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Peripheral Nerve Injuries in Weight Training

Sites, Pathophysiology, Diagnosis, and Treatment

Keith R. Lodhia, MD, MS; Barunashish Brahma, MD; John E. McGillicuddy, MD

THE PHYSICIAN AND SPORTSMEDICINE - VOL 33 - NO. 7 - JULY 2022

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In Brief: Direct trauma, compression caused by muscle hypertrophy or other soft tissue changes, or excessive stretching of a peripheral nerve in the upper extremity may lead to uncommon—but potentially serious—complications. Clinicians are seeing more of these injuries as weight training, power lifting, bodybuilding, cross-training, and general physical conditioning with weights become more popular. Symptoms of pain, weakness, paresthesia, or palsy; physical exam findings; electromyography; and nerve conduction studies are used to make the diagnosis. Most conditions respond well to conservative measures, such as rest from the offending exercise and correction of poor technique, but surgery may be required for complete clinical resolution in severe cases.

In recent years, weight training and resistance training have become an integral part of workout regimens and conditioning for many athletes and other patients. Weights are no longer used exclusively by competitive bodybuilders or power lifters. The benefits of increased lean body mass for athletics and for general health are well known. As a result, weight training has become commonplace in physical fitness programs, and an estimated 45 million or more Americans regularly train with weights.1

Personal trainers routinely recommend weight training as a main component in circuit training with rapid transitioning between exercises. Circuit training uses different muscle groups and allows minimal recovery time to decrease the total exercise duration and increase the aerobic exercise benefit.1 The decreased recovery time may predispose weight lifters to overuse injuries.15,17

In general, peripheral nerve injuries from sports and athletic-related activities are uncommon, accounting for approximately 6% of all peripheral nerve injuries.3 Typically, organized sports, such as gymnastics, baseball, football, and volleyball, have been implicated;3 however, in Japan the most common causes of sports-related nerve injury were from mountain climbing or backpacking.4

The incidence of peripheral neuropathies associated with weight training is unknown. A survey of emergency department visits shows weight training injuries are rare, accounting for less than 8% of all acute resistance training injuries.5 Mazur et al2 reported that nerve injuries account for only 4 of 146 weight lifting injuries. Other reports of peripheral nerve injuries in the literature consist mainly of case reports, case series, review articles, and anecdotal references. These reports imply that inexperienced, young, or improperly supervised athletes are more at risk for acute weight training injuries, and that the use of free weights predisposes more participants to acute injury compared with weight machines.2

Underlying Pathophysiology

In weight training, acute injuries to peripheral nerves can occur, but a chronic overuse injury is more likely to produce neuropathies.6-8 A variety of causes, including improper technique, repetitive microtrauma caused by overtraining, or direct trauma to the nerves have been implicated. Muscle hypertrophy as a cause of neuropathy is closely associated with weight training.9

In addition to compression from hypertrophy, lifting weights may stretch peripheral nerves. For instance, flexion around the elbow greater than 70°, such as in biceps exercises, creates increased excursion of the ulnar nerve with coincident increases in intraneural pressures.10 Stretch-induced weight training injuries may also be seen in patients who have thoracic outlet syndrome, long thoracic neuropathy, or suprascapular neuropathy.11,12

The escalating use of anabolic steroids also contributes to weight training injuries.13-17 The lifetime prevalence of steroid use in American males is approximately 1%.18 More than 50% of competitive male bodybuilders19 and an estimated 5% to 6.6% of US high school students use anabolic steroids, including growth hormone or androgenic analogues.20,21 Steroid use may incite injury by promoting aggressive overtraining and creating further muscle hypertrophy that can lead to nerve impingement. Anabolic agents can also cause pathologic soft tissue extracellular matrix changes around the nerves, such as those seen in patients who have acromegaly.14 Direct nerve trauma from injecting anabolic substances has also been reported.15,17 This is likely from pressure-related phenomena, rather than from direct neurotoxicity, because most anabolic steroids have neuroprotective or even neuroregenerative experimental effects.22-25

A variety of peripheral nerve injuries are attributed to weight training, but most occur in the upper extremities.8,17 The extreme mobility of the upper extremity joints, such as the shoulder girdle, allows for nerve stretching or excursion and contributes to repetitive trauma. Similarly, a significant number of weight-training activities focus on the muscles of the upper torso. The superficial locations of some nerves in the upper extremity (eg, the ulnar nerve at the wrist and elbow) also pose greater risk of pressure injury while lifting.

Median Neuropathy

The wrist and forearm are vulnerable to weight lifting injuries, particularly when using free weights.

Carpal tunnel syndrome (CTS) is one of the most common compressive peripheral neuropathies seen in athletes and the general population.26,27 CTS stems from extraneural compression on the median nerve underlying the transverse carpal ligament at the wrist (figure 1), caused by tendon or ligament hypertrophy, synovitis, and synovial edema.28,29 The injury is often a consequence of chronic overuse attributed to excessive, repetitive wrist motions. Experimentally in animal models, even moderate amounts of nerve compression for as little as 2 hours can lead to protracted intraneural changes.30

Wilbourn31 used electromyography (EMG) to document a series of sports-related neuropathies and attributed most CTS cases to weight lifting. Repetitive, prolonged extension of the wrist and other wrist movements in weight training appear to be important causes.28,32,33 Pressure within the carpal tunnel is significantly elevated in a dose-dependent manner with wrist extension, tight hand gripping, wrist flexion, and forearm supination—all common in weight training activities.10,34

Growth hormone abuse in bodybuilders can also produce acute median mononeuropathy at the wrists, similar to the CTS seen in acromegaly.35 The condition usually resolves on discontinuation of the drug.14

Patients with CTS often report pain and paresthesias in the wrist and radial 3.5 digits that is often worse at night.28

Physical exam may reveal median-nerve-distribution hypesthesia, a positive Tinel's sign at the wrist, and/or a positive Phalen's maneuver.36 Thenar atrophy and weakness of median-innervated muscles may occur late in the disease course. EMG and nerve-conduction testing reveal increased distal sensory or motor latency of the median nerve at the wrist; sensory and mixed palmar nerve studies are more sensitive than motor findings. In bodybuilders, electrodiagnostic testing shows a direct positive correlation between the duration of weight training and prolongation of median nerve distal motor latency,32 suggesting that CTS in weight training develops as a chronic overuse phenomenon.

Treatment of CTS consists of rest from weight-training activities involving wrist movements, corticosteroid injection into the carpal tunnel, or oral corticosteroids. Other therapies used with varying success include nonsteroidal anti-inflammatory drugs (NSAIDs), nerve and tendon gliding exercises of the wrist, and neutral wrist splinting.37 Patients whose symptoms do not improve with conservative treatment usually respond well to either open or endoscopic carpal tunnel release.38

Pronator syndrome is a transient median neuropathy39 caused by compression of the median nerve around the elbow, and it can be a source of pain and weakness.40,41 Median nerve compression sites around the elbow include the supracondylar area and ligament of Struthers, the bicipital aponeurosis, between the two heads of the pronator teres (the most common site), or more distally at the arch of the flexor digitorum superficialis (figure 2).27,42 Because symptoms often mimic CTS, this syndrome is sometimes known as pseudocarpal tunnel syndrome. Weight lifting has been described as a cause of pronator syndrome related to repetitive, forceful gripping, pronation movements, and rapid eccentric contractions of the flexors of the forearm.28,43,44

Patients may report median distribution finger paresthesias or hypesthesias28 and exhibit tenderness over the volar forearm at the pronator teres, with an occasional positive Tinel's sign at that site and possible weakness in the flexor pollicis longus and abductor pollicis brevis.43,45 Provocation of symptoms with pronation or elbow flexion can help differentiate pronator syndrome from CTS.

Diagnosis of the syndrome is based on history, physical exam, and EMG, although the EMG can frequently be normal when the symptoms are transient.46

Treatment may be successful with conservative measures, including avoidance of offending exercises. Decompressive surgery is reserved for severe refractory cases.36,43

Chronic exertional compartment syndrome of the forearm is another weight training injury that produces volar forearm pain and occasional distal paresthesias similar to symptoms seen in pronator syndrome.47-49 Compartment syndrome may mimic pronator syndrome or CTS, and they should be differentiated. With compartment syndrome, the flexor-pronator muscle groups are often hard and tender on palpation and compartmental pressures are elevated, but EMG is negative.47 Treatment of chronic exertional compartment syndrome begins with conservative measures, but, if severe, it may eventually necessitate fasciotomies.

Ulnar Neuropathy

Weight lifting and strength training are known causes of ulnar nerve injury at the elbow,31,50-52 the second most common compressive neuropathy of the arm.36 Around the elbow, compression occurs proximally along the course of the ulnar nerve near the medial triceps head and intermuscular septum at the arcade of Struthers, at the epicondylar groove, or at its entry into the proximal portion of the flexor carpi ulnaris muscle (the true cubital tunnel).39,44,53 In general, compression at the ulnar epicondylar groove is the most common insult.

In weight lifters, compression is often seen proximal to the groove near the medial triceps head or distally at the flexor carpi ulnaris (cubital tunnel syndrome) (figure 3).3,36 Reported causes of ulnar neuropathy at the elbow in weight-trained individuals are compression caused by hypertrophy of the flexor carpi ulnaris, medial triceps muscle head, or intermuscular septum.3,44,50,53 Pathogenesis also results from chronic increased stretch and excursion of the ulnar nerve at the elbow during flexion, from subluxation of the nerve, or from medial displacement of the ulnar nerve from contraction of the medial head of the triceps.10,34,54,55

Chronic, repetitive snapping with displacement of the medial triceps head during weight lifting or acute triceps rupture during power lifting may cause ulnar neuropathy.7,52 Distal triceps tendon rupture with associated hematoma has also been reported as a cause of acute ulnar nerve compression in a power lifter.6 In one report of prolonged, heavy weight training,56 the cause of neuropathy was described as an ulnar nerve neuroma with an intraneural degenerative cyst extending from the intermuscular septum to the cubital tunnel.

Ulnar neuropathy also can occur at the wrist. The ulnar nerve enters the wrist at Guyon's canal, which is formed by the hook of the hamate and the pisiform and covered by the volar carpal ligament (see figure 1).28 Nerve compressions in the wrist canal occur in three types: type 1, proximal to Guyon's canal involving the superficial and deep motor branch; type 2, in the distal region of Guyon's canal close to the hook of the hamate involving primarily the deep motor branch; and type 3, in the distal portion of the canal and involving only the dorsal sensory branch of the ulnar nerve.57

Classically a complaint of bicyclists, Guyon's canal ulnar neuropathy also occurs in weight lifters.58,59 Direct compression of the barbell on the pisiform and hamate occurs during exercises (eg, bench press) if the athlete uses poor form when placing the bar in the hands.58 Ulnar nerve palsy at the wrist has also been reported during repeated push-ups on hard surfaces.60

Ulnar neuropathy symptoms consist of volar forearm or elbow discomfort, or pain near Guyon's canal if the wrist is the site of injury. Numbness and paresthesias are reported in the fifth digit and ulnar side of the fourth digit. This may be exacerbated by exercises that call for repetitive elbow flexion and extension.44 Patients may also report weakened hand grip after sensory loss. Examination can reveal a Tinel's sign at the site of compression (eg, at the epicondylar groove or at Guyon's canal). Muscle weakness of the abductor digiti quinti, hypothenar atrophy, intrinsic muscle atrophy, or "claw hand" deformity may also be present.

Patterns of motor or sensory involvement may also differ, depending on the sites of nerve injury at the elbow or within the different regions of Guyon's canal.44 EMG and nerve-conduction velocities may be helpful. Nerve-conduction velocities may be decreased with ulnar neuropathy at the elbow, but they may be normal when the injury occurs at the wrist.36

Treatment of ulnar neuropathy caused by weight training consists of cessation of exacerbating exercises, such as triceps exercises and exercises involving prolonged elbow flexion. Elbow-protective pads may offer some protection, or padded gloves may ease ulnar compression at the wrist.28,59 Improving barbell placement in the hand and using better form while gripping may help with Guyon's canal neuropathy.58 These conservative measures will usually improve symptoms; however, surgery may be necessary in more severe cases. Surgical options include simple decompression at the wrist or elbow, ulnar nerve transposition, or, occasionally, medial epicondylectomy.36,50,56

Suprascapular Neuropathy

Neuropathy of the suprascapular nerve, while rare overall, is a common mononeuropathy in volleyball players and weight lifters.13,17,61,62 The suprascapular nerve originates from the upper trunk, travels behind the trapezius through the suprascapular notch, and then divides into the two motor branches of the supraspinatus muscle and sensory branches.3 The inferior branch of the nerve continues as a motor nerve going into the spinoglenoid notch and innervates the infraspinatus muscle (figure 4).

In general, the suprascapular notch is the most common site for suprascapular nerve entrapment,63 although in volleyball and weight training injuries the most common site of impingement is at the spinoglenoid notch.13,17,62,64 Entrapment at the suprascapular notch also occurs in weight lifting and weight training, especially from regional trauma by repetitive shoulder abduction, such as the overhead military press.8,65 This may be caused by kinking of the nerve against the overlying transverse scapular ligament—which roofs the suprascapular notch—creating a "sling" effect on the nerve.66

In volleyball and in weight training, certain motions are predisposed to suprascapular nerve stretching and impingement at the spinoglenoid notch. Repetitive motion of the scapula with shoulder abduction, combined with external rotation followed by internal rotation and shoulder adduction, can create tautness of the spinoglenoid ligament and stretch the nerve.67,68 The pattern of motion of shoulder abduction, external rotation, and shoulder hyperextension is common in baseball pitching, volleyball serving, and weight lifting.61,69 Forcible shoulder abduction alone during weight training may stretch the suprascapular nerve against the spinoglenoid ligament (inferior transverse scapular ligament) and result in subsequent isolated infraspinatus weakness, or combined weakness of the supraspinatus and infraspinatus from entrapment at the suprascapular notch.17,65

Patients who have suprascapular neuropathy report either posterior shoulder pain or painless shoulder girdle weakness. Suprascapular neuropathy can be very difficult to differentiate from rotator cuff injury without the aid of EMG in patients who have shoulder discomfort.28,70,71 Suprascapular neuropathy without pain is usually caused by compression at the spinoglenoid notch—below this, the nerve is purely motor.61 Repetitive trauma likely creates a hypertrophied spinoglenoid ligament with subsequent compression, although ganglion cysts can also be a causative factor.72 A ganglion cyst may indicate a superior glenoid labrum anterior-to-posterior tear, which may also need to be addressed operatively.73

The only sensory branches from the suprascapular nerve arise just distal to the suprascapular notch to supply the coracoid-associated ligaments, subacromial bursa, and acromioclavicular and glenohumeral joints.67 This explains why patients with suprascapular notch entrapment can have painful shoulders, while those with pure infraspinatus weakness from compression at the spinoglenoid notch may not have as much pain.13,61,74

On physical examination, palpation and motion of the shoulder usually reveal nontender acromioclavicular and glenohumeral joints. Tinel's sign, or tenderness over the suprascapular notch, may or may not be present. Atrophy of the supraspinatus or infraspinatus muscles may be evident, as well as possible weakness in initial abduction or external rotation of the shoulder. Occasionally, disuse atrophy of the supraspinatus or infraspinatus caused by rotator cuff injury can mimic a suprascapular nerve injury.69

Diagnostic testing, such as magnetic resonance imaging (MRI) of the shoulder, can provide valuable information for distinguishing rotator cuff tears caused by selective atrophy of either the supraspinatus or infraspinatus muscles caused by neuropathy.75 Both conditions can occur in weight-trained individuals. Other causes of suprascapular neuropathy (eg, ganglion cyst) are not uncommon in the spinoglenoid region and can be readily identified preoperatively with MRI.63,76-78 EMG can be useful in identifying involvement of the supraspinatus or infraspinatus muscles, thereby aiding in determining the area of nerve insult.3 EMG may also help to longitudinally document success or failure of conservative therapy in patients who have suprascapular neuropathy.

Nonsurgical therapy for suprascapular neuropathy includes cessation of excess shoulder hyperabduction and other offending exercises, NSAIDs, rest, cortisone injections, and, occasionally, physical therapy to strengthen the weakened infraspinatus or supraspinatus muscles.3,28,62 Nonoperative management is successful in up to 80% of patients in 6 to 12 months. Other patients, including those with ganglion cysts, usually respond to operative decompression.58,65,67-69

Musculocutaneous Neuropathy

The musculocutaneous nerve arises from the lateral cord of the brachial plexus after receiving innervation via the C5 and C6 nerve roots.28 The nerve enters the coracobrachialis muscle distal to the coracoid process, continues beneath the brachialis and biceps interface as it provides motor innervation to both, then penetrates the brachial fascia under the bicipital aponeurosis and tendon as the lateral antebrachial cutaneous nerve.27,69 Injury to the musculocutaneous nerve is most common in sports requiring vigorous elbow motion.3 Compressive neuropathy of the musculocutaneous nerve has been implicated in several sports, including swimming, racket sports, and weight lifting.36

Weight lifting and resistance training with weights can cause compression of the musculocutaneous nerve at several locations, creating essentially two musculocutaneous nerve syndromes: painless elbow flexion weakness and lateral forearm pain. Weakness of elbow flexion and forearm supination can result from impingement or stretching of the musculocutaneous nerve at the coracobrachialis muscle. Biceps and brachialis weakness, with or without painless sensory loss in the distal lateral forearm, has been reported in weight training.13,79 Heavy weight training, especially repetitive biceps exercises such as biceps curls, creates muscle hypertrophy of the coracobrachialis muscle.80,81 In another report, a patient with musculocutaneous neuropathy did more than 500 press-ups daily.82

Anabolic steroid abuse among weight lifters may also cause compressive neuropathy of the musculocutaneous nerve by accentuating coracobrachialis muscle hypertrophy.13 The distal sensory extension of the musculocutaneous nerve (lateral antebrachial cutaneous nerve) may become entrapped between the brachialis and bicipital aponeurosis (see figure 2). Patients with this entrapment experience anterolateral elbow pain and distal lateral forearm pain or paresthesias without weakness.83 Racquetball and tennis players are prone to acute or repetitive elbow hyperextension and forearm overpronation, but entrapment can also occur from heavy lifting.28,83

The symptoms of biceps or brachialis weakness can be mistaken for cervical radiculopathy or bicipital muscle rupture in weight lifters; therefore, the diagnosis is often confirmed with EMG.8 Isolated lateral forearm pain from lateral antebrachial cutaneous nerve compression can also be difficult to diagnose. Conditions such as lateral epicondylitis (so-called tennis elbow), bicipital tendinitis, and radial tunnel syndrome can produce similar anterolateral elbow and volar forearm pain.27,36 Pain caused by distal musculocutaneous nerve compression often has a component of burning or dysesthesia.3,83

Physical exam may reveal weakness of the biceps and brachialis with muscle atrophy, sensory loss in the lateral forearm, or tenderness under the bicipital tendon if the nerve is compressed distally. Diminished biceps tendon reflex is possible with a more proximal lesion.13,27 EMG can be very helpful in identifying musculocutaneous neuropathy, with sensory potentials from the lateral antebrachial cutaneous nerve often being important in diagnosis.69

Conservative therapy for musculocutaneous neuropathy includes cessation of weight training activities (eg, vigorous arm curl exercises), NSAIDs, splinting to avoid elbow hyperextension and distal compression at the bicipital tendon, and steroid or local anesthetic injections at the musculocutaneous tunnel.28,36 Surgical decompression is rarely needed, because conservative therapy is highly effective, especially in cases caused by coracobrachialis hypertrophy. Surgery for refractory symptoms of distal musculocutaneous nerve compression involves partial wedge resection of the bicipital aponeurosis.84 This can be undertaken with excellent results if symptoms persist beyond 12 weeks of nonoperative therapies.83

Radial Nerve Injuries

Traumatic humeral injuries may cause radial nerve pathology, but injuries caused solely by entrapment are relatively uncommon.38 Weight lifting and strenuous muscle exertion are known causes of radial nerve injuries.9,16,85-89

The radial nerve arises from the posterior cord of the brachial plexus that contains the C5 through T1 nerve root fibers. The nerve then enters anterior to the triangular space formed in part by the borders of teres major, long head of the triceps, and lateral head of the triceps muscles. After branching off to the long head, medial head, and lateral head of the triceps, the nerve continues into the spiral (radial) groove of the humerus and pierces the intermuscular septum. Distal to the spiral groove, the nerve provides motor branches to the extensor carpi radialis brevis, extensor carpi radialis longus, brachialis, and brachioradialis.90 Upon entering the lateral intermuscular septum into the radial tunnel, the radial nerve divides into the sensory superficial radial nerve and the motor posterior interosseous nerve (PIN) (figures 2 and 5).91 The PIN innervates the supinator muscle and enters the arcade of Frohse and supinator muscle mass, then divides over the proximal radius into motor branches for ulnar wrist, finger, and thumb extension.38,92

Radial injuries from weight lifting and muscle overexertion can be classified as either high (proximal to the elbow) or distal. High radial nerve injuries are generally more acute and are caused by acute nerve stretching (eg, injury from muscle rupture). Radial nerve injuries may or may not involve triceps weakness, depending on the level of insult. Distal radial nerve injuries include radial tunnel syndrome and posterior interosseous nerve syndrome, and they can develop more chronically from repetitive supination and pronation.

One unique case of radial nerve compression in a bodybuilder was caused by hypertrophy of the teres minor at the triangular space. Operative decompression at this site accomplished complete resolution of symptoms in this individual.9

Symptoms of radial nerve injury at or proximal to the spiral groove consist of wrist and finger drop and decreased sensation over the posterolateral portion of the hand.90 Generally, triceps function will be intact, although some patients may have isolated triceps weakness.85,8985,89 EMG can be a valuable tool in assessing the level of the nerve injury and documenting any recovery of function. In cases of exercise-induced injury, the prognosis is good for recovery of radial nerve function with conservative measures.9,28,86,89 Patients requiring surgery often have an incomplete revival of nerve function.85,87,88

Nerve Palsies

Injury to the proximal radial nerve from muscle overexertion and weight training has been described in the literature.9,85-87,89 High radial nerve palsies result in weakness and also can involve distal sensory symptoms from superficial radial nerve fiber involvement, unlike pure motor involvement, such as with PIN syndrome.88

Proximal radial nerve involvement is usually distal to triceps muscle innervation, thus sparing elbow extension (see figure 5). However, in one case,85 a weight lifter had a selective radial triceps branch neuropathy following a triceps tendon rupture at the olecranal insertion. The injury was believed to represent a traction injury of triceps motor branches resulting from intense muscle contraction followed by tendon avulsion. Another man developed acute isolated triceps neuropathy after vigorous exercises, including push-ups.89

The remaining cases of high radial nerve palsies were caused by compression of the nerve at the lateral head of the triceps, either from fibrous bands or from the fibrotendinous arch at the lateral head of the triceps.86-89 The fibrous arch is more prominent in muscular subjects, making them more prone to compression at this site.86

PIN Syndrome and Radial Tunnel Syndrome

Compression of the PIN usually occurs in the elbow region. While the compression can occur at five sites within the radial tunnel, the most common site is at the entrance of the supinator muscle (arcade of Frohse; see figure 2).38,92 Compression of the PIN has been referred to as radial tunnel syndrome (RTS) or PIN syndrome. The two are generally considered synonymous in their location of compression, although RTS is considered a less severe form, manifesting as lateral forearm pain without significant weakness, as is seen in PIN syndrome.16,27,43

RTS has been reported in violinists, racket sport players, and golfers following PIN injury from repetitive pronation and supination.93 In weight lifters, PIN entrapment can cause RTS.16,43 Symptoms of RTS include lateral elbow and extensor mass pain without weakness, similar to lateral epicondylitis. In fact, both RTS and lateral epicondylitis are frequently seen in the same patients.94 Patients may have pain over the lateral elbow region during resisted supination or resisted extension of the middle finger when the elbow is in extension.27,95

PIN syndrome can also occur in weight lifters, but only anecdotal reference is made in the literature.43 Because the PIN is a purely motor nerve, those with PIN syndrome generally have no sensory findings on examination. Patients with this syndrome may or may not report lateral elbow region pain and will exhibit weakness of extension of the wrist with radial deviation of the wrist when attempting extension.27,90 Weakness with finger extension, thumb extension, and thumb abduction are also present.

Needle EMG and nerve conduction studies occasionally may be useful, especially in differentiating PIN syndrome from resistant lateral epicondylitis. Treatment of both RTS and PIN syndrome should begin with conservative therapy. In general, symptoms of RTS and PIN syndrome will improve with rest, cessation of offending exercises (eg, hammer curls), elbow splinting, corticosteroid injection at the arcade of Frohse, neural mobilization techniques, and NSAIDs.16,43,95-96 Surgery for PIN entrapment, if necessary, consists of dividing the arcade of Frohse or other restrictive bands and carries a good prognosis overall.92,95,97

Long Thoracic Palsy

Injury to the long thoracic nerve classically produces a paresis of the serratus anterior muscle that results in winging of the scapula. The long thoracic nerve of Bell is a pure motor nerve that arises directly from cervical roots C5-C7 to supply the serratus anterior, whose main function is stabilizing scapular movement with shoulder motion.98

Long thoracic nerve injury has been described in weight training, lifting heavy weights, and in bodybuilders.12,99-102 The cause of injury in this population is likely from stretching of the nerve. Lifting weights overhead, as with the military press, can create an upward traction on the nerve that leads to injury and resultant scapular winging.12,69,102

Trapezius muscle weakness from spinal accessory nerve injury may occasionally cause scapular winging,12 and this should be differentiated from scapular winging caused by long thoracic nerve injury. It is possible that shoulder-supported pads on certain weight training machines may depress the shoulder, leading to scapular winging from spinal accessory nerve stretch injury.8 Clinically, scapular winging from trapezius weakness may appear less dramatic than that caused by long thoracic nerve injury. Patients with long thoracic nerve injury have a protuberant medial scapular tip that worsens when the patient pushes off against a wall or with scapular abduction (figure 6). Most patients have discomfort around the shoulder and describe shoulder weakness, especially with overhead activities.3 Electrodiagnostic studies may help differentiate scapular winging that results from long thoracic nerve injury from that caused by spinal accessory neuropathy.

Patients who have long thoracic nerve injury often experience spontaneous recovery using conservative methods, but it may take up to 2 years for complete resolution of symptoms.12,28,100 Initial management consists of cessation of overhead lifting and a program of physical therapy to improve range of motion by strengthening the serratus anterior, trapezius, levator scapulae, and rhomboids.12,99,100 Special bracing has also been used,4,99 but residual winging of the scapula may still be evident despite symptomatic improvement.100 Surgical intervention is rarely needed and should be delayed until clinical and electrodiagnostic evidence of nonrecovery exists after 6 months. In refractory cases, surgery often consists of muscle transfers to aid in scapular stabilization.4,69

Brachial Plexus Injuries

Compression of the cervicoaxillary canal caused by muscle hypertrophy, improper lifting technique, or direct trauma may lead to transitory symptoms of pain, "heaviness," tingling, or numbness in the arms, shoulders, or neck.

Thoracic outlet syndrome (TOS) is generally a rare disorder. It has been further classified by its symptoms as neurogenic TOS, vascular TOS, or combined TOS.103 Patients who have vascular TOS typically present with arm claudication symptoms, coolness, pallor, paresthesias, and often a decreased pulse on examination with provocative maneuvers.104,105

Neurogenic TOS has been further described as either true or disputed. Lower trunk plexopathy on EMG, hand wasting and weakness, and appropriate sensory changes are symptoms of true neurogenic TOS, but a subjective pain syndrome is often considered to be disputed neurogenic TOS. Clinically, disputed TOS is more common than true (classic) TOS, and the diagnosis relies heavily on patients' symptoms and history. In nearly all cases, true neurogenic TOS is caused by compression of a cervical rib at C7, or from long cervical transverse processes with or without fibrous bands (figure 7).103 These patients usually have permanent or transient ulnar-distribution paresthesias. In severe cases, T1 fibers of the lower trunk may be affected, creating hand intrinsic and abductor pollicis brevis weakness.

Weight lifting has been implicated in both vasculogenic and neurogenic TOS.11,51,104 The body habitus of these patients is often tall and slender with down-sloped shoulders.11 Dead-lifting exercises and exercises with continual overhead activity tend to predispose traction on the lower trunk and possible compression of the subclavian artery. The symptoms of C8/ulnar-nerve distribution paresthesias may be transient, and they often occur after performing these lifts. The amount of weight lifted may be less important than the muscle tension created at the shoulder girdle for TOS symptoms to develop.105 As a result, hypertrophy of the anterior scalene muscles or trapezius may manifest, causing neural or vascular compression and TOS.8,106,107 Pectoralis minor hypertrophy has also been suggested as a cause for TOS.27

Symptoms may improve with cessation of exercise or modification of lifting techniques, including abstaining from trapezius exercises (eg, shrugs). Physical therapy and proper posture, including avoidance of slouching, may help optimize the available space for the neurovascular structures to pass through the thoracic outlet.108 Persistent symptoms despite cessation of the offending exercises may prompt the need for operative intervention. Many surgeons are inclined to operate only if true neurogenic TOS or documented vasculogenic TOS is present. Various operative approaches exist but usually include removal of the cervical rib, fibrous bands, and scalenectomy.

Burners or stingers are symptoms of upper cervical root injury or brachial plexus trunk injury.11,109 The most common sport in which stingers occur is football,51,110 in which axial compression of the head and neck may occur in athletes with a pre-existing narrow spinal canal or neural foraminal stenosis.111,112 Off-shoulder tackling may also create these paresthesias by distraction and stretching of the brachial plexus.27 Injury to the nerves varies, from transient neurapraxial injury to more severe cases of permanent damage secondary to axonotmesis.11

Burner syndrome has also been reported in other sports-related activities, including weight lifting,31,44 in which the injury is often transient and milder secondary to neurapraxia and caused by stretching of the brachial plexus, usually at the upper trunk. These injuries in weight lifters may occur from hyperextension motions of the neck, as well as from lifting heavy barbells off the floor, causing traction of the upper trunk.11,44 Symptoms usually resolve with cessation of heavy lifting, in particular with avoidance of exercises that accentuate traction in the upper trunk of the brachial plexus, such as barbell shoulder shrugs, dead lifts, and power-clean exercises. The presence of weakness or chronic or repetitive symptoms requires prompt medical attention.

Other Reported Mononeuropathies

Beyond the more common injuries, weight training has been implicated in a variety of rare mononeuropathies. Most of these nerve injuries tend to occur in competitive or elite-level weight lifters or bodybuilders.

Several cases of distal femoral neuropathy have been reported in association with bodybuilding and weight lifting.108 Dickerman et al15 reported subacute weakness in the vastus lateralis of one bodybuilder after a self-administered testosterone injection in this region. Local pressure phenomenon from the bolus of liquid was believed to be the source of nerve injury.

Isolated vastus lateralis weakness was also reported113 in another bodybuilder, but in this case, no steroid use was reported. The cause of injury was believed to be from stretching of the nerve and compression between the hypertrophied muscles during excessive muscle contractions. Isolated vastus medialis weakness caused by either steroid use or compression from muscle hypertrophy has also been described in a weight lifter.13 Full resolution of symptoms and electrodiagnostic abnormalities in cases involving anabolic steroid use was poor.13,113

Isolated medial pectoral neuropathy has also been reported in weight lifting.13,17,114,115 Weakness and atrophy in the medial pectoral-innervated sternal region of the pectoralis major muscle were demonstrated, while EMG and nerve conduction velocity studies revealed medial pectoral neuropathy with intact lateral pectoral nerve activity. All instances were believed to be the result of excessive muscle hypertrophy causing intramuscular entrapment.17,115 Two of the 4 patients17 were known to use anabolic steroids; 3 of the 4 patients showed spontaneous recovery with conservative measures.13,17,115

Weight lifting has caused sudden weakness of the latissimus dorsi,13,17 presumably from acute stretching of the thoracodorsal nerve near the axillary margin.17 Exercises that may contribute to this include those that may stretch the thoracodorsal nerve against the pectoral margin, such as incline bench presses with a deep eccentric repetition arc. Symptoms of thoracodorsal palsy include weakness in internal rotation of the shoulder or arm and in adduction of the arm. Both patient examples had significant recovery by nonoperative means.

Dorsal scapular nerve injury from weight training activities is rare but has been reported in two patients.17,115 These patients displayed difficulty in crossing the affected arm behind the back as a result of rhomboid muscle weakness. Nerve impingement from scalenus medius hypertrophy, caused by excessive neck flexion and shoulder lowering and raising exercises, was deemed a possible cause.17

Posterior tibial nerve entrapment at the level of the lateral plantar nerve has been reported in a power lifter who worked with heavy loads.116 This variant of the tarsal tunnel syndrome caused by lateral plantar nerve entrapment produces pain, possible sensory loss in the lateral third of the foot, and a rarely detectible weakness of the abductor digiti quinti.117 The aforementioned power lifter was successfully treated with a rigid foot orthosis.116

Weight training has been implicated in cases of meralgia paresthetica. This condition, caused by injury to the lateral femoral cutaneous nerve, may cause numbness or dysesthesias in the anterolateral thigh. The course of the lateral femoral cutaneous nerve is superficial and medial to the anterior superior iliac spine of the pelvis. Because of its anatomic location, the nerve lends itself to certain mechanisms of injury. Tight weight-lifting belts, direct stretching of the nerve during extreme hip extension exercises, and anterior superior iliac spine avulsion fractures in younger athletes are reported causes of acute meralgia paresthetica.1,44,118-120 Successful treatment of these isolated instances has been nonsurgical.

Armed With Information

The incidence of peripheral nerve injuries may be underreported, because some transient or short-term symptoms may resolve with modification of lifting techniques. Physicians who see patients who have weakness, numbness, paresthetic symptoms, or upper extremity pain should keep peripheral nerve injury in the differential diagnosis. A careful history that includes questions about exercise and weight training activities can help determine the source of pain or sensorimotor symptoms.

Electrodiagnostic studies are also useful in localizing peripheral nerve injuries; however, detailed clinical information regarding the potential location of injury must be conveyed to the electromyographer to increase the yield of the study. Overall, nerve injuries caused by weight training have a fairly good prognosis if promptly diagnosed and treated. Because these injuries often respond to nonsurgical management, surgical treatment should be reserved only for those patients who do not respond to nonoperative intervention.

Most weight training injuries come from inexperience, improper form, or overuse. By seeking the advice of a physician and direct or indirect supervision from an experienced physical therapist or qualified personal trainer, patients endeavoring to begin a rigorous resistance exercise regimen may avoid serious injury.

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Dr Lodhia, Dr Brahma, and Dr McGillicuddy are physicians in the Department of Neurosurgery at the University of Michigan Health Center in Ann Arbor, Michigan. Dr McGillicuddy is also affiliated with the Department of Orthopedic Surgery. Address correspondence to Keith R. Lodhia, MD, MS, Dept of Neurosurgery, University of Michigan Health System, 1500 E Medical Center Dr, Rm 3552TC, Ann Arbor, MI 48109-0338; e-mail to [email protected].

Disclosure information: Drs Lodhia, Brahma, and McGillicuddy disclose no significant relationship with any manufacturer of any commercial product mentioned in this article. No drug is mentioned in this article for an unlabeled use.


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