ACL Tears in Teens

With more and more young athletes participating in sports each year, injuries to the anterior cruciate ligament (ACL) of the knee have become quite common. Youngsters, particularly during the period of rapid growth—generally around age 12 for girls and 14 for boys—are at increased risk for ACL tears. For various reasons, adolescent girls may be 3 to 8 times more likely than their male counterparts to tear their ACL. Fortunately, new injury prevention programs have emerged that can help at risk athletes, particularly adolescent females, to avoid ACL tears.



Knee anatomy and the ACL
The knee is a complex joint made up of 3 bones: the femur (thighbone) and the tibia (shinbone) meet to form a hinge that allows for flexion (bending) and extension (straightening) with a minor degree of rotation while the patella (kneecap) covers its front and helps extension. These bones are held together by 4 ligaments: the 2 collateral ligaments and the 2 cruciate ligaments (Fig.1). The collateral ligaments run along either side of the knee, limiting side-to-side motion and providing stability. The outside ligament is known as the lateral collateral ligament and the inside as the medial collateral ligament. Inside the knee joint are the 2 cruciate ligaments, so called because they criss-cross, forming an X. The posterior cruciate ligament or PCL is in the back while the often-injured anterior cruciate ligament or ACL is in the front. The ACL slides within the intercondylar notch, or the space between the 2 rounded ends of the femur. Its primary function is to prevent the tibia from either moving too far forward or from rotating too far inward underneath the femur.


Risk factors for ACL tears in teens
While participation in demanding sports such as football, basketball, and soccer has been linked to a greater likelihood of ACL tears (Fig. 2), further investigation into risk factors has divided ACL tears into nonmodifiable and modifiable categories.1 Nonmodifiable risk factors include issues with knee structure, hip-knee alignment, hormone function, neuromuscular maturation, and reduced muscular strength. Modifiable risk factors include various neuromuscular imbalances and deficiencies. Both types of risk factors are more closely associated with being female.


A narrow intercondylar notch of the femur or notch stenosis (narrowing) as well as variations in tibial plateau (the upper surface of the tibia within the knee joint) anatomy, such as an increased slope, can lead to pinching of the ACL by the femur and possible rupture. Also, by adolescence, females have a wider pelvis than males and thus a greater Q-angle or angle of hip-knee alignment, concentrating more force on the ACL and increasing the likelihood of a tear. Moreover, during their developmental phase, females exhibit less neuromuscular maturation along with greater inner knee rotation and valgus (knock-knee). They also have a greater ground reaction force—the force exerted on the body when landing a jump. Furthermore, young female athletes have less strength in proportion to bone size in the muscles that stabilize the knee than male athletes, yet experience the same twisting and loading forces on this joint. Lastly, hormone fluctuations may cause the collateral ligaments to become looser at certain points during the menstrual cycle and so unable to absorb the stresses placed on them, putting the ACL at risk of injury.


Modifiable risk factors for ACL tears include neuromuscular imbalances and deficiencies. Traditionally, boys have participated in sports, such as soccer, that involve twisting movements at an earlier age than girls. By adolescence, they may have developed the muscle coordination and reflexes needed to protect the knee while girls may have neuromuscular imbalances and deficiencies—such as knee ligament, muscle, or overall leg dominance, as well as various muscular weaknesses—that can make them more prone to ACL injuries.


Ligament dominance is a condition that results in decreased medial-lateral (side-to-side) neuromuscular control of the knee joint. This neuromuscular deficiency can lead to valgus collapse, or medial displacement, of the knee and possibly to an ACL tear. Quadriceps dominance—a condition where the quadriceps muscles in the front of the thigh overpower the hamstrings in the back of the thigh—can cause excessive anterior translation, or forward slippage, of the tibia and strain the ACL.1 Leg dominance, which predisposes the nondominant leg towards valgus collapse, can also be a factor in sustaining ACL injuries.


Muscular weakness
Weaknesses in the gluteal (buttocks), hamstring (back of the thigh), and gastroc soleus (back of the calf) muscles can lead to a valgus collapse and consequent ACL strain, especially during a jump landing.2 Moreover, weak core (abdominal and mid and lower back) muscles mean an unstable pelvis, resulting in too much lateral trunk motion and pronation (inward rolling of the feet), and thus increased risk of an ACL injury.


Prevention programs
Prevention programs have been created to train athletes to resist injury. Prevention programs for ACL tears focus on neuromuscular imbalances and deficiencies. While each program has its own specific regimen that combines plyometrics (jump training that makes the leg muscles exert maximal force in a brief amount of time in order to increase speed and power) with conditioning and strengthening exercises,1 all of them concentrate on developing more appropriate landing techniques along with better balance and stability in the lower extremity. For teens, the most effective regimens are those that implement neuromuscular training and emphasize plyometrics and strengthening both preseason and in season.

While not all studies have shown a reduction in ACL injury for their particular study group,3 the bulk of evidence indicates that these programs can work.1, 4 One study reviewing several prevention programs saw a 52% risk reduction for ACL tears in females, and for males the rate was even higher at 85%.4 Two programs that have been shown to significantly reduce ACL injuries in females are Sportsmetrics and Prevent Injury and Enhance Performance (PEP).5, 6 With all prevention programs, it should be noted that success depends largely on the athlete’s degree of compliance.1 As prevention is still the most efficient and cost-effective method to avoid ACL injuries, screening for at-risk athletes has been considered.


ACL surgery
Over the past 30 years, ACL reconstructive surgery to stabilize the knee and lessen further damage has advanced considerably. While such progress has led to improved outcomes that potentially allow the athlete to return to play, it has also heightened expectations. Affected athletes must realize that they may still have limitations after ACL reconstruction. In their study, Ardern et al. showed that among athletes with ACL injuries, 82% returned to sport, but only 63% to their pre-injury sport, and just 44% at a competitive level. Furthermore, the knee with the ACL tear has been shown to be more likely than the uninjured knee to develop arthritis.7


The best cure
An ACL tear can be a significant life-altering injury for a young athlete, and teens, particularly girls who participate in sports, are at increased risk. While more research is needed, appropriate ACL injury prevention programs have been shown to reduce the overall number of ACL tears. As with all types of injuries, prevention is the best cure. Such programs should therefore be seriously considered before a young athlete suffers an ACL tear.


Author: David A. Lalli, DO | Niceville, Florida

Reprinted with permission from the Hughston Health Alert, Volume 28,Number 4, Fall 2016.


1. Hewett TE, Torg JS, Boden BP. Video analysis of trunk and knee motion during non-contact anterior cruciate ligament injury in female athletes: lateral trunk and knee abduction motion are combined components of the injury mechanism. British Journal of Sports Medicine. 2009;43(6):417-22.
2. Hewett TE, Lindenfeld TN, Riccobene JV, Joyes FR. The effect of
neuromuscular training on the incidence of knee injury in female athletes:
A prospective study. American Journal Sports Medicine. 1999;27(6):699-706.
3. Sadoghi P, von Keudell A, Vavken P. Effectiveness of anterior cruciate ligament injury prevention training programs. Journal Bone and Joint Surgery, American. 2012;94(9):769-76.
4. Ardern CL, Webster KE, Taylor NF, Feller JA. Return to sport following anterior cruciate ligament reconstruction surgery: a systematic review and
meta-analysis of the state of play. British Journal Sports Medicine. 2011;45(7):596-606.
5. Mandelbaum BR, Silvers HJ, Watanabe DS, et al. Effectiveness of a neuromuscular and proprioceptive training program in preventing anterior cruciate ligament injuries in female athletes: a 2-year follow-up. American Journal of Sports Medicine 2005;33(7):1003-10.
6. Pfeiffer RP, Shea KG, Roberts D, et al. Lack of effect of a knee ligament injury prevention program on the incidence of noncontact anterior cruciate
ligament injury. Journal of Bone and Joint Surgery, American. 2006;88(8):1769-74.
7. Mather RC 3rd, Koenig L, Kocher MS, Dall TM, et al. Societal and economic impact of anterior cruciate ligament tears. Journal of Bone and Joint Surgery, American. 2013;95(19)1751-9.

Don’t “Just Do It” – Do It Right


In 1988, an upstart advertising firm in Portland, Oregon was approached by Buck Knight to help with his company’s print and television campaign. Interestingly, while developing the campaign,  Dan Weiden found inspiration in the last words spoken by Gary Gilmore—a convicted murder who was executed by firing squad in 1977. Just before his life ended, Gilmore shouted “Let’s do it.”  Born out of Gilmore’s final words, Weiden’s famous slogan “Just Do It” is considered one of the top 5 slogans of the 20th century. Weiden described his slogan as “a tough, take no prisoners, intensely personal” ad campaign targeted at all Americans, regardless of their level of physical fitness. After the “Just Do It” campaign, Nike’s athletic shoes market-share went from 18% to 43% in the United States. In recognition of the impact of Dan Weiden, Nike and its slogan are enshrined in the Americana exhibit at the Smithsonian National Museum.


Caring for orthopaedic patients and their injuries is not easy work. The doctor must quickly assimilate the information given by you, and put together a comprehensive plan for recovery. Teamwork is the key to successful outcomes in orthopaedic care. The team will always include at least two participants, known as the doctor-patient relationship team. The doctor uses his or her years of training and experience to create the game plan and you, the patient, uses your understanding, efforts, and biofeedback to execute that plan. Not only is it time to “Just Do It,” it’s time to “Do It Right.” Your health and recovery take focused and consistent effort. Although other team members, such as physical therapists may get involved in the patient-care episode, there is only one person ultimately responsible—YOU.


All too often, I see a patient and prescribe a comprehensive treatment plan, only to find out that this plan wasn’t properly executed, or wasn’t attempted at all. The patient returns with continued complaints, and seeks more options. Effort, energy, and ownership of your health and well-being are your option.  Don’t “Just Do It,”—Do It Right. You might not be enshrined in the Smithsonian, but your reward will be equally gratifying.


Author: Marc A. Tressler, DO | Hughston Clinic Orthopaedics, Hendersonville, TN

Bone Grafting: An Essential Guide


Bone grafting is a surgical procedure in which an orthopaedic surgeon transplants bone tissue. Bone grafts are used to repair fractures that are complex or have failed to heal, to replace missing bone following trauma or tumor removal, and to correct deformities. They are also used in spinal surgery to help fuse vertebrae. Bone grafts work because, given sufficient space and proper scaffolding, bone tissue has a remarkable ability to regenerate.



Osseous, or bone, tissue consists of protein fibers called collagen embedded in a matrix of intercellular liquid hardened by deposits of calcium and phosphate salts. Within and around the matrix, 3 types of bone cells build, maintain, and remodel bone. These include osteoblasts, or immature bone cells, which produce the bone matrix; osteocytes, or mature bone cells, which serve to maintain the matrix; and osteoclasts which break down and remove bone tissue (Fig. 1).


Bone grafts

A bone graft grows and repairs a defect according to 3 different processes. The first is osteogenesis, or the formation of new bone by living cells within the graft such as osteoblasts. The second, osteoinduction, is a chemical process in which protein molecules within the graft recruit and stimulate the patient’s undifferentiated cells to become osteoblasts. Lastly, osteoconduction is the process by which the matrix of the graft serves as a scaffold to maintain space so the recipient’s cells can generate new bone tissue. Bone grafts thus provide a structure for bone to grow, but then slowly dissolve, leaving behind only the new bone.



An autograft, or bone obtained from a patient’s own body, is considered the gold standard in bone grafting procedures largely because native bone is osteogenic as well as osteoinductive and osteoconductive. It is also non-immunogenic, which means it is compatible with the patient’s own tissues and the body will not attack or reject it. As all bone requires an adequate blood supply, depending on the graft size and transplant site, a section of the periosteum (the thin layer of connective tissue that covers the bone) and its accompanying blood vessels may be included with the autograft and reattached at the site to ensure its blood supply.

There are additionally 2 types of bone that can be used for an autograft: cancellous or soft bone and cortical or hard bone. Compared to cortical bone, cancellous bone has greater surface area and is much more porous, allowing cells to infiltrate and blood vessels to form. It thus has more bone-forming potential than cortical bone, but cortical bone, being harder, can provide immediate structural support for new bone. Common sources of cancellous autograft bone are the iliac crest (upper portion of each side of the pelvis), upper tibia (shinbone), and the radius (wrist). Cortical autografts can be harvested from the diaphysis, or shaft, of the fibula (outer bone of the lower leg) and used to reinforce reconstructions, such as for spinal injuries or to replace segments where bone has been lost due to a trauma or tumor removal.

While autografts are the preferred material, harvesting bone from the patient’s own body necessitates additional surgical time and blood loss, and the amount of bone that can be harvested is always limited. The chief drawbacks to an autograft, however, are potential complications at the harvest site, such as infection and possible nerve injury.


Allografts and synthetic materials

A graft obtained from donor (cadaveric) bone is called an allograft. After being harvested, the bone tissue is tested for disease, cleansed, frozen, and stored in tissue banks. Allografts are not osteogenic, but they are able to stimulate cells to become osteoblasts and to provide a scaffold for bone growth. Unlike autografts, they do not require the patient to undergo an additional surgery; this reduces the risk of infection and precludes pain and loss of function at a second surgical incision site.

A variety of natural and synthetic replacement materials can also serve as substitutes for natural bone or can be mixed with either allograft or autograft tissue as bone extenders. These include ceramics like calcium phosphates, bioglass, and calcium sulphate. All of these materials are biologically active to some degree. For example, allograft bone that has been treated with a strong acid to remove the inorganic mineral deposits, known as demineralized bone matrix, possesses some osteoinductive properties. Additionally, coral, which has a biochemical and physical structure similar to bone, can act as a scaffold for new bone. Natural substances, such as bone morphogenetic proteins (BMPs), which contain growth factors, can be added to these synthetic materials to enhance their biological activity.

Allografts, either alone or mixed with extenders or enhancers, are often used in pelvic, knee, and femur (thighbone) reconstructions, but, ultimately, the type of bone graft used depends on the site and the exact nature of the injury being repaired. Since allograft tissue is not the patient’s own, the bone quality may vary. Moreover, the graft may take longer to incorporate with the patient’s native bone than an autograft. There is also a greater risk of reabsorption of the graft as well as the possibility of immune response complications, though taking anti-rejection drugs helps diminish this. Likewise, advanced testing and cleansing methods have greatly reduced the risk of transferring a disease along with an allograft.


Bone grafting procedures

During a bone grafting procedure, the orthopaedic surgeon will either place the graft material directly into the bone defect or lay it across to bridge the area to be fused. In some instances, the bone graft is held in place with pins, plates, or screws. When additional stability or protection is needed during the healing process, a splint, cast, or brace can be applied.

Recovery from a bone grafting procedure can take from 2 weeks to more than a year, depending on the size of the defect and the condition of the surrounding bone at the time of the surgery. More severe cases take longer and can require follow-up surgery.



Certain behaviors and conditions can affect the outcome of a graft. For instance, smoking can diminish outcomes because the carbon monoxide in cigarettes reduces local blood flow, decreasing osteoblast formation and bone metabolism at the graft site. Diabetes mellitus, which can cause peripheral nerve and vascular problems, may negatively impact fracture healing and bone grafting. Deficiencies in dietary calcium and vitamin D impair bone metabolism while metabolic conditions, such as thyroid problems and low growth hormone levels, have been associated with high rates of nonunions (fractures that fail to heal). Additionally, some drugs, such as nonsteroidal anti-inflammatory medications and corticosteroids, can interfere with bone healing. By inhibiting osteoclasts, bisphosphonates used to treat osteoporosis (low bone density) can decrease the rate of bone remodeling. Overall, bone grafting is highly successful in patients who do not smoke and follow their surgeon’s instructions when it comes to medications and activity modification.


Author: Thomas N. Bernard, Jr., MD | Columbus, GA

Reprinted with permission from the Hughston Health Alert, Volume 29,Number 1, Winter 2017.

Atrial Fibrillation in Athletes

Atrial Fibrillation is the most common cardiac arrhythmia (heart rhythm) affecting over 5 million people in the United States with projections up to 20 million people by 2030.1 Physicians define atrial fibrillation as rapid, chaotic electrical impulses in the upper heart chambers known as the atria that result in irregular heartbeats. In the early phases of the disease, abnormal impulses from pulmonary veins—which carry oxygenated blood and connect directly to the left atrium of the heart—trigger the arrhythmia. As the disease progresses, the normal cellular architecture of the atria changes as thicker scar tissue replaces healthy muscle, which in turn causes the atrial fibrillation to worsen. Based on the patient’s symptoms, treatment can include medications or catheter ablation (a minimally invasive procedure) to disrupt the faulty signals.



Risk factors

Other than rare genetic disorders, atrial fibrillation is an acquired condition. It often presents in the sixth and seventh decades of life, with a lifetime risk of 25% for people who are over 40 years of age. Typical risk factors for atrial fibrillation include age, heart failure, valvular (heart valve) disease, obesity, sleep apnea, hypertension, diabetes mellitus, and alcohol consumption.1 In addition to causing cardiovascular symptoms, it increases stroke risk 5-fold and can lead to heart failure. To determine stroke risks, physicians use the CHADS-VASC score (Table). Based on a score of 2 or more risk factors, anticoagulants (blood thinning medications) are used to reduce the chance of stroke.



Endurance athletes

Cardiovascular exercise is generally beneficial for patients with atrial fibrillation; however, there are some scenarios where exercise can increase the episodes. Endurance exercise including marathon running, triathlons, and similar long-duration exercise can increase the risk of developing the condition. One study of endurance athletes showed a 2- to 10-fold increase of occurrence compared to sedentary individuals.2 In endurance athletes, the left atrium is often enlarged and there is usually some degree of cardiac muscle stiffening. A leading theory for increased atrial fibrillation in endurance athletes includes increased vagal tone. When the vagus nerve controls the heart rate through the parasympathetic nervous system, nerve fibers slow the heart rate—this is called vagal tone. Prolonged episodes of heightened vagal tone, necessary for endurance activities but possibly arrhythmia provoking, is the most established theory. In this scenario, increased vagal tone leads to increased heart rate variability and ectopy (a rhythm disturbance) thereby triggering atrial fibrillation. The phenomenon appears to be more common in men and in those under the age of 60. Additionally, theories involving athletes include increased physical stress on the heart, inflammation, prolonged electrolyte imbalance, remodeling of the heart muscle, and increase in pulmonary vein trigger firing.3



Most patients with exercise-induced atrial fibrillation usually have the mildest form, which doctors define as episodes lasting less than 1 week. To assess the contribution of heavy exertion, physicians often advise their patients to stop endurance training for 3 months. Exercise-induced atrial fibrillation is different from that seen in the general population, although the treatment strategies for the condition remain similar. For those with 2 or more risk factors for stroke, physicians often prescribe anticoagulants. Medical treatment of atrial fibrillation in athletes can be challenging since most medications can slow the resting and exertional heart rate thereby limiting the ability to exercise. Physicians often prescribe anti-arrhythmic medications specifically designed to treat the disease; however, these tend to have other types of unwanted side effects. Catheter ablation in the endurance athlete has become a more favorable option since it provides freedom from the condition and can eliminate the need for long-term medications.


How much is too much?

Despite findings of increased atrial fibrillation in endurance athletes, physicians do not recommend stopping exercise as a means to reduce the risk. Recommendations for weekly cardiovascular exercise regimens totaling 150 minutes remain part of standard practice. In fact, one study reported that a monitored diet and exercise program for 3 months after an ablation procedure greatly reduced the rate of recurrence; therefore, exercise plays a beneficial role in care.4 However, researchers need to determine the ideal balance before the risk of atrial fibrillation increases. Strength training, such as moderate weight lifting does not increase or decrease the risks. For athletes taking supplements and consuming energy drinks, there is little information to provide any guidance; however, many of these products contain caffeine and other stimulants that have shown to trigger atrial fibrillation events. The question of “how much is too much” in exertional activities remains unclear.


Don’t overdo it

Atrial fibrillation is a common cardiac arrhythmia that has significant health implications including increased risks of heart failure and stroke. Medications and ablation procedures are often effective along with lifestyle modifications in preventing progression of the condition. Cardiovascular fitness is important in reducing episodes; however, extreme training and endurance events can increase the risks. Moderate exercise training regimens are likely the best strategy to reduce the incidence of atrial fibrillation in athletes.


Author: Michael L. Bernard, MD, PhD | New Orleans, LA

Reprinted with permission from the Hughston Health Alert, Volume 30,Number 4, Fall 2018.



  1. Morin DP, Bernard ML, Madias C, Rogers PA, Thihalolipavan S, Estes NA 3rd. The State of the Art: Atrial Fibrillation Epidemiology, Prevention, and Treatment. Mayo Clinic Proceedings. 2016 Dec; 91(12):1778-1810.
  2. Estes NA 3rd, Madias C. Atrial Fibrillation in Athletes: A Lesson in the Virtue of Moderation. JACC: Clinical Electrophysiology. 2017 Sep;3(9) 921-8.
  3. Sanchis-Gomar F, Lucia A. Pathophysiology of atrial fibrillation in endurance athletes: an overview of recent findings. Canadian Medical Association Journal. 2016 Dec;188(17-18):E433-35.
  4. Pathak RK, Middeldorp ME, Meredith M, et al. Long-Term Effect of Goal-Directed Weight Management in an Atrial Fibrillation Cohort. A Long-Term Follow-Up Study (LEGACY). Journal of the American College of Cardiology. 2015 May;65(20):2159–69.

“Dr. Google” Misses the Mark Most of the Time


In the age of the Internet, all too often we seek the medical opinion of “Dr. Google” prior to obtaining a medical evaluation and treatment recommendations. Sometimes, “Dr. Google” can accurately predict the cause of your problem; but more often than not, its algorithm formula misses the mark. In fact, the Pew Research Center’s Internet and American Life Project found that 39% of all Internet searches are related to medical topics or conditions. Of those searches, 82% of the medical information was gathered from either Google, Bing, or Yahoo, whereas only 13% of the medical information was gathered from an actual medical website like the Hughston Health Alert or WebMD. Furthermore, the Pew Research Center found that only 46% of all people who decided that they had a medical problem actually sought the opinion of a medical professional. Meanwhile, another 38% of respondents initially self-diagnosed and self-administered the treatment “Dr. Google” suggested. Of the 46% of people who ended up going to the doctor’s office for evaluation, only 41% of them found that their Internet diagnosis was correct.


With this information in mind, how can the doctor-patient visit be optimized? Upon intake (with the doctor’s assistant) for your appointment, reveal to the assistant your beliefs about what your Internet research has concluded. It’s your doctor’s job to listen. Once you have revealed your beliefs…sit back, relax, and learn what your doctor’s years of medical training and experience can teach you. The reality is almost all medical conditions are “cause and effect” scenarios. Diagnosing the “effect,” or confirming the reason you are here is the easy part. Determining the “cause” of why you acquired this “effect” is what you really want to know. This breadth of knowledge is power.


It helps if you can get answers and take ownership of these questions:

What is it?

What’s the source?

Why did it happen?

What should I do now?

Why would I decide for or against surgical treatment?


All this information undoubtedly will be a lot to take in. It is also a lot for the doctor to get through. As such, inquire if there are summary handouts for you to review. Lastly, ask your doctor which websites he or she feels are the most reliable sources to learn more about your medical condition. Talk to your doctor because “Dr. Google” gets it wrong most of the time.


Author: Marc A. Tressler, DO | Hughston Clinic Orthopaedics, Hendersonville, TN

Brachial Plexus: Traumatic Nerve Injuries

The brachial plexus are nerves that conduct signals to the shoulder, elbow, and hand muscles and provide feeling in the arm. If these nerves become injured you can lose function, sensation, and experience pain. Some injuries to the brachial plexus are minor and brief, while others are severe and can cause permanent disability. These injuries often occur after a traumatic event, such as a sports injury, an automobile accident, or from complications at birth.

Brachial plexus injuries involve the C5, C6, C7, C8, and T1 nerves that originate from the spinal cord in the neck. As these nerves leave the neck, they form the brachial plexus, which weaves together then branches as they pass under the clavicle (collarbone) toward the shoulder. Depending on the extent of the injury and which nerve is damaged, brachial plexus injuries are sometimes called Erb’s palsy, Klumpke palsy, Parsonage-Turner syndrome (brachial plexus neuritis), and burners and stingers. Most brachial plexus injuries are minor and you will recover within a few weeks with limited treatment; however, other injuries can require rehabilitation or surgery and take longer to heal.


Often, brachial plexus injuries occur during high-speed automobile accidents, blunt trauma from a fall, or from the violence of a stab or gunshot wound. Difficult births are a major cause of brachial plexus nerve injuries in newborns. The nerve injuries can also result from medical conditions such as inflammation, compression from a growth or tumor, and nerve disease.

The damage occurs when 1 or more nerves are pulled, stretched, compressed, or torn. The nerve injury can be an avulsion (pulled away from the spinal cord), a stretch (pulled but not torn), or a rupture (stretched with a partial or complete tear). Often, the nerves closer to the neck are damaged when the shoulder is forced down and the nerves closer to the armpit are more likely damaged when your arm is forced upward or above your head. In addition, athletes in contact sports can sustain transient brachial plexus injuries known as “burners and stingers” after sustaining a blow to the neck and shoulder girdle region. The injury occurs when the arm is forcibly pulled or stretched downward and the head is pushed to the opposite side. Interestingly, brachial plexus insult can also occur in an idiopathic (unknown cause) fashion after inflammation of the nerves.


For most brachial plexus injuries, only one side is usually affected and depending on the severity and location, the signs and symptoms vary. For example, the minor damage caused by a burner or stinger can produce an electric shock or burning sensation shooting down the arm and numbness and weakness in the limb. The symptoms can last a few seconds or they can last for days. Traumatic brachial plexus injuries can present with partial or complete motor and sensory paralysis of the arm, shooting pains in the affected arm and an inability to use all or selected muscles on the affected side. These injuries can be transient and slowly resolve over time or can persist for longer periods leading to permanent damage. If you experience a serious injury, such as an avulsion, you may become unable to use certain muscles in your shoulder, arm, or hand. You may experience severe pain or lose feeling and the ability to move the limb. Acute injuries to the brachial plexus often warrant close follow-up with a medical professional.

You should seek medical advice and treatment if a brachial plexus injury is suspected, especially when symptoms persist without improvement. Additionally, you should see a doctor if you have recurrent burners and stingers, weakness in your hand or arm, or experience neck pain.

Screening and diagnosis

A thorough health history and physical exam are of paramount importance in screening patients for potential brachial plexus injuries. Your physician may first order chest, spine, or shoulder x-rays to rule out a fracture or dislocation that can cause entrapment (compression of the nerve) of the brachial plexus. Performing a computerized tomography with myelography (a CT scan using dye) a few weeks after the initial injury is the current gold standard to identify the nerve injury level. Other imaging modalities that can be useful include magnetic resonance imaging (MRI), electromyography (EMG), nerve conduction velocity (NCV), and other nerve studies based on the discretion of the healthcare provider. If your physician suspects an infectious cause, he or she will include laboratory work in the screening process.


The mainstay treatment for brachial plexus injuries remains nonsurgical management with close observation for symptom resolution. The physician conducts frequent and thorough exams over the first 3 to 6 months and performs additional testing as needed to evaluate the recovery. Partial brachial plexus injuries with a halt in neurologic resolution can require surgery. If your physician suspects an inflammatory process, a course of pain control, physical therapy, and oral corticosteroids may be necessary.

Patients with open injuries, progressive neurologic deficits, and penetrating injuries such as gunshot wounds, often require immediate surgical treatment. For patients with a total plexus injury, surgery will likely take place around 4 to 6 weeks after the initial injury. New advances in nerve surgery are helping to restore movement and function in the shoulder, elbow, and hand, which once was impossible. There are many surgical techniques available depending on the specific injury encountered. Some of these include direct nerve repair, nerve grafting, nerve transfers, muscle or tendon (tissue connecting muscle to bone) transfers, osteotomies (bone surgery), and arthrodesis (fusion of a joint). Reconstruction procedures can take up to 3 years before full recovery occurs, especially since nerve regeneration occurs at a slow rate of approximately 1 mm/day. When comparing injuries of the upper (C5, C6) and lower (C8, T1) brachial plexus, the upper plexus tend to have better outcomes as hand function remains preserved.

Be patient

Nerves heal and regenerate slowly, so you must be patient. Your doctor may prescribe a rehabilitation program to follow to keep your muscles strong and healthy while the nerve heals. Outcomes after sustaining brachial plexus injuries are dependent on the extent and level of your injury. However, given enough time, many brachial plexus injuries heal without lasting damage.

Author: Devin W. Collins, DO

Reprinted with permission from the Hughston Health Alert, Volume 30, Number 4, Fall 2018.


Medal of Honor recipient Al Lynch Reception and Presentation

Please join Hughston on May 2nd at the National Infantry Museum for a Meet-the-author, Book Signing, and Presentation by Medal of Honor recipient Al Lynch. We look forward to seeing you out there!


Tennessee Physicians Carry on the Hughston Legacy

Our physicians at Hughston Clinic Orthopaedics are continuing Dr. Hughston’s vision of exceptional orthopaedic care and legacy of sports medicine. Featured on Nashville Medical News Blog, an article written by the Hughston Foundation’s Dennise Brogdon gives us insight into Dr. Hughston’s history and vision.

“In Columbus, Ga., and in orthopaedics, Jack C. Hughston, MD, is a well-known pioneer in the field of sports medicine. In Tennessee his notoriety is not as well known. However, Hughston orthopaedic physicians are carrying on his legacy through their local clinics and sports medicine programs. Dr. Hughston established The Hughston Clinic in Columbus in 1949. Now, 70 years later, the practice continues to grow with clinics in 6 states, specialized trauma services in major hospitals, and over 50 board-certified, specialty-trained physicians.”

Read the full article here:

Jack Hughston Memorial Hospital Recognized as a CMS 5-Star Rated Hopsital

Jack Hughston Memorial Hospital is among only 293 hospitals in the nation that were recognized as 5-star hospitals by CMS, last week. This rating is based on the following categories:

  • Timely and effective care
  • Complications and deaths
  • Unplanned hospital visits
  • Use of medical imaging
  • Payment and value of care

CMS assesses various metrics for each of the categories, for over 4,500 hospitals, to determine and assign the star rating. The overall hospital rating, which ranges from 1 to 5 stars, shows how well each hospital performed, on average, compared to other hospitals in the U.S. Our 5-star rating shows we are, indeed, striving for “Excellence Always”!

For detailed information about our rating, visit Hospital Compare


Read press releases here:

MEDHOST Customers Get Recognized by CMS as Five-Star Hospitals

Raymond Long, MD Wins Research Award

Raymond Long, MD presented his research “The Posterolateral Approach for Fixation of Posterior Malleolar Fractures” at the Orthopaedic Trauma Association’s national meeting held in Vancouver, BC, Canada. Dr. Long’s research video was selected as a top-three finalist from a host of submissions.