Upper Extremity Weakness In A Collegiate Football Player

HISTORY: An 18-year-old, right-hand dominant safety sustained a direct hit from an opposing player’s helmet to his right anterior shoulder during a regular season game the preceding year. He had immediate onset of pain and weakness in his right upper extremity, which he described as an especially bad stinger. Treatment included weekly rehabilitation sessions. He was cleared for full participation by a local medical provider. He arrived for football camp with ongoing proximal dysfunction. PHYSICAL EXAMINATION: Cervical spine range of motion was full and pain free. Marked atrophy of the right upper extremity musculature including the deltoid, biceps, triceps, and wrist extensors. Proximal weakness and hypotonia including deltoid 3/5, biceps 1/5, triceps 4/5, wrist extensors 2/5, full finger flexion and intrinsic hand strength. Keeps right upper limb dangling at his side. Absent biceps and brachioradialis reflexes, diminished triceps. Diminished light touch sensation in C5/C6 dermatomes. Able to mobilize hand and fingers with relative ease, no difficulty with use of his phone. DIFFERENTIAL DIAGNOSIS: Right C5, C6, C7 nerve root avulsions Right upper trunk brachial plexopathy Multiple right upper extremity mononeuropathies Left cerebrovascular accident TESTS AND RESULTS: Brachial plexus MRI revealed lobulated signal within the right C4-5, C5-6, and C6-7 neural foramen representing perineural intraforaminal cysts versus sequelae of nerve root avulsions. The visualized portion of the brachial plexus otherwise demonstrates no intrinsic or extrinsic abnormality. No muscle signal abnormality to suggest denervation or atrophy. EMG at outside institution performed 7 weeks post-injury demonstrated normal nerve conductions, reduced recruitment of the deltoid, biceps, and triceps. The cervical paraspinals were not examined. FINAL WORKING DIAGNOSIS: Right C5 - C7 nerve root avulsions TREATMENT AND OUTCOMES: Held from football participation and resumed formal physical therapy on campus. He has made significant progress including obtaining near full antigravity range of motion in all planes. He has initiated a trial of shoulder pace-maker training. Navigating insurance coverage barriers to obtain MRI cervical spine, repeat right upper extremity EMG and evaluation in comprehensive brachial plexus clinic.