Brachial Plexopathy in Athletes: EMG/NCS Evaluation and Return-to-Play Guidance

The Clinical & Business Connection Newsletter

Clinical Insight

Brachial plexus injuries represent a heterogeneous group of peripheral nerve injuries encountered across contact sport disciplines, most frequently involving the upper trunk (C5–C6) via traction and/or compression mechanisms. While transient neurapraxia — the so-called “stinger” or “burner” — comprises the majority of athletic brachial plexus events, clinicians must maintain a high index of suspicion for axonotmesis and, less commonly, neurotmesis, particularly in athletes presenting with persistent deficits or recurrent episodes.

Mechanisms and Classification

Three primary mechanisms account for most athletic brachial plexopathies:

• Ipsilateral compression: direct blow depressing the shoulder while the neck is forced laterally away, typically implicating the upper trunk at Erb’s point

• Contralateral traction: lateral neck flexion away from the ipsilateral shoulder, stretching the upper trunk and its roots

• Direct compression: hyperextension or axial loading mechanisms causing foraminal narrowing, often in athletes with pre-existing cervical stenosis

Seddon’s classification (neurapraxia, axonotmesis, neurotmesis) and Sunderland’s grading system remain the standard frameworks for communicating injury severity. In practice, electrodiagnostic grading guides prognosis and the return-to-play decision more reliably than clinical symptom duration alone.

Role of Electrodiagnostic Testing

EMG/NCS provides objective characterization that clinical examination alone cannot offer. Key diagnostic parameters include:

• NCS: reduced compound muscle action potential (CMAP) amplitude or conduction velocity across the affected segment; sensory nerve action potential (SNAP) findings help distinguish pre-ganglionic from post-ganglionic lesions

• Needle EMG: the appearance of fibrillation potentials and positive sharp waves (establishing axonal loss) is time-dependent; Wallerian degeneration requires 3–4 weeks to manifest on needle exam — premature evaluation may underestimate the degree of injury

• Paraspinal sampling: normal paraspinal muscles in the context of peripheral motor unit changes support a post-ganglionic localization, whereas paraspinal denervation suggests root avulsion or pre-ganglionic involvement

For athletes with suspected neurapraxia only (rapid full clinical recovery within minutes), early electrodiagnostic testing may be deferred unless symptoms recur or fail to fully resolve. When testing is indicated, the optimal window for comprehensive needle EMG evaluation is 21–28 days post-injury.

Referral Triggers for Electrodiagnostic Evaluation

We recommend early referral for EMG/NCS when any of the following are present:

• Symptom duration exceeding 15 minutes

• Residual motor weakness on formal testing (deltoid, biceps, infraspinatus) at any time point

• Third or subsequent episode within a single season

• Bilateral symptomatology (raises concern for central or multilevel etiology)

• Prior cervical imaging showing foraminal stenosis or disc pathology

Our team provides rapid turnaround on diagnostic reports with specific guidance on return-to-play readiness, enabling your patients to get back to sport with confidence and appropriate medical oversight.

References

1. Clancy WG. Brachial plexus and upper extremity peripheral nerve injuries. In: Torg JS, ed. Athletic Injuries to the Head, Neck, and Face. 2nd ed. Mosby; 1991:215–220.
2. Weinberg J, Rokito S, Silber JS. Etiology, treatment, and prevention of athletic “stingers.” Clin Sports Med. 2003;22(3):493–500.
3. Sallis RE, Jones K, Sunshine S, et al. Brachial plexus injuries in football players. Am Fam Physician. 1992;45(4):1699–1703.
4. Seddon H. Three types of nerve injury. Brain. 1943;66(4):237–288.
5. Krivickas LS. Peripheral nerve injuries in athletes. Sports Medicine. 1997;23(2):109–122.

Business Success Strategy

Protecting Physician Wellbeing This Summer: A Strategic Framework for Work-Life Balance

Summer marks a natural inflection point in the clinical calendar. Patient volumes often shift, staff take vacations, and scheduling complexity peaks — even as the opportunity to recalibrate personal bandwidth presents itself. For high-volume referring physicians, this quarter is an ideal moment to audit operational efficiency and build in structural recovery time before the fall surge.

Burnout among physicians remains an ongoing crisis. According to the American Medical Association, more than half of U.S. physicians report symptoms of burnout — with administrative burden, scheduling inefficiencies, and diagnostic uncertainty among the leading contributors. The good news: there are high-leverage, low-disruption steps you can take right now.

Three High-Leverage Moves for Summer

1. Streamline your diagnostic referral workflow.
Reduce administrative friction by centralizing referral tracking, utilizing digital intake portals, and automating referral confirmations. These steps minimize manual coordination and free up your staff for patient-centered tasks.

2. Protect non-clinical time as a non-negotiable.
Research consistently shows that physicians who maintain structured time away from clinical duties demonstrate better decision-making quality, lower error rates, and higher patient satisfaction scores. Summer provides a natural window — use it intentionally.

3. Audit your referral patterns for efficiency.
Assess your diagnostic partners by benchmarking report turnaround times and the clarity of findings. Consolidating referrals to providers who deliver consistent, actionable data will streamline your decision-making and expedite patient care.

At Hands-On EMG Testing, we are committed to being the kind of diagnostic partner that reduces the load on your practice — not adds to it. If there is anything we can do to make the referral process easier for your team this summer, please reach out directly. (add more eg confirming referrals to mean reducing administrative burden)

Spotlight on Excellence

Dr. Hasan Chughtai, DO

Physical Medicine & Rehabilitation Expert (PM&R)

Referring Physician

At Hands-On EMG Testing, we are proud to recognize Dr. Hasan Chughtai, DO, as a valued physician in the delivery of coordinated, patient-centered care. Dr. Chughtai’s clinical acumen and commitment to thorough diagnostic workup make him an outstanding leader in his field. Dr. Chughtai brings a thoughtful, thorough approach to evaluating complex neuromuscular and musculoskeletal conditions. His commitment to accurate diagnosis and to ensuring his patients receive the right pain management treatment plan at the right time makes him exceptional in the care continuum.

We are honored to support Dr. Chughtai’s practice and his patients with timely, expert electrodiagnostic testing and clear, actionable reports. His trust in our collaborative team means the world to us, and we are grateful for the opportunity to work together to improve patient outcomes.

To reach Dr. Chughtai:
visit www.wellnesspmr.com
718-658-5639

Updates You Should Know

The Introduction to EMG, Nerve Conduction Studies, and Musculoskeletal Ultrasound Imaging course just wrapped — and it was a phenomenal success.

This quarter, Hands-On EMG Testing hosted the American Academy of Clinical Electrodiagnosis (AACE) and the American Academy of MSK Ultrasound (AAMU) for the Introduction to EMG, Nerve Conduction Studies, and Musculoskeletal Ultrasound Imaging with 40+ clinicians gathering for two days of intensive, hands-on training.

Attendees left with:

• Real-world skills in EMG, nerve conduction studies, and MSK ultrasound imaging
• The clinical context needed to make more confident, accurate referrals
• 20.5 CEUs (physical therapy professionals) or 20.5 CMEs (physicians and medical providers)
• A direct connection to the HODS Leadership Team, who works personally with your admin and marketing staff to tailor strategies for your practice and market

The energy in the room was electric — and the demand is only growing!

Want in on the next one? For all upcoming dates and locations please visit emgintro.com.

How We Can Help

Hands-On EMG Testing serves physicians and patients across several locations in Manhattan, Queens, the Bronx, Brooklyn, and Long Island.

To refer a patient, please use our online referral form. To learn more about our services, email in**@********mg.com, or call +1 (855) 248-4021.

If you are interested in incorporating our Medical Diagnostic Model into your practice to provide immediate testing results and create a strong business opportunity, please contact Dr. Dimitrios Kostopoulos at di**@********mg.com.