not a good thing because bottom line is there's lots of people that are asymmetrical, and particularly somebody like this who's thrown this shot put from a young age. However, what is interesting is again, is when you look at follow up of patients who have some ongoing symptoms, not relating to their stinger or burner, but because of compensations, it does seem to relate to changes in scapular symmetry.

So if you like, they're compensating because of changes or protect patterns around the shoulder. Or maybe because they temporarily accommodated some weakness. But essentially about a third of patients get some change in scapular dyskinesis. Again, it needs to be a little bit cautious, but it does seem to give them a slight increased risk of reinjuring themselves.

And I guess again, it's just that whole engagement with the shoulder and having good strength and control into that situation. So as well as liaising with this girl's coach when she was ready to go back, we did a lot of cervical strength. And if you actually go onto YouTube and you put in Springboks and you put neck strengthening, there's some really lovely ideas.

There's some really simple ways of getting the neck strong, and certainly I use loads of those ideas there, as ever it's on a good solid framework. So as you'll know if you've listened to me before, it's not about working the cuff or the scapular in isolation. It's making sure that we've got a really good foundation of working those things together and then strengthening in a functionally relevant way.

And then once we are confident she's got those ingredients, then getting her back to doing the things that she wants to do. So, definitely a time when strength is needed. So she's ready and robust. And to be quite honest, I think because she was naturally strong, the issue with this girl is that she essentially just hadn't done an awful lot in terms of strengthening and preparing and had got all carried away. And essentially on that background of laxity, with the problems in terms of her shoulder instability, I suspect there was some subconscious protection going on as well.

I hope this has answered the questions. Sometimes, particularly with people in sport and particularly people who are getting a recurrent injury, perhaps just looking at considering the other things that could be going on in their life that could be contributing.

Essentially some nice questions here. So, what is a good treatment option to treat shoulder instability? Again, we've talked about instability on one of the Facebook Lives before. So it's definitely worth just going onto the public page and searching shoulder instability and it should take you to that. But I'm not gonna just leave you with that as a quick summary.

So why is shoulder instability any different from shoulder pain? Well, bottom line is, it isn't. We still need to do the same things in terms of our key foundations. Essentially getting things doing their job through range, making sure the cuff can do its job with the weight of the arm. But where instability seems to be a little bit different is there is more evidence to support specific proprioceptive deficits.

So one, in terms of that feed forward, get ready for action. And secondly, reactive stabilisation, so the muscles reacting quickly enough to perturbation and under loaded conditions. Now there's some really nice simple programs out there, the Derby Instability Program, which when you consider, as well as those proprioceptive deficits, deficiencies in the posterior cuff, some evidence to support some specific muscular weaknesses in relation to the scapula, so, serratus. And then finally some core stability issues. Though all those things have been given some credence in the instability literature. The bottom line is the Derby Instability Program, I really like it to complement those foundations and making sure the cuff's doing its job because it addresses those two things. So there's weightbearing exercises in the concepts of the kinetic chain, and there's also some drop and catch and plyometric stuff. So it kind of ticks both those boxes. And if nothing else, it gives you some really nice exercise ideas.

A very different approach is that described by Lyn Watson. She does some really scapular based stuff to start with, where she puts band over the shoulder and really gets them that upward rotation to get the scapular upwardly rotating and then adding in external rotation and working it through range.

Less about some of those other proprioceptive things I talked about, but later in the program, she does more eccentric work that we know, addresses that feed forward, and then more sort of plyometric work. So there are some things out there, there have been some comparisons. There's small numbers studies. The key thing with instability is most studies say it'll take six months for people to get better. You expect them to improve before that. But again, like anything, what's really important from the outset is reassuring the patient because clearly you told you've got an unstable shoulder. That's not terribly reassuring, and for some patients that can make them very fearful about moving because of the risk of subluxation. So as ever, it's really important to ascertain those things because we know even in atraumatic instability, if patients have fears, kinesiophobia, fear of re-subluxation, they're more likely to do it because the protective strategies actually make their shoulder more vulnerable.

That was a quick whiz through instability. Definitely have a look at those couple of things because they're probably the best resources out there. I've just actually finished, well, Jeremy Lewis's new textbook that I was very lucky to contribute a few chapters to. Essentially, I was involved with some other authors looking specifically at instability and as I say, those are really the sound bites that as well as your key foundations addressing those specific elements of proprioception seem to be really relevant. And they're definitely things that I reflect in my practice. So, closed chain for the gain in terms of that feedforward. Drop & catch and plyo-type work for the reactive stuff. But again, always making it relevant to the patient. So thank you very much for that question. I really hope you took some interesting things away from that. I think generally, in rugby particularly, and the American football teams that I'm involved with, I tend to see people with really chronic grotty shoulder things that haven't got better.

Generally, the club physios are all over these injuries because it's something they see very regular. Certainly in American football it's the most common neck injury. The important message is, most of them do well. Remember though, if they've had one, they're more likely to get another one.

And secondly, I think when I look back on my practice, probably I didn't spend quite enough time strengthening the neck as well as everything else around the shoulder. And it's a bit of a no-brainer, anybody going into contact to really target those specific things.

So Mohamed, nice to have you here. Is it the same rehab approach in supraspinatus tendinopathy versus tendon tear on what best options of treatment so far? Now Mohamed, I could spend a whole day talking about that. Again, we have talked about some specific things on the Facebook lives before that will cover that.

The big thing for me, if we look at anybody with shoulder pain as ever, there are some key foundations. So my general go-to is looking at something through range because we know that has good value in restoring non-painful efficient movement for want of a better description and making sure the cuff can do its job. That's my bias, if you like.

In terms of where things might differ, if I've got a tendinopathy rather than a tear, the first thing to say is if it's a younger person with a tendinopathy because of too much loading. Bottom line is it's probably gonna take 12 weeks to get better. If I have an older degenerative supraspinatus tendon tear, so an older patient with proven degenerative pathology, then the evidence says they could take up to six months to get better.

So, it's gonna affect my expectations. The ingredients of what I'm do will be similar. But the way in which I load that tendon might be a little bit different. So again, it's going to depend if it's traumatic or non-traumatic in terms of the tendinopathy, how long they've had it. And when I get to a loading intervention, it might just change the specifics that I use, but Mohammed, what I would suggest is, we've done a load of free videos about treating and assessing shoulders.

We did one about the use of eccentric, which talks about their application potentially in that tendinopathy group if they're not doing well. But then arguably I could do exactly the same in somebody with a tendon tear. I think the key thing is I'll probably just progress a little bit more cautiously.

If it's somebody with an acute tear, again, my general approach is just let's make life easier for the shoulder, unload it, and that might just be changing the lever arm. If it's really irritable, it might be supporting the weight of the arm, bit of resistance to remind the posterior cuff to do its job. And then, as I say, make it doing some supported cuff work until they can cope with load and progressing it up.

But as ever, as soon as I can with loading, making it relevant to the patients. So I feel like there's a very kind of politician's answer, but that's a kind of subject that probably would be a good subject for a future Facebook Live. There's loads of great resources there that might help you with that already. I hope that's given you a quick summary of how I'd approach it. Thanks for your question. Hope you've taken some useful tips and tricks away as ever, and I'll look forward to seeing you for some more shoulder information and some more interesting cases. Enjoy the rest of your week guys. See you again very soon. Bye for now.