Nerve Entrapment Summary Sports

Sports Med 2005; 35 (8): 717-738REVIEW ARTICLE 0112-1642/05/0008-0717/$34.95/0

2005 Adis Data Information BV. All rights reserved.

Peripheral Nervous System Injuries inSport and RecreationA Systematic Review

Cory Toth,1 Stephen McNeil1 and Thomas Feasby2

1 Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada2 Department of Medicine, University of Alberta and Capital Health, Edmonton,

Alberta, Canada

ContentsAbstract . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 718

1. Cervical Radiculopathy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7192. Spinal Accessory Nerve (at the Lateral Neck) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7193. Brachial Plexus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7194. ‘Stinger’ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7235. Thoracic Outlet Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7246. Long Thoracic Nerve . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7247. Thoracodorsal Neuropathy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7248. Dorsoscapular Nerve . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7259. Suprascapular Nerve . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 725

10. Medial Pectoral Neuropathy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72611. Axillary Nerve (at the Shoulder) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72612. Median Nerve . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 727

12.1 Entrapment at Pronator Teres . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72712.2 Entrapment Within the Carpal Tunnel at the Wrist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72712.3 Entrapment Within the Palm of the Palmar Branch . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 728

13. Ulnar Nerve . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72813.1 At the Elbow in the Cubital Tunnel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72813.2 In the Forearm at Flexor Carpi Ulnaris . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72913.3 At the Wrist in Guyon’s Canal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72913.4 In the Palm at the Deep Motor Branch . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 729

14. Musculocutaneous Nerve . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73015. Lateral Antebrachial Cutaneous Neuropathy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73016. Radial Nerve . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 730

16.1 At the Spiral Groove . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73017. Posterior Interosseous Neuropathy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73018. Superficial Radial Nerve . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73119. Digital Nerves (at the Fingers) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73120. Lumbar Radiculopathy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73121. Pudendal Nerve . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73122. Iliohypogastric Nerve . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73223. Sciatic Nerve . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73224. Femoral Nerve . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73225. Lateral Femoral Cutaneous Nerve . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73326. Obturator Nerve . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73327. Posterior Cutaneous Nerve of the Thigh . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 733

718 Toth et al.

28. Peroneal Nerve . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73328.1 Common Peroneal Nerve . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73328.2 Superficial Peroneal Nerve . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 734

29. Tibial Nerve (at Tarsal Tunnel) and Lateral and Medial Plantar Nerves . . . . . . . . . . . . . . . . . . . . . . . . 73430. Sural Nerve . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73431. Saphenous Nerve . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73432. Dorsal Cutaneous Nerve of Foot . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73433. Interdigital Nerves of Foot . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73434. Morton’s Neuroma of Plantar Nerve . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73435. Calcaneal Neuropathy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73536. Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 735

Many sports are associated with a variety of peripheral nervous system (PNS)Abstractinjuries specific to that sport. A systematic review of sport-specific PNS injurieshas not been attempted previously, and will assist in the understanding ofmorbidities and mortality associated with particular sporting activities, eitherprofessional or amateur. A systematic review of the literature using PubMed(1965–2003) was performed examining all known sports and a range of possiblePNS injuries attributable to that sport. Numerous sporting activities (53) werefound to have associated PNS injuries. The sports most commonly reported withinjuries were football, hockey, soccer, baseball and winter activities. There are anumber of sporting activities with injuries unique to the individual sport. Thisreview should be of assistance for the neurologist, neurosurgeon, orthopaedicsurgeon, physiatrist, sports medicine doctor, athletic trainer and general physicianin contact with athletes possessing neurological injuries.

Neurological injuries are varied and numerous and prognosis have been included, as well as recom-depending on the nature of the sporting activity, age mendations for diagnostic and therapeutic interven-of the participants, and intensity of play. The type of tions for specific sports-related injury. The numer-sport may vary from recreational games such as ous peripheral nerve injuries attributable to eachlawn darts, or spectator sports such as professional sport have been listed.football. The physician may be confronted with

A MEDLINE search was performed using thesymptoms and signs reflecting injury to a number of

website of the National Library of Medicineneurological levels, including the peripheral nerve,(‘PubMed’) to examine the literature for all possiblespinal roots and brachial plexus. Recognition ofscientific papers discussing sports and neurologicalspecific injury and its relationship to a specificinjuries published between the years of 1966–2003.sporting activity may assist the physician with theMeSH search terms and non-MeSH terms used in-rapidity of diagnosis and possible therapy.cluded all combinations as listed in table I. AllWe have performed a systematic review of theabstracts found using these MeSH terms were ex-scientific peer-reviewed literature in order to obtainamined. Articles were included for consideration inan exhaustive description of injuries to the peripher-this review if they met the following criteria: (i)al nervous system (PNS) associated with specificpapers describing a series of injuries or a single casesporting activities. Injuries have been categorised byreport of injury, including those of a neurologicalanatomical location of peripheral nerve injury.basis, within one sport or activity; and (ii) papersWhenever possible, comments about pathogenesis

2005 Adis Data Information BV. All rights reserved. Sports Med 2005; 35 (8)

PNS Injuries in Sport and Recreation 719

Table I. List of MeSH and non-MeSH terms used

MeSH terms

Athletic injuries; badminton; baseball; baseballs; basketball; boxing; brachial plexus; compression neuropathy; dancing; diving;entrapment neuropathy; epidural haematoma; facial nerve injuries; facial neuropathy; traumatic; football; footballs; golf; hockey; fieldhockey; ice hockey; injuries; sports; lacrosse; lumbar plexus; marathon; mononeuropathies; racquet sports; racket sports; snow sports;sports; sports equipment; sports medicine; medicine; sports; racquetball; rugby; skating; skiing; snowboarding; soccer; sports injuries;squash; tennis; wounds and injuries; wounds and injury; wounds; injury; wrestling

Non-MeSH terms

Anterior interosseus nerve; archery; auto racing; axillary nerve; ballet dancing; common peroneal nerve; femoral nerve; gluteal nerve;median nerve; musculocutaneous nerve; nerve injury; neurological injury; peroneal nerve; plexopathy; plexus injury; posteriorinterosseus nerve; quadriplegia; radial nerve; radiculopathy; sciatic nerve; superficial peroneal nerve; sural nerve; tibial nerve; ulnarnerve

describing one particular form of peripheral nerve results of our MEDLINE search by listing injuries toinjury within a group of sports. the central nervous system (CNS) by peripheral

nerve lesion beginning in the upper extremities in aWhenever possible, full publications were ob-proximal to distant gradient.tained in place of abstracts. References found within

the obtained papers, which met the above criteria, 1. Cervical Radiculopathywere also used to obtain further relevant papers,textbooks, or scientific presentations for data to be Although controversial, the ‘stinger’ (describedused within this review. In situations where the in sections 3 and 4) is believed by some authors toassociation between a sporting activity and injury be due to a transient C5 or C6 radiculopathy,[1] whilewas questionable, the article was not included with- others believe it to be due to dysfunction of thein this review. Categorisation was performed by upper trunk of the brachial plexus.[2,3] Football play-each individual sport or activity. Injuries of the PNS ers are subject to more persistent cervicalare organised by sport within table II, and are or- radiculoplexopathies including upper trunk brachialganised anatomically in table III. plexopathies.[4,5] However, cervical radiculopathy is

probably underreported, as no other associationsA total of 270 abstracts were found using thewith sporting activities can be located in the litera-defined search criteria. Examination of referencesture.within the initially found manuscripts revealed an

additional 92 articles to be obtained. The final refer-2. Spinal Accessory Nerve (at theence list consisted of 139 papers or books. Refer-Lateral Neck)ences were obtained in full in 68% of cases, and

abstracts were used in remaining cases where the Although the martial arts have been associatedjournal could not be located or was in a foreign with numerous injuries, neurological injuries occurlanguage, resulting in the abstract being used for in an unusual manner secondary to direct blowsinformation. Sporting activities associated with pe- leading to a presumed nerve contusion, including aripheral nerve injury are listed in alphabetical order, mononeuropathy affecting the spinal accessoryspecific by sport, within this article. The majority of nerve.[6]

the references located were of individual case re-ports, or of a small series of similar injuries within 3. Brachial Plexusone sporting activity. In all cases, emphasis wasplaced upon those cases where electrophysiological The brachial plexus is most often at risk due toevidence of a nerve lesion was demonstrated. traumatic injuries, although traction can also lead toFigures 1–7 demonstrate the PNS and the lesion brachial plexopathy. Football is perhaps the mostsites where particular sports have been associated common sporting activity associated with brachialwith peripheral nerve injury. This article outlines the plexus injury (figure 1). American and Canadian


720 Toth et al.

Table II. Peripheral nervous system injuries by sport

Archery Digital nerve compression; median neuropathy at wrist; median neuropathy at pronator teres; longthoracic nerve palsy

Arm wrestling Radial nerve palsy

Auto racing Brachial plexopathy; sciatic neuropathy; peroneal neuropathy

Ballet dancing Suprascapular neuropathy; femoral neuropathy; peroneal neuropathy; sural neuropathy; dorsalcutaneous neuropathy; Morton’s neuroma

Baseball Suprascapular neuropathy; radial neuropathy; ulnar neuropathy; median neuropathy at pronator teres;thoracic outlet syndrome; axillary neuropathy with quadrilateral space syndrome; digital neuropathy atthumb; brachial plexopathy (‘pitcher’s arm’)

Basketball Suprascapular neuropathy; stinger; median neuropathy at the wrist (wheelchair athletes); ulnarneuropathy at the wrist (wheelchair athletes)

Bicycling Ulnar neuropathy at Guyon’s canal; ulnar neuropathy at the elbow; median neuropathy at wrist;pudendal neuropathy; posterior cutaneous nerve of the thigh neuropathy; sciatic nerve palsies(unicyclists)

Bodybuilding and weightlifting Ulnar neuropathy at the deep motor branch; ulnar neuropathy at flexor carpi ulnaris; ulnar neuropathyat the deep palmar branch; ulnar neuropathy at the elbow; posterior interosseous neuropathy; medialpectoral neuropathy; suprascapular neuropathy; median neuropathy at the wrist; long thoracicneuropathy; lateral antebrachial cutaneous neuropathy; musculocutaneous neuropathy; femoralneuropathy; thoracodorsal neuropathy; dorsoscapular neuropathy; stinger; rectus abdominissyndrome with rhabdomyolysis

Bowling Digital neuropathy of the thumb

Boxing Stinger

Cheerleading Digital neuropathy; median neuropathy at the palmar branch

Football Stinger; upper trunk brachial plexopathy; radiculopathy of C5, C6, L5 or S1 roots; axillary neuropathywith or without dislocated shoulder; suprascapular neuropathy; ulnar neuropathy at the elbow;median neuropathy at the wrist; long thoracic neuropathy; radial neuropathy; thoracic outletsyndrome; iliohypogastric neuropathy; peroneal neuropathy with knee dislocation; sciatic nerve(hamstring syndrome)

Frisbee Posterior interosseous neuropathy

Golf Median neuropathy distal to wrist; carpal tunnel syndrome; ulnar neuropathy at flexor carpi ulnaris

Gymnastics Posterior interosseous neuropathy; lateral femoral cutaneous neuropathy; femoral neuropathy

Handball Handball goalie’s elbow

Hockey Stinger; axillary neuropathy; tibial neuropathy due to tarsal tunnel syndrome; peroneal neuropathy

In-line skating, rollerskating and Superfical peroneal neuropathyskateboarding

Judo, karate and kickboxing Morton’s neuroma of a plantar nerve; ulnar neuropathy at trauma site; axillary neuropathy at traumasite; spinal accessory neuropathy at trauma site; long thoracic neuropathy at trauma site; peronealneuropathy at trauma site

Mountain climbing, hiking Tarsal tunnel syndrome; rucksack paralysis – brachial plexopathy (upper and middle trunks);suprascapular neuropathy; axillary neuropathy; long thoracic neuropathy

Rugby and Australian rules Axillary neuropathy; obturator neuropathyfootball

Running Peroneal neuropathy; lateral femoral cutaneous neuropathy; tibial neuropathy at the tarsal tunnel;posterior tibial neuropathy; Morton’s neuroma of a plantar nerve; interdigital neuropathies; plantarneuropathies; calcaneal neuropathy; sural neuropathy; superficial peroneal neuropathy; saphenousneuropathy; rhabdomyolysis

Scuba diving Lateral femoral cutaneous neuropathy

Shooting Long thoracic neuropathy

Continued next page



Table II. Contd

Skiing, snowboarding, sledding Femoral neuropathy (cross-country skiing); ulnar neuropathy (cross-country skiing)and ski jumping

Snowmobiling and all-terrain Brachial plexopathy; ulnar neuropathy at Guyon’s canalvehicle riding

Soccer Peroneal neuropathy

Surfing Common peroneal neuropathy; saphenous neuropathy

Swimming Thoracic outlet syndrome

Tennis and racquetball Posterior interosseous neuropathy at the arcade of frohse; suprascapular neuropathy; long thoracicneuropathy; lateral antebrachial cutaneous neuropathy; radial neuropathy secondary to fibrous archesat lateral head of triceps; digital neuropathy; superficial radial neuropathy due to constrictivesweatband; thoracic outlet syndrome

Volleyball Suprascapular neuropathy; axillary neuropathy; long thoracic neuropathy

Wrestling Stinger; brachial plexopathy; axillary neuropathy; ulnar neuropathy; median neuropathy at the wrist;long thoracic neuropathy; suprascapular neuropathy

football is an aggressive sport with significant phys- Asymptomatic professional and amateur baseballical contact and high risk of injury, particularly to pitchers have had reduced sensory nerve action po-the brachial plexus. In most studies, football is re- tentials in the throwing arm, although this did notported as the sport most likely to be associated with appear to impact player performance. The authorsinjury, serious injury, as well as neurological injury. reporting the phenomenon of ‘pitcher’s arm’ specu-The injury rate for football in collegiate-level ath- lated on this being a repetitive use syndrome affect-letes is estimated at 1.5 per 100 athlete exposures in ing the brachial plexus,[13] although this remainsgames as well as practices.[7] High-school football is unclear.no different in that football was also associated with

Injury rates amongst mountain climbers are low,the highest injury rate per 100 player-seasons

estimated at two cases per 1000 climbers.[14] PNS(3.66).[8] As would be expected, contact with anoth-

injuries are uncommon in mountain climbers ander player was the most frequent method of injury in

hikers, but exist. The use of a backpack by hikersfootball.[7]

has been associated with a unique condition calledThe majority of injuries affecting the nervous rucksack paralysis, a syndrome leading to injury of

system appear to be CNS in nature, but brachial the brachial plexus at the upper and middleplexus injuries appear to be the most common PNS trunks.[15-17] Traction upon the brachial plexus is theinjury. In Canadian varsity football players, brachial probable aetiology, and one predisposing factor forplexus injuries were the third most common specific this condition is the use of a pack without waistdiagnosis in football injuries,[9] while the incidence support.[16] Often, there are paraesthesias, but noat two University centres was 49% of all injuries.[10] pain. Electrophysiology may demonstrate conduc-The incidence of plexus injury has been reported to tion block or axonal loss in particular patients withbe as high as 2.2 cases per 100 players.[11] Football rucksack paralysis, with axonal loss suggesting aplayers can be subject to more persistent upper trunk poorer prognosis for recovery.brachial plexopathies.[4,5]

PNS injuries due to snowmobiling include brach-In racecar drivers, the brachial plexus is at risk of ial plexus injuries in 4.8% of snowmobile accident

injury due to the tight fastening by seatbelts of arm victims.[18] A complete brachial plexopathy is seento helmet to prevent centrifugal force for auto driv- in 67% of snowmobile accidents with brachial plex-ers.[12]

us injury, often associated with orthopaedic shoul-der injury.[19] Supraclavicular injuries were moreThe notion of a ‘pitcher’s arm’ on elec-common and more severe than infraclavicular inju-trodiagnostic testing can make evaluation of poten-ries.[18]tial nerve disorders in the baseball pitcher difficult.


722 Toth et al.

Table III. Injuries of the peripheral nervous system due to sport organised by anatomical location

Digital nerves Archery; baseball; bowling; cheerleading; tennis

Median nerve

wrist Archery; basketball (wheelchair); bicycling; bodybuilding/weightlifting; football; golf;wrestling

palmar branch Cheerleading; golf

pronator teres Archery; baseball

Ulnar nerve

at the elbow Baseball; bicycling; bodybuilding/weightlifting; judo, karate and kickboxing; cross-countryskiing; wrestling

at the wrist Basketball (wheelchair); bicycling; football; cross-country skiing; snowmobiling

at flexor carpi ulnaris Bodybuilding/weightlifting; golf

at the deep motor branch Bodybuilding/weightlifting

Radial nerve Arm wrestling; baseball; football; tennis/racquetball

Posterior interosseous neuropathy Bodybuilding/weightlifting; frisbee; gymnastics; tennis/racquetball

Superficial radial nerve Tennis/racquetball

Axillary nerve Baseball; football; hiking; hockey; judo, karate and kickboxing; rugby; volleyball; wrestling

Spinal accessory nerve Judo, karate and kickboxing

Musculocutaneous nerve Bodybuilding/weightlifting

Lateral antebrachial cutaneous neuropathy Bodybuilding/weightlifting; tennis

Thoracic outlet syndrome Baseball; football; swimming; tennis

Long thoracic nerve Archery; bodybuilding/weightlifting; football; judo, karate and kickboxing; hiking; shooting;tennis/racquetball; volleyball; wrestling

Thoracodorsal neuropathy Bodybuilding/weightlifting

Dorsoscapular nerve Bodybuilding/weightlifting

Suprascapular nerve Ballet dancing; baseball; basketball; bodybuilding/weightlifting; football; hiking; tennis/racquetball; volleyball; wrestling

Medial pectoral neuropathy Bodybuilding/weightlifting

Brachial plexus Auto racing; baseball; football (upper trunk); hiking (upper, middle trunks); snowmobiling;wrestling

Stinger Basketball; bodybuilding/weightlifting; boxing; football; hockey; wrestling

Cervical radiculopathy Football

Femoral nerve Ballet dancing; bodybuilding/weightlifting; gymnastics; cross-country skiing

Obturator nerve Rubgy/Australian rules football

Peroneal nerve Auto racing; ballet dancing; football; hockey; judo karate and kickboxing; running; soccer;surfing

Pudendal nerve Bicycling

Iliohypogastric nerve Football

Sciatic nerve Auto racing; bicycling; football (hamstring syndrome)

Superficial peroneal nerve Running

Interdigital nerves of foot Running

Tibial nerve

at tarsal tunnel Hockey; hiking; running

Sural nerve Ballet dancing; running

Lateral femoral cutaneous nerve Gymnastics; running; scuba diving

Posterior cutaneous nerve of the thigh Bicycling

Superficial peroneal nerve Rollerskating; running

Continued next page



Table III. Contd

Saphenous nerve Surfing; running

Dorsal cutaneous nerve of foot Ballet dancing

Lumbar radiculopathy Football

Morton’s neuroma of plantar nerve Ballet dancing; judo, karate and kickboxing; running

Plantar nerves of feet Running

Calcaneal neuropathy Running

Rhabdomyloysis Bodybuilding/weightlifting; running

Amateur wrestling is an aggressive sport with dysfunction of the upper trunk of the brachial plex-frequent CNS injury, and injury rates in wrestling us.[2,3] In most cases, the stinger presents acutelyare second only to football amongst high-school after trauma to the shoulder region. The stingercompetitors, with an injury rate of 1.58 per 100 comprises approximately 36% of all neurologicalplayer-seasons.[8] Brachial plexus injury is relatively upper extremity injuries related to football.[5] Pa-common in wrestling compared with other sports, tients note pain and paraesthesias shooting down theand tends to occur with holds that force the opposing arm into a few of the fingers, associated with tran-wrestler’s head in a direction opposite to one shoul- sient weakness and prompt recovery over minutes.der, such as with a full- or half-Nelson hold.[20]

Rarely, weakness may persist for several months,[21]

suggesting upper trunk brachial plexus axonotmesis,4. ‘Stinger’

which has been documented by electromy-ography.[10] Electromyography and nerve root stim-Initially called a nerve pinch syndrome, this phe-ulation studies may find abnormality in 12% ofnomenon is now colloquially termed a ‘stinger’, orplayers with such injuries.[2] Electromyographic ab-‘burner’. The basis of the stinger is controversial,normalities in such injuries best correlate with thewith some authors advocating C5 or C6

radiculopathy,[1] while others believe it to be due to presence of weakness at 72 hours post-injury.[22] The

Dorsal scapular N.Bodybuilding/weightlifting

Suprascapular N.Ballet dancing,baseball, hiking

Upper trunkFootball,hiking

Middle trunkHiking

Medial pectoral N.Bodybuilding,weightlifting

Thoracodorsal N.Bodybuilding/weightlifting

Cervical roots Football

Spinal accessory N.Bodybuilding/weightlifting

Brachial plexusAuto racing, baseball,football, hiking, snowmobiling, wrestling

'Stinger'Basketball,bodybuilding/weightlifting,boxing, football,hockey, wrestling,

Thoracic outlet syndromeBaseball, football,swimming, tennis

Lateral pectoral N.

Musculocutaneous N.

Axillary N.

Radial N.Median N.

Ulnar N.

Subscapular N.

Medial brachial and antebrachial cutaneous nerves

Long thoracic N.Archery,bodybuilding/weightlifting,football, hiking,judo/karate/kickboxing,racquetball, shooting, tennis,volleyball, wrestling

Fig. 1. Anatomy and lesions by sport affecting the brachial plexus and its branches. N = nerve.


724 Toth et al.

stinger has rarely been seen in basketball players.[23] cles, and modifications in the mechanism of draw-Brachial plexus injuries are rare in the bodybuilder, ing the bowstring.[29] A single report of a longbut stingers have rarely been reported in weight- thoracic neuropathy has been reported in a world-lifters.[23] class marksman, probably due to positional stress

during repetitive shooting postures while holdingBoxing has become a controversial sport due tothe gun.[30]the high risk of injury, long-term sequelae, and

occurrence of death during competition. Most box- Bodybuilding has been associated with a numbering injuries are the result of CNS trauma. The lone of entrapment neuropathies secondary to repetitiveperipheral nerve injury is one usually seen in foot- motions or excessive muscle bulk, sometimes asso-ball players, the ‘burner’ or ‘stinger’, which is rarely ciated with anabolic steroid use. Often, the nature ofreported.[23] The most common ice hockey injuries the mononeuropathies in the bodybuilder or weight-to affect the nervous system are concussions and lifter is unique. Repetitive movements at the shoul-spinal cord injuries, while PNS injuries are less der as well as relative muscular hypertrophy incommon. Although more common in football play- bodybuilders may lead to compression of the longers, the ‘stinger’ has also been rarely reported in thoracic nerve.[4,31-33] In one patient, the use of ana-hockey players.[23] Stingers also account for 37% of bolic steroids may have been associated with exces-all head and neck injuries in competitive wres- sive muscular hypertrophy of the shoulder and flanktlers.[23,24] region muscles; resting of the affected region led to

some improvement with return of serratus anterior5. Thoracic Outlet Syndrome bulk.[32]

Local trauma to the shoulder and axillary regionThe controversial and rare entity of thoracic out-while blocking or tackling has been associated withlet syndrome has been previously reported in base-long thoracic neuropathy in football players.[4] Localball pitchers.[25,26] In one case, thoracic outlet syn-trauma in the martial arts may have also been associ-drome has presented as numbness in the fingers ofated a long thoracic neuropathy due to nerve contu-the throwing hand of a college baseball player, withsion.[34] Peripheral nerve injury in wrestlers maycompression of the neurovascular bundle demon-occur with excessive shoulder manipulation, whichstrated using magnetic resonance angiography withcan lead to long thoracic neuropathy.[4]

arm held in abduction.[27] Thoracic outlet syndromeRucksack paralysis in backpacking hikers, nor-has also been reported in the throwing shoulder of

mally associated with a brachial plexopathy, hasfootball quarterbacks,[25,26] and rarely in the domi-also been associated with an isolated long thoracicnant arm of tennis players.[25,26] In swimmers, tho-neuropathy.[15-17] Traction upon the shoulder is aracic outlet syndrome may occur in association withpossible aetiology with a predisposing factor beinghypertrophied pectoralis minor muscles.[25,26]

the use of a pack without waist support.[16]

Long thoracic neuropathy is rarely reported in the6. Long Thoracic Nervetennis player.[35] An isolated mononeuropathy of the

A number of sports have been associated with a long thoracic nerve may occur in the dominant armpalsy of the long thoracic nerve, either related to a of younger volleyball players, perhaps related torepetitive swinging motion, local trauma, or muscu- excessive repetitive shoulder movements of thelar hypertrophy. The use of a bow in archery has serving arm.[36]

been associated with development of an isolatedlong thoracic nerve palsy,[28] likely due to repeated 7. Thoracodorsal Neuropathydrawing of the bow and possible hypertrophy ofshoulder and periscapular muscles. Measures that A thoracodorsal mononeuropathy occurred in amay improve archery safety include using a light- bodybuilder who was using anabolic steroids, withweight bow, conditioning of forearm flexor mus- both clinical and electrophysiological findings that



improved with resting of the affected region and ed.[43] Alternatively, the medial tendinous marginwere associated with return of latissimus dorsi between the infraspinatus and supraspinatus mus-bulk.[37,38] Entrapment of the nerve by hypertrophied cles may impinge against the lateral edge of thesubscapularis muscle may have been the cause of scapular spine, leading to compression of the infras-this palsy. pinatus branch of the suprascapular nerve.[44]

Favouring the latter theory is the favourable re-8. Dorsoscapular Nerve sponse of elite volleyball players to a spinaglenoid

notchplasty procedure.[44] With a probable similarUnilateral weakness of the rhomboid muscles hasmechanism, suprascapular neuropathy has also beenoccurred in a bodybuilder using anabolic steroids,reported in tennis players, with compression at thewith suspected entrapment of the dorsoscapularsuprascapular or supraglenoid notches, as well asnerve by muscular hypertrophy,[38] possibly of thewith a ganglion cyst.[45,46]

scalenus anterior and medius muscles.Although injuries in baseball are typically acute,

9. Suprascapular Nerve such as with the most frequent mechanism of base-ball-related injury, being hit by the ball (62% of

The suprascapular nerve is subject to injury with- acute injuries),[35] local nerve lesions are relativelyin a number of sports, with mechanisms varying common in baseball players as well. Many of thefrom repetitive throwing or swinging motions of a peripheral nerve injuries occur during the act ofshoulder, direct trauma, to traction injury. Perhaps pitching. During the biomechanics of throwing thethe most frequently associated sport with supras- baseball, the humerus is whipped with a maximumcapular nerve palsy is volleyball. Volleyball is one torque of nearly 1600Nm.[47] This degree of torqueof the safest competitive and recreational sports requires significant muscular force and places greatplayed by high-school and collegiate athletes. The stress upon musculoskeletal and nervous elements.injury rate is only 0.14 per 100 volleyball player- Suprascapular nerve injuries presenting as shoulderseasons for high school student participants, the pain accompanied by weakness of shoulder abduc-lowest of ten sports examined in one study.[8] PNS tion and external rotation can occur in a pitchinginjuries due to volleyball are frequently reported. arm.[48,49] Entrapment of the suprascapular nerve inOne frequent form of mononeuropathy is an isolated pitchers may occur at the suprascapular or spinogle-entrapment of the suprascapular nerve at the spi- noid notches.[50] Often, suprascapular nerve injurynoglenoid notch, presenting with painless weakness can mimic a rotator cuff tear. Although not reportedof dominant arm external rotation with evidence of with suprascapular nerve injuries in the baseballinfraspinatus atrophy on examination.[39,40] This player, the presence of spinoglenoid cysts or labralneuropathy only occurs with the serving, or domi- pathology has been associated with suprascapularnant, arm.[38] In one study of international-level vol- neuropathy.[51]

leyball players, the overall prevalence of supras-While basketball injuries are relatively common,capular neuropathy was surprisingly found to range

only the minority of these injuries are neurologicalfrom 33% to 45% based on clinical and elec-in nature. A single report of a suprascapular nervetrophysiological examination.[41,42] Up to 12% oflesion without any history of shoulder girdle traumavolleyball players may have subclinical suprascapu-has been reported in a basketball player, perhaps duelar neuropathy.[39] Electromyography in these casesto repeated nerve traction over the coracoid notchdiscloses denervation and loss of motor units re-during dunking of the basketball.[52] Recovery instricted to the infraspinatus muscle with the supras-this player was nearly complete after 3 weeks ofpinatus and other shoulder muscles found to beinactivity.[52]

normal.[40] A possible association between increasedUpper extremity peripheral nerve lesions arerange of motion of the shoulder joint and presence of

rarely reported in dancers. There is an isolated reportisolated suprascapular neuropathy has been suggest-


726 Toth et al.

of painless, isolated weakness of external rotation of trauma to the anterolateral deltoid region (figurethe right arm of a professional dancer with clinical 2).[57] Although many athletes with axillary neurop-and electrophysiological evidence of suprascapular athy fail to regain full axillary nerve function, 91%neuropathy. The injury was possibly secondary to of such athletes return to pre-injury levels of profes-repetitive, forceful movements of the arm with ex- sional sports activities.[57] Axillary neuropathy dueternal rotation and abduction, with postulated en- to direct contact without shoulder dislocation hastrapment of the nerve at the spinoglenoid notch. also been reported in two hockey players.[57,59] Pe-Near complete recovery of muscle function oc- ripheral nerve injury is unusual in the martial arts,curred after 4 months of rest from dance.[53]

but direct blows leading to a presumed nerve contu-Bodybuilders are at risk for suprascapular neu-

sion have been reported to lead to an axillary neu-ropathy likely because of repetitive activity of the

ropathy.[6]shoulder.[4,54] Bodybuilders may demonstrate both

Rodeo injury incidences vary amongst the differ-clinical and electrophysiological findings of entrap-ent events, but are the highest in bull riding, bare-ment of the terminal branch of the suprascapular

nerve.[55] Resting of the affected shoulder region back riding, and saddle bronc events.[60] Concus-may be associated with recovery of strength and sions rather than peripheral nerve injuries accountmuscle bulk. for the great majority of neurological injuries due to

The physical action of blocking or tackling by rodeo.[60] Little has been reported about peripheralfootball players can lead to direct trauma to the nerve injury although it may occur. The authorsshoulder and scapular region, which has been asso- have seen an axillary neuropathy secondary tociated with suprascapular neuropathy.[4] In wres-tlers, excessive shoulder and scapular manipulation,such as with the hammerlock manoeuvre, can lead tosuprascapular neuropathy.[4]

Lastly, rucksack paralysis in hikers has beenassociated with an isolated suprascapular neuropa-thy,[15-17] likely due to excessive shoulder tractionand improper waist support for the backpack.[16]

10. Medial Pectoral Neuropathy

Another unique weightlifting-associated neurop-athy is a progressive bilateral medial pectoral neu-ropathy secondary to postulated pectoralis minorhypertrophy and subsequent intramuscular entrap-ment of the medial pectoral nerves.[4,56]

11. Axillary Nerve (at the Shoulder)

Peripheral nerve injuries in football may occursecondary to blocking or tackling techniques. In onestudy, football was the most common sport to causeinjury in patients referred for electrodiagnostic test-ing.[4] Mononeuropathies reported in upper limbs offootball players have included axillary neuropa-thy,[4,57] which can be associated with shoulder dis-location[4,58] or can be isolated secondary to direct

Axillary N.Baseball, football,judo/karate/kickboxing,hiking, hockey, rugby,volleyball, wrestling

Musculocutaneous N.Bodybuilding/weightlifting

Lateral antebrachial cutaneous N.Bodybuilding/weightlifting,tennis

Fig. 2. Anatomy and lesions by sport affecting the axillary, mus-culocutaneous and lateral antebrachial cutaneous nerves. N =nerve.



shoulder dislocation after a violent dismount duringa bull riding event.

Rugby and Australian rules football are bothhighly subject to cerebral concussion, the most com-mon neurological concern within both of thesesports.[61] However, peripheral nerve lesions havebeen reported. Direct trauma to the anterolateraldeltoid without shoulder dislocation has been re-ported as a cause of axillary neuropathy in rugbyplayers.[59] Peripheral nerve injury in wrestlers canalso occur due to excessive shoulder manipulationor local nerve trauma causing presumed nerve con-tusion, as may occur with axillary neuropathy.[4]

An isolated mononeuropathy of the axillarynerve has been reported in younger volleyball play-ers, perhaps related to a quadrilateral space syn-drome.[36,62] Quadrilateral space syndrome has alsobeen reported within the pitching arm of a baseballpitcher due to compression of the distal axillarynerve and partial compression of the posterior hu-meral circumflex artery.[63]

Lastly, rucksack paralysis in hikers has occasion-ally presented as an isolated axillary neuropa-thy[15-17] due to presumed excessive shoulder trac-tion and a backpack without proper waist support.[16]

Median N.

Median N.(pronator teres syndrome)Archery, baseball

Palmar cutaneous branchCheerleading, golf

Palmar digital N.Archery, baseball, bowling, cheerleading,tennis

Median N.(carpal tunnel syndrome)Archery, bicycling, golf,football, wheelchair basketball,weightlifting/bodybuilding

Thumb digital N.Baseball, bowling

Fig. 3. Anatomy and lesions by sport affecting the median nerveand its branches. N = nerve.

12. Median Nerveteres,[64] likely related to repetitive throwing actionsor relative hypertrophy of the forearm muscles in-12.1 Entrapment at Pronator Terescluding the pronator teres.

Median nerve entrapment is most common at thewrist within the carpal tunnel; however, compres- 12.2 Entrapment Within the Carpal Tunnel atsion as it passes through the pronator teres is another the Wristpossible site of entrapment with sports injuries. Theuse of a bow in archery has been associated with The carpal tunnel is, by far, the most commoncompression of the median nerve at the pronator site of median nerve entrapment with or withoutteres intersection,[29] suspected to be due to repeated sports-related injury. It is often difficult to discrimi-drawing of the bow and possible hypertrophy of nate those lesions with direct relationship to sportingforearm muscles such as pronator teres (figure 3). activities and those without direct relationship. Al-Measures that may improve archery safety include though forms of neuropathy are reported very rarelythe use of a lightweight bow, conditioning of fore- in traditional basketball players, compression neu-arm flexor muscles, and modifications in the mecha- ropathies of the arms are common injuries in wheel-nism of drawing the bowstring.[29] Pronator syn- chair basketball players. In one study, 30% ofdrome in the proximal forearm of the pitching arm world-class wheelchair basketball players weremay occur in baseball pitchers due to entrapment of found to have symptoms consistent with carpal tun-the median nerve by fibrous bands of the pronator nel syndrome, with 70% of these having elec-


728 Toth et al.

trodiagnostic confirmation.[65] Similar incidences pressure upon the palm by the handle of the golfwere found in another case-control study of upper club.extremity electrophysiology in other forms ofwheelchair athletes.[66] 13. Ulnar Nerve

Although the ulnar nerve is more likely to becompressed at the wrist in cyclists, the median nerve

13.1 At the Elbow in the Cubital Tunnelmay also be abnormal in many cyclists. In one studyof professional cyclists, symptoms of carpal tunnel

Ulnar neuropathy is another common entrapmentsyndrome occurred in 25% of hands, with 62% ofneuropathy where it is difficult to discriminate thosesymptomatic hands tested demonstrating abnormalcases with certain sports-related aetiologies fromelectrodiagnostic findings on stimulation of the me-those without association. Ulnar neuropathy at thedian nerve.[67] Bilateral median nerve compressionelbow is common amongst baseball pitchers,[64,71-75]may also occur in the cyclist.[68]

although it is uncertain if ulnar neuropathy occursGolf is usually regarded as a relaxing recreationalmore commonly than within a control populationsport with an expected low injury rate. Much of the(figure 4). In one study of 72 professional baseballliterature regarding golf-related injuries to the ner-players undergoing arthroscopic or open elbow sur-vous system is based upon single case reports. Re-gery, ulnar neuropathy was diagnosed in 15% ofports of golf-induced carpal tunnel syndrome are notplayers.[71] Of adult baseball players with ulnarentirely clear, but repetitive gripping and sustainednerve entrapment who underwent surgical correc-hyperflexion and hyperextension may contribute totion with anterior transfer of the nerve and place-the few noted cases.[69]

Although not commonly reported in footballplayers, median neuropathy at the carpal tunnel withclinical and electrophysiological evidence has beenreported and associated with blocking techniques.[4]

Peripheral nerve injury in wrestlers can occur due toexcessive arm and wrist manipulation, which maylead to entrapment of the median nerve at the carpaltunnel.[4] Repetitive flexion-extension of the wrist inbodybuilders may possibly lead to carpal tunnelsyndrome.[4] Lastly, the use of an archery bow hasled to compression of the median nerve at thewrist,[29] possibly related to repeated drawing of thebow

12.3 Entrapment Within the Palm of thePalmar Branch

Golfers may be subject to an atypical location formedian nerve entrapment. A neophyte golferpresented with an unusual location for median neu-ropathy, with segmental demyelination found2–3cm distal to the wrist crease, after presentationwith sensory deficit within the distal median nervedistribution.[70] This unusual location may relate to

Ulnar N.(cubital tunnel)Baseball, bicycling,bodybuilding,cross-country skiing,judo/karate/kickboxing,weightlifting, wrestling

Ulnar N.(Guyon’s canal)Bicycling, cross-country skiing,football, snowmobiling,wheelchair basketball

Ulnar N.(deep palmar branch)Bodybuilding,weightlifting

Ulnar N.(flexor carpi ulnaris)Bodybuilding,golf, weightlifting

Fig. 4. Anatomy and lesions by sport affecting the ulnar nerve andits branches. N = nerve.



ment deep to the flexor muscles, about 50% returned 13.3 At the Wrist in Guyon’s Canalto playing.[72]

Recreational and competitive cycling, includingRepetitive flexion-extension of the elbow inBMX biking and both road and off-road cycling, is

bodybuilders may predispose to ulnar neuropathy atassociated with a wide range of neurological injuries

the elbow.[4] The ulnar nerve may also be at risk for affecting the peripheral and central nervous system.direct trauma and nerve contusion. The action of Probably the most common form of nerve entrap-blocking or tackling can lead to local trauma in the ment is that of the ulnar nerve at the wrist, seenarms of football players, which has been associated among cyclists resulting in weakness of grip andwith development of ulnar neuropathy.[4] Direct numbness of the fourth and fifth digits.[64] In cy-blows to the elbow in the martial arts presumably clists, the most common location of ulnar nerveleading to a nerve contusion have led to ulnar neu- entrapment is within Guyon’s canal.[80] Within aropathy.[6] Peripheral nerve injury in wrestlers can large cross sectional study of 160 male professionaloccur due to local nerve trauma causing presumed cyclists, 30% reported paraesthesia or numbness innerve contusion, as may occur with ulnar neuropa- the fingers, mostly from the ulnar innervated re-

gion.[81] Recovery in cyclists with ulnar neuropathythy.[4] Lastly, ulnar neuropathy has been reported inmay occur spontaneously or with avoidance of ac-a single cross-country skier in whom it was attribut-tivity, rather than with an operative procedure.[82]ed to forceful poling.[76]

Modification of hand grips on the bicycle handle-One mimic of ulnar neuropathy is a musculoskel-bars may result in recovery in cyclists with Guyon

etal condition that occurs in a European sport, hand-canal ulnar nerve compression.[83]

ball. This sport combines skills of basketball andThe use of a wheelchair in wheelchair basketball

soccer. Epidemiological studies of injuries within players places the ulnar nerve at risk for compres-the sport are few. Some goalkeepers have a condi- sion at the wrist – 12% of symptomatic wheelchairtion termed ‘handball goalie’s elbow’ presenting as basketball players had abnormal electrophysiologyradiating pain or numbness in the ulnar territory of of the ulnar nerve at the wrist.[65] Similar incidencesthe forearm in addition to local pain in the elbow have been demonstrated in another case-controlregion pain. Although this may mimic an ulnar study of upper extremity electrophysiology in otherneuropathy, electrophysiological assessment is neg- forms of wheelchair athletes.[66]

ative, and the condition likely represents a musculo- Ulnar neuropathy secondary to forceful poling inskeletal source of pain due to repetitive forced a cross-country skier has been reported with entrap-hyperextensions of the elbow.[77] ment of the ulnar nerve at the wrist.[76] We have seen

one patient with bilateral ulnar neuropathies atGuyon’s canal after a full day of snowmobiling with13.2 In the Forearm at Flexor Carpi Ulnarishis hands secured to the handlebars with duct tape.

Ulnar neuropathy has also been reported in a13.4 In the Palm at the Deep Motor Branch

39-year-old competitive male weightlifter due tosuspected compression between the heads of flexor Repeated bench presses over 2 weeks in a youngcarpi ulnaris with electrophysiological evidence.[78]

male was associated with weakness of interosseii,A professional golf instructor was reported to have 4th and 5th lumbricals, adductor pollicis and abduc-ulnar neuropathy localised as a focal conduction tor digiti minimi secondary to injury to the deepblock in the distal forearm approximately 7cm prox- motor branch of the ulnar nerve with severe conduc-imal to the ulnar styloid, perhaps due to enlargement tion block identified on sequential nerve conductionof the flexor carpi ulnaris and subsequent compres- studies.[84] A compressive lesion of the deep palmarsion of the adjacent ulnar nerve found at surgery.[79] branch of the ulnar nerve was reported in a patient


730 Toth et al.

who entered an intensive programme of push-ups ona hard floor.[85]

14. Musculocutaneous Nerve

Upper arm and shoulder muscular hypertrophy aswell as repetitive movements at the shoulder may beassociated with the presence of musculocutaneousneuropathy in bodybuilders.[37,65,86]

15. Lateral AntebrachialCutaneous Neuropathy

Repetitive flexion and extension of the elbow aswell as forearm muscular hypertrophy inbodybuilders has led to a lateral antebrachial cutane-ous neuropathy.[4] Compression of the lateral cuta-neous nerve of the forearm has also been seen in avigorous tennis player,[87] perhaps due to muscularhypertrophy of the forearm flexor muscles and ex-cessive elbow flexion.

16. Radial Nerve

Radial N.Arm wrestling,baseball, football,racquetball, tennis

Superficial radial N.Racquetball, tennis

Posterior interosseous N.Bodybuilding,frisbee, gymnastics,racquetball, tennis,weightlifting

Fig. 5. Anatomy and lesions by sport affecting the radial nerve andits branches. N = nerve.

16.1 At the Spiral Groovetackling.[4] The authors have seen once case of radial

Arm wrestling has a relatively common compli- neuropathy secondary to humeral fracture in a rodeocation of humeral shaft fractures, particularly during performer after a violent dismount.times when full force is exerted in an attempt to win Finally, tennis players are subject to radial nervethe match or to change momentum. In 23% of these palsy secondary to compression of the nerve bycases, a concurrent radial nerve palsy was reported – fibrous arches at the lateral head of the triceps.[92,93]

the sole peripheral nerve injury reported in armwrestlers (figure 5).[88] 17. Posterior Interosseous Neuropathy

Windmill pitching, a technique used by softballTennis, and other related racquet sports, involvepitchers where the pitching arm rotates through ex-

repetitive arm swinging. This can lead to a numbertension and abduction, has been associated withof musculoskeletal difficulties that may mimic aradial neuropathy at different anatomical sites in-nerve entrapment syndrome. Specific nerve entrap-cluding the spiral groove.[89] In some cases, thements do occur within tennis players, and rangesoftball pitcher has experienced a humeral shaftfrom rare to common. Electrophysiologically prov-fracture associated with the radial nerve palsy.[90]

en posterior interosseous nerve entrapment appearsHumeral shaft fracture in baseball pitchers have alsoto be common among tennis players and occurs atbeen associated with radial nerve palsies.[91] Inthe Arcade of Frohse, resulting in weakness of theadults with humeral fractures associated with throw-wrist extensors and metacarpophalangeal exten-ing a baseball, 16% of patients had concurrent radialsors.[64,94]nerve palsy.[91]

Radial neuropathy in football players has been A professional bodybuilder presenting with prox-associated with local trauma to the upper arm during imal forearm pain and supinator tenderness analo-



gous to radial tunnel syndrome secondary to com- excessive pressure on the palmar surfaces of thepression of the posterior interosseous nerve was fingers by the tennis racquet.reported. In this case, power squats in which thewrists are in severe extension and elbows in severe 20. Lumbar Radiculopathyflexion were possibly implicated, and conservativetreatment led to symptomatic improvement.[95] Lumbosacral neuropathy is likely underreported

in athletes as it relates to sports, as only a singleA distal posterior interosseous neuropathy hasreport of a L5-S1 radiculopathy related to footballbeen attributed to repetitive wrist dorsiflexion in ainjury has been reported in a single football playergymnast.[96]

(figure 6a).[4]Finally, the lone reported peripheral nerve lesionin active frisbee players is a posterior interosseuosnerve syndrome,[97] with probable relationship to 21. Pudendal Nerverecurrent flexion-extension of the wrist.

A unique form of neuropathy in the cyclist is thepudendal neuropathy. In fact, ‘bicycle seat neuropa-18. Superficial Radial Nervethy’ is one of the most common injuries reported by

The use of a constrictive wrist band or rac- cyclists (figure 6b).[104] One report of male competi-quetball strap has been associated with a superficial tive cyclists documented symptoms of recurrentradial neuropathy.[98] numbness of the penis and scrotum after prolonged

cycling, along with an altered sensation of ejacula-tion and micturition and reduced awareness of defe-19. Digital Nerves (at the Fingers)cation. Cyclists may develop pudendal neuropathies

A variety of sports may cause neuropathy of the secondary to racing-bicycle saddles applying pres-digital nerves. For example, the use of a bow in sure on the perineum. Changes in bike saddle posi-archery has been associated with compression of the tion and riding technique may lead to symptomaticdigital nerves,[29] possibly related to repeated draw- improvement.[105] In a larger cross-sectional study ofing of the bow over the length of the fingers. The 160 male professional cyclists, 22% reported symp-action of batting in baseball may lead to susceptibili- toms of penile numbness or hypesthesia after a longty to a traumatic neuroma of the ulnar digital nerve duration of cycling, and 13% reported transient im-of the thumb.[99] potence for weeks. 85% of cyclists reporting genital

Ten-pin bowling has only rarely been associated numbness and impotence also reported hand numb-with injury to the nervous system. The repetitive ness after cycling, perhaps suggesting predisposingnature of the activity can lead to injuries to the liability to neural injury.[81] In another study ofdigital nerve of the thumb, which is placed inside the cyclists participating in a 500-mile (805km) bicycleten-pin bowling ball holes.[100] Perineural fibrosis of tour, 45% reported mild or transient perineal numb-the digital nerve of the thumb,[100] as well as a thumb ness, 10% reported severe symptomatology, and 2%neuroma, have both been reported as a result of reported temporary breaks in riding due to symp-chronic trauma due to bowling.[101] toms.[106] Not exclusive to male cyclists, 34% of

Cheerleading is not an activity that one would female cyclists also reported perineal numbness.[107]

expect to be associated with peripheral nerve injury. Bicycle seat neuropathy may be due to entrapmentA sole report of a median palmar digital neuropathy of the pudendal nerve passing through the Alcockin a 16-year-old girl perhaps related to chronic trau- canal enclosed by ischial bone and obturator in-ma to the palm during cheerleading activities ex- ternus.[108] Adjustment of the bike seat by tilting theists.[102] nose of the seat down and lowering the bike seat

Also, digital nerve injuries have been seen in position to relieve pressure on the perineum may bevery active tennis players,[103] presumably due to beneficial.[108]


732 Toth et al.

Sciatic N.Auto racing,bicycling,football

Plantar N.Ballet dancing,judo/karate/kickboxing,running

Calcaneal N.Running

Common peroneal N.Auto racing,ballet dancing,football, hockey,judo/karate/kickboxing,running, soccer, surfing

Tibial N. (tarsal tunnel)Hockey,hiking,running

Posterior cutaneousN. of thighBicycling

Lumbar rootsFootball

Sural N.Ballet dancing,running

IliohypogasticFootball

Pudendal N.Bicycling

Obturator N.Australian rules football

Saphenous N.Running, surfing

Dorsal cutaneousbranch of peroneal N.Ballet dancing

Common peroneal N.Auto racing, ballet dancing, football, hockey,judo/karate/kickboxing,running, soccer, surfing

Femoral N.Ballet, bodybuilding,cross-country skiiing,gymnastics, weightlifting

Lateral femoral cutaneous N.Gymnastics,running

Superficial peroneal N.Rollerskating,running

a b

Fig. 6. Peripheral nervous system anatomy of (a) the ventral lower extremity and lesions; and (b) by the dorsal lower extremity and lesionssport. N = nerve.

22. Iliohypogastric Nerve subject to the controversial ‘hamstring syndrome’,which has been mimicked by sciatic neuropathy in

The syndrome of ‘footballer’s hernia’ with lower some cases.[109]

abdominal bulging may relate to an iliohypogastricneuropathy in some reported cases.[109]

24. Femoral Nerve

23. Sciatic NerveFemoral neuropathy has been reported in dancers

Sciatic nerve lesions may also be underreported who perform repeated simultaneous hip extensionin sporting activities, as only scattered case reports and knee flexion (the ‘Horton Hinge’).[64] Gymnas-detailing sports-related sciatic neuropathy exist. A tics requires difficult manoeuvres and body posturesunique injury dubbed ‘pedal pusher’s palsy’ with that place the body at risk for injury, particularlybilateral sciatic nerve palsies can occur following with the involvement of trampolines. Femoral neu-prolonged unicycle riding.[110] The small size of the ropathy secondary to iliacus haematoma or haemor-auto racing cockpit places the racecar driver at risk rhage within the nerve sheath has occurred in gym-for compressive sciatic neuropathy, presumably nasts.[111,112] An anabolic steroid-using bodybuildernear the sciatic notch.[12] Finally, football players are developed clinical and electrophysiological evi-



dence of a femoral neuropathy, thought to be associ- 28. Peroneal Nerveated with hip girdle muscular hypertrophy.[37]

Cross-country skiing has occasionally been asso- 28.1 Common Peroneal Nerveciated with mononeuropathies. Cross-country skiing

The common peroneal nerve is at risk for entrap-has an injury rate of 0.72 injuries per 1000 skier-ment at the fibular head, a relatively commondays, with more injuries occurring in inexperiencedclinical condition. The nerve at this site is at risk forskiers, often when they were on a downhilllocal trauma as well as the possibility of injury withslope.[112] An isolated femoral neuropathy was re-knee injury. Lower limb mononeuropathies in foot-ported in a single cross-country skier with vigorousball players have included peroneal neuropathies,activity.[113]

particularly in cases where complete knee disloca-tion and ligamentous injury has occurred. The inci-

25. Lateral Femoral Cutaneous Nerve dence of peroneal neuropathy when musculoskeletaltrauma has occurred at the knee may be as high as

Lateral femoral cutaneous neuropathy, or the 24%.[4,118] Peroneal neuropathy has only rarely beenclinical condition known as meralgia paraesthetica, documented in the ice-hockey player due to eitheris another relatively common condition that may laceration of the nerve with a skate blade or due toalso be underreported in athletes. A single gymnast direct blunt nerve trauma.[119,120] Local blunt nervehas been reported with a lateral femoral cutaneous trauma occurring in the martial arts has also beenneuropathy after she entered an intensive pro- associated with contusion of the peroneal nerve.[6]

gramme of jumping rope, with the nerve injury Running is a highly repetitive activity that hasblamed upon repetitive hip flexion and exten- been uncommonly associated with lower extremitysion.[114] Meralgia paraesthetica secondary to lateral neuropathy. In one detailed assessment of 25 long-femoral cutaneous neuropathy has been attributed to distance runners, no signs of neuropathy wereexcessive jogging.[115] A single report of peripheral found, although mild changes in quantitative senso-neuropathy is present for scuba divers with occur- ry threshold amplitudes and nerve conduction veloc-rence of lateral femoral cutaneous neuropathy due to ities were reported.[121] Peroneal entrapment neurop-compression of the diver’s weight belt upon the athies have been reported in high mileage runners, innerve.[109]

one case, bilaterally.[65,115] Peroneal neuropathy inrunners has been demonstrated with electrophysio-logical evidence of entrapment of the peroneal nerve26. Obturator Nerveat the fibular neck in several serious runners.[122]

One cause of peroneal neuropathy due to running isRugby and Australian rules football players are atinversion ankle sprain.[123-125] A differential diagno-risk for obturator neuropathies,[116,117] due to a fasci-sis of peroneal neuropathy in runners should includeal entrapment of the obturator nerve at the shortthe anterior tibial compartment syndrome, an is-abductor muscle of the thigh. This condition appearschaemic myopathy presenting with post-exertionalto be very responsive to surgical neurolysis.[116,117]

pain and swelling and possible foot drop.[115]

Many of the injuries experienced by soccer play-27. Posterior Cutaneous Nerve of ers are musculoskeletal in nature, affecting the low-the Thigh er extremities. Peripheral nerve injury is only very

rarely reported in soccer players. There is a singleAlthough not seemingly as common as pudendal case report of peroneal nerve compression at the

neuropathy in the cyclist, another neuropathy due to fibular neck attributed to excessive play in one soc-prolonged bicycle use is posterior cutaneous thigh cer player only.[122] Prolonged wave-surfing mayneuropathy.[109] lead to repetitive microtrauma and development of a


734 Toth et al.

common peroneal neuropathy in young trophysiological improvement after cessation ofmales.[126,127] wearing the skates.[135]

Lastly, auto racing drivers are at risk for common30. Sural Nerveperoneal neuropathy due to compression within a

small cockpit and awkward leg placement.[12]Sural neuropathy due to tight ribbons and elastics

in dancing shoes has also been reported in profes-28.2 Superficial Peroneal Nerve sional dancers.[128] Runners can be subject to a num-

ber of neuropathies involving the foot, which canThe superficial peroneal nerve is at risk for en- include sural neuropathy.[130]

trapment with compression along the anterior lowerleg. For instance, dancers wearing tight ribbons and 31. Saphenous Nerveelastics in dancing shoes have been reported to be at

Surfing has only rarely been reported to be asso-risk for superficial peroneal neuropathy.[128] Periph-ciated with peripheral nerve injury. Repetitiveeral nerve injury has not been reported due to inlinemicrotrauma due to prolonged wave-surfing hasskates, but tight roller skates have been associatedbeen associated with a common peroneal neuropa-with an entrapment of the superficial peronealthy and a saphenous neuropathy in youngnerve.[129]

males.[126,127] Runners are also at risk for saphenousThe lower extremities of runners are subject to aneuropathy, possibly due to traction and perineuralnumber of forms of neuropathy, including lesions offibrosis.[130]

the superficial peroneal nerve.[130] The superficialperoneal nerve may be susceptible to traction due to

32. Dorsal Cutaneous Nerve of Footperineural fibrosis following inversion ankle spraininjury.[131] The sole reported lesion of the dorsal cutaneous

nerve was reported in professional dancers, who29. Tibial Nerve (at Tarsal Tunnel) and may compress this nerve when they sit on their feet,Lateral and Medial Plantar Nerves placing pressure on the dorsum of the foot.[128]

Tarsal tunnel syndrome, a compressive lesion of 33. Interdigital Nerves of Footthe posterior tibial nerve, can result from repetitive

Another cause of neuropathy of the foot in run-dorsiflexion of the ankle among very active run-ners is the repetitive pressure upon the sole, leadingners.[64] A branch of the tibial nerve, the anteriorto lesions of the interdigital nerves.[130]

calcaneal branch, can become entrapped where thenerve passes between edges of the deep fascia of 34. Morton’s Neuroma of Plantar Nerveabductor hallucis and os calcis.[132] In runners withheel pain, abnormalities in nerve conduction studies Excessive load upon the heel and midfoot regionsare more commonly found for the medial plantar may occur in runners with pes planus, which maynerve as opposed to lateral plantar nerve.[133] In contribute to forms of focal neuropathy includingaddition to runners, tarsal tunnel syndrome may also Morton’s neuroma in the feet.[136] Morton’s neuro-be caused by repetitive dorsiflexion of the ankle in ma can occur in runners, and must be differentiatedpoor fitting footwear worn by hikers and mountain from plantar fasciitis and metatarsal bursitis.[35,137]

climbers due to compression of the distal portion of Just as in active runners, serious dancers can occa-the tibial nerve beneath or distal to the flexor reti- sionally present with a Morton’s neuroma of thenaculum.[64,134] plantar nerves.[138] Lastly, a Morton’s neuroma has

Tarsal tunnel syndrome secondary to inflatable been reported in one karate participant, presumablyice hockey skates was reported in a male recreation- due to repeated irritation of the ball of the foot fromal hockey player with significant clinical and elec- fighting stances.[6]



35. Calcaneal Neuropathy PNS injuries is very important, and should continueto be reported in cases of injury related to sports or

Excessive load upon the heel and midfoot regions recreational activities.may occur in runners with pes planus, which may

This article is intended to help the healthcarecontribute to forms of focal neuropathy in the feet,

professional in the recognition of sport-specific in-including calcaneous nerve lesions.[136]

juries, as well as to assist in judging their prognosis.It may serve as a reference for physicians who36. Conclusionsencounter athletes with unique or difficult problems.

This review has been extremely broad in terms of For physicians not faced with sports-related injuriessporting disciplines and range of injuries. We at- on a regular basis, and sports medicine physicianstempted to provide an overview of sporting-related not diagnosing neurological lesions on a regularinjuries, but identification of rarely occurring sport- basis, this review may provide a guide for thesespecific injuries has also been attempted. The mutually distinct subspecialties.unique nature of particular injuries, such as atypicalmononeuropathies in golfers and weightlifters, pro- Acknowledgementsvide a contrast to common injuries such as brachial

No sources of funding were used to assist in the prepara-plexopathy and median neuropathy within this re-tion of this review. The authors have no conflicts of interestview.that are directly relevant to the content of this review.

We found that nervous system injury can occurwith almost any sport. Even apparently benign

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