Hi, my name is Mike Henehan, and I'm a faculty member in the Stanford O'Connor Sports Medicine Fellowship Program. This case presents a good example to show an on-the-field exam. In the case of an athlete coming off the field, holding their arm often in a position obviously in pain, the immediate things we think about would be, was there a cervical spine injury? Could it be a so-called stinger? Is it an AC joint injury? Or was there possibly a shoulder dislocation? So when I'm evaluating a patient, usually a football player who comes off the field, with that presentation, my main concern is to prioritize my exam so that I look at the things that would be most worrisome first. So I'll typically just palpate the cervical spine, posteriorly looking for any focal point tenderness. I'll then have the athlete rotate their neck, so doing active motion, so go ahead and rotate to the right, rotate to the left. If there's tenderness to palpation, or they're unable or unwilling to do active rotation, I stop right there. We're going to evaluate this person for potential cervical injury. If I don't get either of those, the next thing I'll do is an axial load. I'll turn on the vertebral column just to see if there's any tenderness with that maneuver. If everything checks out for that part of the exam, then I start thinking of less catastrophic types of problems. So I'll have the athlete face me usually. Often they have their shoulder pads on, so you have to kind of deal with that. I'll reach up under their shoulder pads, and I'll palpate the AC joint to see if there's any focal tenderness. I'm also palpating the shoulder to make sure it isn't stepped off that would be consistent with a shoulder dislocation, because rather than a normal, rounded feel of the shoulder, it would be squared off, and it's rather dramatic. It's hard to miss that one. If that all checks out, then the next thing that I'm thinking about is, could this be a stinger? The athlete in the case presentation was fairly unusual in that it was a bilateral stinger, and that's not the usual presentation. Usually it's one side or the other. That would certainly be more worrisome, but just, again, to demonstrate what you would normally see where the symptoms are on one side, where you consider it the normal presentation for a stinger. So at this point, to evaluate that, again, the first step was to realize bad things. But now let's take a look at strength. So I have the athlete bring their arm up. I push down, have them resist, push up, have them push against internal and external rotation. If that looks good, then I'll move on to sensation, and I'll look at C5, C6, C7, C8, make sure there's no sensory deficit. And then if I have a reflex hammer, I would tend to do reflexes as well. Often there'll be weakness when you first do the strength testing, but that's more from pain or apprehension of the athlete, and that generally clears up fairly quickly. It's not uncommon, however, that you have to do serial exams looking at a stinger because the big concern is, you know, could there be neurologic injury in the brachial plexus from usually a tackle? And if that's the case, your serial exam is going to show continued weakness, and then you would be wanting to do a further evaluation. You certainly wouldn't put an athlete back in until their neurologic symptoms are cleared completely.

2nd Edition, CASE 52

2nd Edition

Spine

on-field evaluation

arm injury

cervical spine

shoulder dislocation

brachial plexus