Ebook Handbook of neurological sports medicine: Part 1

H a n d b o o k

o f

Neurological
Sports Medicine
Concussion and Other
Nervous System Injuries in the Athlete

Anthony L. Petraglia, MD
Julian E. Bailes, MD
Arthur L. Day, MD

Human Kinetics


Library of Congress Cataloging-in-Publication Data
Petraglia, Anthony L., 1980- author.
Handbook of neurological sports medicine: concussion and other nervous system injuries in the athlete /
Anthony L. Petraglia, Julian E. Bailes, Arthur L. Day.
p. ; cm.
Includes bibliographical references and index.
I. Bailes, Julian E., author. II. Day, Arthur L., author. III. Title.
[DNLM: 1. Athletic Injuries. 2. Brain Injuries. 3. Trauma, Nervous System. QT 261]
RD97.P4816 2015
617.1'027--dc23
2014009602
ISBN: 978-1-4504-4181-0 (print)
Copyright © 2015 by Anthony L. Petraglia, Julian E. Bailes, and Arthur L. Day
All rights reserved. Except for use in a review, the reproduction or utilization of this work in any
form or by any electronic, mechanical, or other means, now known or hereafter invented, including

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E5835


Contents
Contributors ix
Preface xi
Acknowledgments xiii

Part I

General Concepts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Chapter 1 Athletes and Neurological Injuries: A View From 10,000 Feet . . . . . . 3
The Present  4
Spectrum of Neurological Injury in Sport  4
Concluding Thoughts  32
References 32

Chapter 2 Medicolegal Considerations in Neurological Sports Medicine . . . . 43
With Increased Awareness Comes Increased Scrutiny  43
The King of Concussions  44
Negligence 44
Duty and Breach  45
Violation of a Statutory Duty  45
Standard of Care Defined by Experts  46
Standard of Care Established Through Literature, Rules, Protocols,
and Textbooks  47
Good Samaritan Laws  48
Proximate Cause  48
Assumption of the Risk  48
Theories of Negligence  49
Cases of Interest  49
NFL and NCAA Concussion Litigation  52
Concluding Thoughts  54
References 55

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iv 

• • • 

Contents

Chapter 3 Having a Game Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
Developing an Emergency Action Plan  59
Caring for Athletic Injuries  64
Responsibilities of Host and Visiting Medical Staff  71
Concluding Thoughts  73
References 73

Part II

Sports-Related Head Injuries . . . . . . . . . . . . . . . . . . . . 75

Chapter 4 Biomechanics, Pathophysiology,



and Classification of Concussion . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
Biomechanics and Basic Concepts  77
Lessons Learned From Football  80
Lessons Learned From Other Sports  84
Pathophysiology of Concussion  89
Classification of Concussion and Grading Systems  94
Concluding Thoughts  96
References 96

Chapter 5 In the Trenches: Acute Evaluation and Management of Concussion . . 103
Presentation 105
Acute Evaluation  110
Concluding Thoughts  114
References 115

Chapter 6 Neuroimaging and Neurophysiological Studies



in the Head-Injured Athlete . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121
Standard Neuroimaging  121
Advanced Structural Techniques  125
Advanced Functional Techniques  129
Neurophysiological Techniques  133
Concluding Thoughts  135
References 135

Chapter 7 Neuropsychological Assessment in Concussion . . . . . . . . . . . . . . 141
Use of Symptom Checklists  142
Value of Neuropsychological Assessment of Concussion  143


Contents 

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v

Issues With Computerized Assessments  147
Other Considerations  150
Other Issues Addressed by Neuropsychologists in Assessing Concussed
Patients 151
Concluding Thoughts  155
References 155

Chapter 8 Role of Balance Testing



and Other Adjunct Measures in Concussion . . . . . . . . . . . . . . . . . . 163
Balance Assessment in Concussion  163
Emerging Technology and Future Directions for Adjunct Measures of Assessment
in Concussion  169
Concluding Thoughts  173
References 173

Chapter 9 Postconcussion Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179
What’s In a Definition  179
Scope of the Problem  181
A Neuroanatomical Substrate for Prolonged Symptoms  181
Psychogenesis of PCS and PPCS  182
A Modern Conceptual Framework for PCS and PPCS  183
Concluding Thoughts  184
References 184

Chapter 10 Neuropathology of Chronic Traumatic Encephalopathy . . . . . . . . . 189
Definition of Chronic Traumatic Encephalopathy  189
Posttraumatic Encephalopathy Versus Chronic Traumatic Encephalopathy  192
Gross Morphology and Histomorphology of Chronic Traumatic
Encephalopathy 194
Concluding Thoughts  202
References 202

Chapter 11 The Emerging Role of Subconcussion . . . . . . . . . . . . . . . . . . . . . . 209

A Working Definition  209
Laboratory Evidence of Subconcussive Effects  210
Clinical Evidence of Subconcussion  211
Concluding Thoughts  214
References 216


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• • • 

Contents

Chapter 12 Severe Head Injury and Second Impact Syndrome . . . . . . . . . . . . 219
Cerebral Contusions and Intraparenchymal Hemorrhage  219
Traumatic Subarachnoid Hemorrhage  220
Subdural Hematoma  221
Skull Fractures  222
Epidural Hematoma  223
Diffuse Axonal Injury  224
Arterial Dissection and Stroke  225
Fatalities 227
Other Posttraumatic Sequelae  228
Second Impact Syndrome  229
Concluding Thoughts  231
References 231

Chapter 13 Neurological Considerations in Return to Sport Participation . . . . 235
History of Return to Play  235
Symptom Complex and Identification  239

Return to Play and Brain Abnormalities  240
Addressing and Resolving Return-to-Play Issues  244
Concluding Thoughts  249
References 249

Chapter 14 The Role of Pharmacologic Therapy and Rehabilitation in Concussion . 251
The Decision to Treat Pharmacologically  251
Somatic Symptoms  252
Sleep Disturbance Symptoms  257
Emotional Symptoms  258
Cognitive Symptoms  260
The Role of Rehabilitation in Concussion Management  262
Concluding Thoughts  264
References 264

Chapter 15 The Research Behind Natural Neuroprotective

Approaches to Concussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 271
Eicosapentaenoic Acid and Docosahexaenoic Acid  271
Curcumin 272
Resveratrol 275
Creatine 276
Green Tea  278


Contents 

• • • 

vii

Caffeine 278
Vitamins E and C  280
Vitamin D  281
Scutellaria baicalensis 282
Examples of Other Neuroprotective Nutraceuticals  283
Another Natural Approach: Hyperbaric Oxygen Therapy  283
Concluding Thoughts  284
Acknowledgment 285
References 285

Part III Sport-Related Injuries of the Spine



and Peripheral Nervous System . . . . . . . . . . . . . . . . . 297

Chapter 16 Cervical, Thoracic, and Lumbar Spine Injuries:

Types, Causal Mechanisms, and Clinical Features . . . . . . . . . . . . 299
Background and Epidemiology  299
Normal Anatomy  300
Types of Tissue Injuries and Neurologic Syndromes  300
Common Cervical Injuries and Conditions  307
Common Thoracic Injuries  313
Common Lumbar Injuries  313
Concluding Thoughts  318
References 318

Chapter 17 Management of Spine Injuries, Including Rehabilitation,

Surgical Considerations, and Return to Play . . . . . . . . . . . . . . . . . 321
On-the-Field Assessment  321
Radiological Assessment  324
Treatment and Rehabilitation  325
Surgical Considerations  330
Cervical Spine Injuries and Their Management and Treatment  331
Thoracic and Lumbar Spine Injuries and Their Management  334
Concluding Thoughts  336
References 337

Chapter 18 Peripheral Nerve Injuries in Athletes . . . . . . . . . . . . . . . . . . . . . . . 341
Epidemiology 341
Pathogenesis 341
Clinical Evaluation  345


viii 

• • • 

Contents

Additional Testing  346
Management Rationale  347
Surgical Options: Primary Nerve Surgery  349
Surgical Options: Secondary Surgery (Soft Tissue or Bony Reconstruction)  350
Postoperative Management and Return to Play  351

Legal Implications  351
Concluding Thoughts  351
References 352

Part IV Other Sports-Related Neurological Issues . . . . . . 353
Chapter 19 Headaches in Athletics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 355
Clinical Approach and Assessment  355
Commonly Recognized Headache Syndromes Coincidental
to Sporting Activity  357
Prolonged Sporting Activity as a Trigger for Commonly Recognized
Headache Syndromes  359
Primary Exertional Headache  360
Headaches Attributed to Head or Neck Trauma  361
Headaches Attributed to Sport-Specific Mechanisms  362
Concluding Thoughts  363
References 363

Chapter 20 Heat Illness in Sport . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 365
Background 365
Contributory Factors in Heat Illness  365
Prevention 367
The Spectrum of Heat Illness and Management  368
Return to Play  370
Concluding Thoughts  370
References 370
Appendix A


American Spinal Injury Association (ASIA) Standard Neurological
Classification of Spinal Cord Injury  373

Appendix B

Sample Concussion Symptom Checklist  375

Appendix C.1 Sport Concussion Assessment Tool (SCAT3)  377
Appendix C.2 Sport Concussion Assessment Tool for Children  383
Appendix D

Concussion in Sports Palm Card  389

Index 391
About the Authors  400


Contributors
Clayton J. Fitzsimmons, Esq.
Fitzsimmons Law Firm
Wheeling, West Virginia
Robert P. Fitzsimmons, Esq.
Fitzsimmons Law Firm
Wheeling, West Virginia
Jennifer Hammers, DO
Department of Forensic Medicine
New York University
New York, New York
Wesley H. Jones, MD
Department of Neurosurgery
University of Texas at Houston
Houston, Texas

Saint-Aaron L. Morris, MD
Department of Neurosurgery
University of Texas at Houston
Houston, Texas
Bennet I. Omalu, MD, MBA, MPH
Department of Medical Pathology
and Laboratory Medicine
University of California Davis Medical
Center
Sacramento, California

Elizabeth M. Pieroth, PsyD, ABPP
Department of Psychiatry
NorthShore University HealthSystem
Evanston, Illinois
Fabio V. C. Sparapani, MD, PhD
Department of Neurological Surgery
Federal University of São Paulo
São Paulo, Brasil
Robert J. Spinner, MD
Department of Neurosurgery
Mayo Clinic
Rochester, Minnesota
Corey T. Walker, MD
Department of Neurosurgery
Barrow Neurological Institute
Phoenix, Arizona
Ethan A. Winkler, MD, PhD
Department of Neurosurgery
University of California, San Francisco

San Francisco, California

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Preface

S

ports medicine is an exciting specialty concerned with the care of injury and illness
in athletes, and it is a specialty that crosses
various medical disciplines. Sport-related neurological injuries are among the most complex
and dreaded injuries that an athlete can sustain. Without a doubt, recent years have been
filled with major cultural and scientific shifts in
the way athletes, coaches, parents, and physicians view sport-related neurological injuries,
particularly concussion. The enormous public
health impact is in part due to the large scope
of athletes susceptible to such injuries, from the
world-class athlete to the weekend warrior and
those participating in youth sports.
There is clearly an increased need for further
neurological expertise and training for those
practitioners caring for athletes with sport-related

neurological injuries. As neurosurgeons, we are
typically involved with the treatment of the
most serious and catastrophic of athletic injuries.
Traditionally, though, we have been trained clinically to deal with the entire spectrum of trauma
and illness in both the central and peripheral
nervous system. We have now come to realize
that injuries once considered mild or minor can
have serious acute and long-term effects requiring proper attention. Skyrocketing levels of public
awareness have allowed our society to gain a
better understanding of these neurological injuries; but we, as a medical community, still have
a long way to go. There is still a great need for
continued prevention programs and improved
systematic and evidence-based approaches to the
athlete with neurological injuries.
An explosion in research initiatives has led to
significant advances in the field of neurological
sports medicine; there is a greater understanding of the causation, diagnosis, and treatment
of sports-related neurological injuries than ever
before. We have come to appreciate the wide
spectrum of spinal injuries in the athlete and their

implications for return-to-play decisions. Sophisticated nonoperative and operative techniques
are being refined and used in the management
of athletic spinal injuries. Often overshadowed by
other types of injuries, peripheral nerve injuries
affect athletes of all ages and can be equally devastating. A better understanding of these injuries
has led to more accurate diagnoses and timely,
appropriate interventions.
The on-field management of acute traumatic
brain injury in the athlete, specifically concussion, has evolved. Our ability to diagnose concussion has improved with the use of ancillary

measures including computerized neuropsychological assessment, balance testing, and advanced
neuroimaging techniques. There has been an
increased emphasis on developing appropriate return-to-play criteria, and these decisions
continue to mature. Although still in its infancy,
we also have a better understanding of the longterm sequelae of repetitive head injury and are
developing ways to better diagnose and treat
these individuals.
For centuries, teams of people with multiple skill sets, experience levels, and technical
competencies have consistently outperformed
individuals acting alone in trying to solve a problem or complete a task. Similarly, the effective
assessment and management of sport-related
neurological injuries require a coordinated,
interdisciplinary approach, with all team members seeking to collaboratively achieve common
objectives. Paramount to efficient and effective
care of the athlete is a sound understanding, on
the part of all practitioners, of the issues pertinent to neurological injury and illness. This can
be challenging in an expansive and constantly
evolving field like neurological sports medicine;
however, this book aims to facilitate just that.
As a concise and complete guide to the recognition, evaluation, and care of athletes with
neurological injuries, this book serves as the

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Preface

definitive handbook of neurological sports medicine and provides the foundation for the clinical
decisions that all sports medicine practitioners
must make. The text begins by highlighting the
scope of neurological injury in sport and provides
a thorough overview of some general key concepts in neurological sports medicine, including a
unique review of the medicolegal considerations
encountered in this area.
The book then guides the practitioner through
a complete yet practical review of how far
we’ve come, where we are, and where we are
going regarding sport-related head injuries. A
review of the biomechanics and pathophysiology underlying concussion sets the stage for a
better understanding of the clinical presentation.
The acute evaluation of the concussed athlete is
covered, including the role of neuroimaging and
other adjunct measures of assessment such as
neuropsychological evaluation. Emphasis is then
placed on bringing the practitioner up to speed
on current return-to-play recommendations
and the role of education in the management
of concussion. A review of participation recommendations for patients with preexisting neurological conditions or structural lesions is also
provided. The long-term effects of concussion are
also stressed, and the most up-to-date evidence
for pharmacotherapy in concussion is reviewed.
More catastrophic sport-related head injuries

are considered as well, and attention is given to
the emerging concept of subconcussion. Closing
out the section on sport-related head injuries is
a unique review of cutting-edge, translational
research that has investigated the potential acute
and chronic neuroprotective benefits of many
naturally occurring compounds and herbs as well
as other natural treatment approaches.
Attention then turns toward covering the
breadth and depth of athletic injuries to the cervical, thoracic, and lumbar spine, as well as the
peripheral nervous system. Special consideration
is given to other sport-related neurological issues
including headache and heatstroke. Several
appendixes at the end of the book provide the
practitioner with essential resources to aid in the
care of any athlete.
Encompassing the full range of neurological
sports-related issues, this text provides athletic
trainers, physical therapists, emergency medical technicians, students, and physicians of all
specialties with an authoritative, comprehensive
review of current literature and bridges the gap
between principles and practice. We hope that
it serves as a practical reference for practitioners
caring for athletes and acts
as a stimulus for continued advancements in the
field of neurological sports
medicine.

Acknowledgments

T

he authors would like to thank their
families; without their endless support this
book would not have been written. Deepest gratitude is also due to the other contributors
in the book, whose knowledge and assistance
have greatly strengthened its content.

This effort was also supported, in part, by a
grant from the Houston Texans and the McNair
Foundation, organizations committed to research
into and protection from lasting effects of athletic-related injuries.

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part

I

General Concepts

S

ports medicine is a branch of medicine
that deals with physical fitness and the
treatment and prevention of injuries
related to sport and exercise. Neurological
injury has always been a potential risk of
participation in sport. Care of those with
neurological injury has evolved significantly
over the years. Neurological injuries can
occur in just about any sport, and a sound
understanding of the breadth of these injuries allows the sports medicine practitioner
to provide comprehensive, efficient care.
In this section we present an overview of
the spectrum of neurological injury in sport,

covering the pertinent epidemiology and
types of injuries observed. We then review
some of the general medicolegal concepts
that any sports medicine practitioner should
be familiar with. Topics such as negligence,
duty and breach, standard of care, and
proximate cause are discussed, as are cases
of interest. Additionally, anyone involved
in the care of athletes should be aware of
the importance of emergency planning. We
review the salient aspects of developing an
effective and practical action plan for the
coverage of athletic events.

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chapter

1

Athletes and Neurological Injuries
A View From 10,000 Feet

S

ports and athletics have been around as
long as humankind has existed. Their
origins can likely be traced to the practice
of hunting and the training of combat skills
necessary to feed and protect one’s family and
tribe. As leisure time developed, such activities
evolved into athletic contests for their own
sake, with games that involved wrestling and
the throwing of spears, stakes, and rocks. Early
reference to such practice can be found in the

book of Genesis: “Jacob was left there alone.
Then a man wrestled with him until the break
of dawn. When the man saw that he could not
prevail over him, he struck Jacob’s hip at its
socket, so that Jacob’s socket was dislocated as
he wrestled with him. . . . At sunrise, as he left
Penuel, Jacob limped along because of his hip”
(New American Bible, Gen. 32:25-26, 32:32).
This is some of the earliest documentation of
sports-related injury as well.
The recognition of injury and illness with
physical activity led to the earliest forms of
sports medicine in ancient Greece and Rome.
In an effort to improve athletic training and
overall supervision, physical education was
implemented. Just as physical education became
a necessary part of a Greek youth’s training, athletic contests became a standard part of Greek
life. While these games were originally associated
with religious observances, they became increas-

ingly popular and ultimately grew into events in
themselves, with the first Olympic Games held
in 776 BC. Those who excelled at such sporting
events quickly gained eminence similar to that
of today’s elite athletes. In many cases, athletic
ability enabled people to improve their social
status by becoming a coach or trainer.
At that time, athletic trainers were expected to
be experts on massage, diet, physical therapy, and
hygiene, as well as proficient in coaching athletes

in the techniques of boxing, wrestling, jumping, and the other sports.[305] By the 5th century
BC, the trainer-coach had become a significant
force in the development of athletics. This influence continued throughout the Roman Empire.
Around 444 BC, Iccus of Tarentum, a former
pentathlon champion, wrote the first textbook on
athletic training and paved the way for others to
document their experiences in a similar fashion.
[95]
One of the most famous trainers was Milo of
Croton, who was a heroic athletic figure in his
own right. One of his documented training methods for gaining strength was to lift a bull daily,
beginning on the day of its birth. He felt that in
doing so, one would be able to lift the animal
when it was full grown—probably the earliest
record of progressive resistance exercise.[305]
Professional conflict between doctors and
trainers at the time led to the physician having
less involvement in preventive training and care

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Handbook of Neurological Sports Medicine

and only being used if an injury occurred. It
wasn’t until Claudius Galen of Pergamum was
appointed physician and surgeon to the gladiators in Pergamum in the 2nd century AD that the
physician became increasingly involved in the
care of the athlete. Galen used his experiences in
the care of athletes to gain considerable skill and
knowledge in anatomy and surgery; and once settled in Rome, he became the personal physician
to the emperor Marcus Aurelius. Widely considered one of the greatest physicians of ancient
Rome, Galen engaged in teaching, publishing,
systematic observations, and aggressive pursuit
of improved treatment methods that paved the
way for practitioners of sports medicine today.

The Present
Just as sport and athletic competition have
evolved over the years in response to economic,
social, and political change, so too has the practice of sports medicine. While the basic tenets of
athletic care have persisted, sports medicine has
evolved from its ancient roots to a more multidisciplinary team effort that includes parents,
coaches, athletic trainers, therapists, and physicians. New sports, superior performance, and
increased levels of competition have all led to
changes in the way athletes are cared for. Never
before have the physiological and psychological effects of sport on the human body been as
carefully scientifically examined and researched
as they are today. Neurological sports medicine
has witnessed growth in research initiatives and
public awareness unlike that of any other aspect
of sports medicine.

Sport-related neurological injuries are among
the most complex and dreaded injuries that an
athlete can sustain. While the rates and types of
neurological injury vary and are dependent on
the sporting activity, age of the participants, and
level of competition,[335, 336] the risk of neurological injury derives primarily from the nature
of the sport (contact vs. collision vs. noncontact) and the specific activities associated with
participation. For most sports, there seems to
be a higher risk of injury during competition
than during practice sessions; however, greater
reporting of injury within sport in recent years
has highlighted the need for increased attention
at all times.

Spectrum of Neurological
Injury in Sport
Increased awareness and medical advances have
certainly led to a greater understanding of the
causation, diagnosis, and treatment of sportsrelated neurological injuries, although it is clear
that there is still much to learn. To grasp the enormous public health impact these injuries have,
it is paramount to appreciate that neurological
injury can occur in just about any type of sport.
It is important to keep in mind that a wealth
of data on neurological injuries exist for some
sports whereas there is a paucity of literature
for others. Additionally, the epidemiological data
for some injuries, such as concussion, are widely
variable, in part due to the significant change in
awareness and diagnosis of athletic neurological
injuries over the past few decades. The following

sections provide a broad overview of neurological injuries across a spectrum of sports ranging
from recreational activities to organized athletic
competition.

American Football
The history of American football can be traced to
early versions of rugby football and soccer. The
first game of intercollegiate football was played
on November 6, 1869, between Rutgers University and Princeton University. The popularity of
collegiate football grew as it became the dominant version of the sport for the first half of the
20th century. The origin of professional football,
though, can be traced back to 1892 when William “Pudge” Heffelfinger accepted $500 to play
in a game for the Allegheny Athletic Association
against the Pittsburgh Athletic Club, marking the
first known time a player was paid for participating in the sport.
The sport has undergone much growth and
change over the past century, becoming one
of the most popular in the United States. Prior
reports cited 1,800,000 participants in all levels of
football.[72] However, new participation numbers
gathered by the National Operating Committee
for Standards in Athletic Equipment (NOCSAE),
the National Federation of State High School
Associations (NFHS), and USA Football are
higher. The NFHS has estimated that there are
approximately 1.1 million high school players


Athletes and Neurological Injuries: A View From 10,000 Feet 

(grades 9 through 12).[227] Reports also indicate
that there are approximately 100,000 post–high
school players in organizations including the
National Football League (NFL), National Collegiate Athletic Association (NCAA), National
Association of Intercollegiate Athletics (NAIA),
National Junior College Athletic Association
(NJCAA), Arena Football, and semiprofessional
football.[227] Additionally, USA Football estimates
that there are 3 million youth football players in
the United States.[227] Thus, according to these
figures, the 2011 football season saw an estimated
4.2 million participants in the United States.
Catastrophic injuries constitute an uncommon
but nonetheless devastating occurrence in football.[10] There were four fatalities directly related
to football during the 2011 football season, with
two in high school football, one in college football, and one in sandlot football.[227] Both of the
high school fatalities resulted from injuries to the
brain; the youth injury was a cervical vertebra
fracture, and the collegiate death was due to brain
trauma. Thus, for the approximately 4.2 million
participants in 2011, the rate of direct fatalities
was 0.10 per 100,000 participants.
Work in the mid-1960s focusing on footballrelated head and neck injuries resulted in a
significant reduction in the incidence of these
accidents owing to improvements in equipment,
education in proper techniques, offseason conditioning, and rule changes. The rate of injuries
with incomplete neurological recovery in high
school and junior high school football was 0.33
per 100,000 players, and the rate at the college
level was 2.66 per 100,000 players.[226] Cervical

cord neurapraxia and the various types of fractures seen in football are covered in greater detail
later in the book.
Concussions are a frequent injury in football.
The rate of concussion in football participants
reported in the literature is widely variable,
in large part due to the changes in concussion
awareness and diagnosis in the past few decades.
One study evaluated concussions in high school
football players that were reported to medical
professionals over a three-season time span.[254]
In this study the concussion rate in high school
football players was found to be 3.66 concussions
per 100 player-seasons, meaning that there were
3.66 concussions every season for every 100 players. That being said, another study surveyed 233
high school football players after one season and

• • • 

5

found that 110 players (47.2%) had experienced
at least one concussion and 81 players (34.9%)
reported having experienced multiple concussions during the season, a much higher rate than
in the former study.[178] A more recent report
found the concussion rate in high school football
players to be 0.21 per 1,000 athletic exposures in
practice and 1.55 per 1,000 athletic exposures in
games.[114] Collectively, the concussion rate was
0.47 per 1,000 athletic exposures. An athletic
exposure is defined as participation in a single

practice, competition, or event.
The concussion rate in collegiate football players studied over a 16-year study period was found
to be 0.37 per 1,000 athletic exposures.[135] As
with high school football players, though, other
studies have suggested a higher rate of concussions in collegiate football players. Another study
found a concussion injury rate of 0.39 per 1,000
athletic exposures in practice and 3.02 per 1,000
athletic exposures in games (an overall rate of
0.61 concussions per 1,000 athletic exposures).
[114]
It is important to note that although it may
seem that the rate of concussion is significantly
greater in college compared to high school football, this may be due to the greater access to
medical care, reporting, and oversight provided at
the college level and not necessarily a reflection
of a difference in the actual number of concussions. Thus a continued emphasis on concussion
awareness at the youth and high school levels is
paramount, considering that younger athletes
may experience more symptoms and recover
more slowly than collegiate and professional
athletes.[72, 201] There is now a greater awareness of the potential for chronic brain injury
with repetitive head injuries, in part due to the
increased numbers of football players diagnosed
with chronic traumatic encephalopathy.[206, 241, 313]
Chronic neurodegenerative diseases, including
dementia pugilistica, chronic traumatic encephalopathy, and mild cognitive impairment, are
covered further in later chapters.
Brachial plexus injury is one of the most
common peripheral nerve injuries in football.
Initially called “pinched nerve syndrome,” this

phenomenon is colloquially referred to as a
“burner” or “stinger.”[52, 91, 310, 335] It has been
reported to account for approximately 36% of all
neurological upper extremity injuries in football.
[171]
The incidence of transient brachial plexus
injury is significant over the course of a high


6 

• • • 

Handbook of Neurological Sports Medicine

school, college, or professional football player's
career.[157] Peripheral nerve injuries in football
may also occur as a result of blocking or tackling
techniques. One study reported that football was
the sport that most commonly caused injury
necessitating referral for electrodiagnostic testing.[172] Mononeuropathies in football have been
reported to involve the axillary, suprascapular,
ulnar, median, long thoracic, and radial nerves.
[172]
Peroneal neuropathy has been reported to
occur in 24% of football players in whom complete knee dislocation and ligamentous injury
have taken place.[172] Even in the absence of serious musculoskeletal injury, the superficial course
of the peroneal nerve lends itself to injury or even
neurapraxia with transient deficits in situations
of contact to the lower extremity.

Archery and Bow Hunting
Archaeological evidence dates archery back over
25,000 years, with the sport first appearing as an
organized event in the Olympic Games in Paris in
1900. Similarly, hunting with bow and arrow has
always been a popular recreational sport for outdoor enthusiasts. Undoubtedly the most common
cause of neurological injury associated with the
sport is accidental falls from hunting tree stands.
Hunting tree stands are typically small platforms
elevated approximately 15 to 30 feet (4.6-9 m)
above the ground, providing hunters with a
greater field of view and decreasing the odds of
their scent being detected by game at the ground
level. Falls from this height can result in speeds
in excess of 30 miles per hour (48 km/h) and a
broad spectrum of neurological injury. Despite
several studies[64, 65, 88, 111, 211, 255, 262, 346] demonstrating that falls represent a significant proportion of
hunting-related injuries, tree stands are still not
widely appreciated as one of the most dangerous
pieces of equipment a hunter owns.
Crites and colleagues [64] retrospectively
reviewed the types of spinal injuries that resulted
from falls from hunting tree stands. Of the 27
patients included in the study, 44% sustained
significant neurological deficits. In total there
were 17 burst fractures, eight wedge compression fractures, four fractures involving the posterior elements, and one coronal fracture of the
sacral body. A significant percentage of patients
had associated injuries. Thirty-three percent of

patients required surgical intervention for their
spinal injuries. In 1994, Price and Mallonee studied the Oklahoma State Department of Health
spinal cord injury (SCI) surveillance data in an
attempt to describe the incidence and circumstances surrounding hunting-related spinal cord
injuries.[255] They found that all of the huntingrelated injuries in the SCI database resulted from
falls from trees or tree stands. The incidence rate
of injury in the study was less than 1 per 100,000
licensed hunters. Urquhart and colleagues also
analyzed patients with injuries related to falls
from hunting tree stands.[346] Of the 19 patients
in the cohort, there was one death, and eight of
the 18 survivors were either paralyzed or permanently disabled.
More recent studies[65, 88, 211] have reminded us
that hunting tree stands are a persistent cause
of neurological sport injury, despite many years
of awareness. Additionally, Metz and colleagues
highlighted in their study of 51 patients that brain
injuries can also occur in falls from tree stands.
[211]
The most common injuries were spinal fractures (51% of patients in the study); however,
closed head injuries were identified in 24% of
patients and included concussions and intracranial hemorrhages, in addition to skull and facial
fractures. All three of the patients in the study
who died had intracranial hemorrhages. It is
clear that tree stand falls are associated with high
morbidity and mortality, and their treatment is
associated with a significant utilization of patient
care resources. Increased attention to hunter
education regarding the safe and proper use of
tree stands is critical to decreasing the incidence

of hunting-related injuries.
Falls aside, the other type of neurological
injury for which the archer is at risk is peripheral
nerve injury in the upper extremity.[259] It is possible for the archer to lacerate a digital nerve and
artery with the razor-sharp broad head used for
bow hunting. Rayan also has described patients
with compression neuropathies of the digital
nerves from the bowstring and median nerve
compression at the elbow as well as the wrist.
[259]
A case of isolated long thoracic nerve palsy
has been described.[296] The patient presented
with classic winging of the scapula and atrophy
of the serratus anterior muscle, presumably due
to recurrent compression and overstretching of
the long thoracic nerve with repetitive practice.


Athletes and Neurological Injuries: A View From 10,000 Feet 

Another archer presented with atrophy of the
infraspinatus muscle secondary to suprascapular
nerve palsy.[130]
Another interesting risk for injury in archery is
bow hunter’s stroke. The condition results from
vertebrobasilar insufficiency caused by vertebral
artery spasm or mechanical injury secondary to
the repeated cervical rotations associated with
the sport.[308] Although it is an unusual condition usually caused by structural abnormalities
at the craniocervical junction, cases have been

reported secondary to lateral intervertebral disc
herniations as well.[348]

Australian Rules Football and Rugby
Rugby originated in England in 1823 and became
a professional sport in 1895. It is an international
sport in which protective gear is at a minimum
and aggressive tackling is an integral part of the
game.[336] Likewise, Australian rules football is an
aggressive sport, with similarities to both rugby
and American football, that began in Melbourne,
Australia, in 1858. Competitions seem to result
in more injuries per exposure, while practice
accounts for a greater percentage of the total
number of injuries. The majority of injuries occur
during the scrum and tackles. Forwards, who are
more physically involved during the game, seem
to be at the greatest risk.[205]
A significant number of injuries are to the
head and neck. Overall, the rate of head, neck,
and orofacial injuries in Australian rules football
is 2.6 injuries per 1,000 participation-hours.[36]
McIntosh and colleagues studied the incidence
of injury in youth rugby over two seasons and
found the rate to be 19.2 injuries per 1,000 hours
of player–game exposure.[205] Thirty percent of
the injuries were to the head, face, and neck;
and of the 234 head injuries, 85% were concussions. A recent systematic review found that the
highest incidence of concussion for adolescent
rugby was 3.3 per 1,000 playing hours.[27] Adams

reviewed 1,000 injuries due to rugby and found
a 14.0% incidence of head injuries.[3] Another
study retrospectively examined Australian rules
football–related fatalities over 9 years.[202] The
authors identified 25 mortalities associated with
the sport; and of these, nine were secondary to
brain injury. They identified intracranial hemorrhage in eight of those nine athletes, as well as

• • • 

7

traumatic subarachnoid hemorrhage secondary
to vertebral artery injury in three players.
Injuries to the spine are not infrequent in
rugby and Australian rules football.[18, 61, 82, 106, 257,
278]
The average annual incidence of acute spinal
cord injuries in these sports has been reported to
be between 1.5 and 3.2 per 100,000 players.[18]
The incidence of spinal injuries in professional
rugby players is 10.9 per 1,000 player matchhours; it seems to be lower during practice, with
an incidence of 0.37 per 1,000 player training
hours.[106] The most common mechanism of
injury seems to be cervical spine hyperflexion,
producing fracture dislocations.[257] Transient
quadriparesis has also been reported in rugby.[278]

Automobile Racing
Automobile racing boasts some of the largest

attendance figures in all of sport. The types of
auto racing can be classified in a variety of ways
(e.g., open- vs. closed-wheel) and can range from
go-kart to stock car racing. The course style and
speeds can vary as well. In Formula 1 racing, cars
often reach speeds in excess of 240 miles per hour
(386 km/h) on tortuous circuits, whereas in drag
racing the vehicles can exceed speeds of 300 miles
per hour (483 km/h) on a straight racing strip.
Evolution of the sport and the use of helmets,
safety restraints, and safety cells and cages have
resulted in a significant reduction in the severity of injury. More than 90% of the neurological
injuries that occur in the sport are to the head.
The full spectrum of brain injury has been
observed, from concussion to diffuse axonal
injury and intracranial hemorrhage. One study
retrospectively reviewed open-wheel racing
accidents at Indianapolis Raceway Park during
six seasons.[312] During 61 open-wheel racing
events, 57 drivers were evaluated at Indianapolis Raceway Park after crashes, and only two
required an ICU admission due to head injury. In
Indy car events from 1985 to 1989, 367 crashes
occurred, involving 413 drivers, with 38 of these
drivers sustaining 48 injuries.[338] According to
this report, 29.2% of the injuries were closed
head injuries despite the use of helmets and other
safety equipment. Trammell and colleagues also
reported that open head injuries occurred in only
5% of these cases.[338] Weaver and coauthors
analyzed data regarding Indy Racing League

8 

• • • 

Handbook of Neurological Sports Medicine

car crashes from 1996 to 2003, comparing the
likelihood of head injury in drivers in a vehicle
that sustained an impact greater than or equal
to 50 g versus those sustaining a lesser impact.
[359]
They found that drivers in a crash with an
impact greater than or equal to 50 g developed
a head injury 16% of the time versus 1.6% for
those involved in crashes with a lesser impact.
Peripheral nerve injuries can occasionally
occur in racing. Some drivers have reported
symptoms consistent with brachial plexus injury.
They describe transient upper extremity paresthesias secondary to the safety straps looped
tightly around their arms. These straps are also
connected to their helmets to combat the high
forces the racers experience. Ulnar, peroneal, and
sciatic nerve injuries can result from the constant
pressure against the seat or other objects in the
car during long races. Heatstroke has even been
reported to occur, although rarely.[147]
Spinal cord injury, spinal fractures, and cervical sprains and strains have also been described
in automobile racing.[335] One study investigated

racing injuries in either single-seat or formula
cars or saloon cars between 1996 and 2000 at
Fuji Speedway in Japan.[222] While extremity
bruising accounted for the majority of injuries
in single-seat car racing, 53.2% of the injuries
in saloon car racing were neck sprains. Another
report found that spinal injuries composed 20%
of injuries experienced by professional automobile drivers.[338] In this review, injuries most commonly occurred during a vehicular rollover and
usually led to cervical spine or spinal cord injury.
In general, thoracolumbar injuries are uncommon, mainly due to the driver’s being so well
restrained. The HANS (head and neck support)
device is a safety item in many car racing sports
(figure 1.1). It reduces the likelihood of head and
neck injuries, such as a basilar skull fracture, in
the event of a crash. The device is primarily made
of carbon-fiber and is U-shaped. The back of the
U sits behind the nape of the neck, and the two
arms lie flat along the top of the chest over the
pectoral muscles. The device is attached only to
the helmet, by two anchors on either side, and
not to the belts, driver's body, or seat. Therefore
it is secured with the body of the driver only.
The purpose is to stop the head from whipping
forward in a crash without otherwise restricting
movement of the neck. In a crash, the device
maintains the relative position of the head to the

Figure 1.1  The head and neck support (HANS) device
reduces the likelihood of head and neck injuries in the
event of a crash.

Picture Alliance/Photoshot

body, transferring energy to the much stronger
chest, torso, shoulder, seat belts, and seat as the
head is decelerated.

Ballet and Dance
Dance has been an important part of life since
ancient civilization. An extraordinary range of
styles exists, from classical ballet and ballroom
to modern dance and breakdancing. Although
typically thought of as an art form, many forms
of dance are physically taxing and can be considered sport. Additionally, dance is incorporated
into a variety of sports including gymnastics,
figure skating, synchronized swimming, and even
martial arts kata. Regardless of style, all types of
dance have something in common—they involve
not only flexibility, athleticism, and body movement, but also physics. If the proper physics are
not taken into consideration, injuries can occur.
Many dance movements require extreme positions that can place the body at risk for acute, subacute, or chronic injury. In general, though, neurological injuries seen in many forms of dance,


Athletes and Neurological Injuries: A View From 10,000 Feet 

such as ballet, result from chronic microtrauma
or overuse, as opposed to the acute injury seen
in other sports. It is important to remember that
as with other athletes, dancers are often highly
motivated to suppress pain and ignore injury
until it affects their performance; this creates a

need for increased awareness.
Dancers are vulnerable to various stressrelated injuries, and muscle strains represent
more than a third of all injuries. Injuries particularly affect the lumbar spine and the peripheral nerves and, to a lesser extent, the cervical
spine. In one study, the National Organization
of Dance and Mime surveyed 141 dancers from
seven professional ballet and modern dance
companies regarding their injuries.[35] Forty-eight
percent had experienced a chronic injury, and
42% reported a more recent injury within the
previous 6 months that had affected their performance. Garrick and Requa[109] reported 2.97
injuries per injured dancer in a large professional
ballet company, with the lumbar spine the second
most frequently involved region. Back problems
are fairly prevalent in dance, with 10% to 17%
of injuries occurring in the vertebral column.[218]
Spondylolysis is a form of overuse injury secondary to chronic hyperextension and hyperlordosis
of the lumbar spine. Microfractures of the vertebral bodies can occur, especially with repetitive
flexion. This can result in wedging and Schmorl’s
nodes at the thoracolumbar junction, a condition
known as atypical Scheuermann’s disease. This
condition can also result from lumbar extension
contracture with excessive flexion demands
transferred to the thoracic spine and resultant
anterior end plate fractures and secondary bony
formation.[30, 182] Fractures of the pars interarticularis and pedicles, arthritic degeneration,
premature arthrosis, scoliosis, and discogenic as
well as mechanical back pain are also common
in dancers. Peripheral nerve injuries including
nerve entrapment, neuropathy, and nerve dysfunction in the legs, ankles, and feet frequently
occur in dancers.[219, 270-273]

It should also be noted that neurologic injuries
can occur in more recreational forms of dance.
Breakdancing, for instance, involves athletic
moves and spinning on various parts of the
body, including the head and hands. One study
described a breakdancer who presented with
headaches and papilledema and was found to
have multiple subdural hematomas.[208] Head

• • • 

9

banging, a popular dance form accompanying
heavy metal music, involves extreme flexion,
extension, and rotation of the head and cervical
spine. The motions can be performed so violently as to cause mild traumatic brain injury,
whiplash injury to the cervical spine, or even
subdural hematomas.[75, 158, 246] In 2008, Patton
and McIntosh performed an observational study
and biomechanical analysis of head banging.[246]
They determined that an average head banging
song has a tempo of about 146 beats per minute,
which is predicted to cause mild head injury
when the range of motion is greater than 75
degrees. Similarly, at higher tempos and greater
ranges of motion, they found a greater risk of
neck injury. Another study reported on a group of
thirty-seven 8th graders participating in a dance
marathon in which head banging occurred; 82%

of the girls and 17% of the boys had resultant
cervical spine pain that lasted 1 to 3 days.[158]

Baseball and Softball
Baseball and softball are extremely popular
sports. Between the fall of 1982 and the spring
of 2008, approximately 10.9 million high school
men and 23,517 high school women competed
in baseball.[47, 72, 225] Over that time frame, an
additional 616,947 men played baseball at the
collegiate level.[225] Approximately 419,000 males
and 900 females participate in baseball at the high
school level annually.[72, 225] In the United States
it is estimated that 23 million organized softball
games are played each year. In 2008, Mueller
and Cantu reported that between the fall of 1982
and the spring of 2008, approximately 30,000
men and 8.1 million women played high school
softball.[225] An additional 323,000 collegiate
women played softball over that time frame.
Around 1,100 men and 313,000 women compete
in softball at the high school level each year.[225]
Injuries resulting from playing recreational
baseball and softball are among the most frequent
causes of sport-related emergency room visits,
accounting for an estimated 286,708 injuries in
2009.[345] Minor injuries are fairly common in
both sports, but catastrophic injuries can occur as
well. Acute neurologic injuries are typically more
common than chronic ones. Pasternack and colleagues studied patterns of injury in 2,861 Little

League baseball players aged 7 to 18 years and
reported 81 total injuries.[245] Eighty-one percent


10 

• • • 

Handbook of Neurological Sports Medicine

were found to be acute, and 19% were reported
to be secondary to overuse. The authors found
that 62% of the acute injuries were due to being
struck by the ball. Interestingly, in softball, base
sliding was found to be responsible for 71% of
the injuries in one study.[146]
These studies are consistent with other studies
that have found the main mechanisms of injury
to be related to being struck by a ball, repetitive
motions or overuse such as throwing or swinging,
collisions, sliding, and, much more rarely, being
struck by a bat. As mentioned previously, severe
neurologic injuries such as epidural hematomas
or intracranial hemorrhages and catastrophic
fatalities can occur but are rarer than mild brain
injury. One study reported catastrophic injury
rates in baseball of 0.37 per 100,000 high school
player-games and 1.7 per 100,000 college playergames.[32] This study also found the fatality rates
in baseball to be 0.067 per 100,000 high school
baseball players and 0.86 per 100,000 college

baseball players.
Powell and Barber-Foss studied 10 different
high school sports over the course of 3 years,
identifying mild traumatic brain injuries, and
found that softball and baseball accounted for
only 2.1% and 1.2% of these injuries, respectively.[254] Two hundred forty-six certified athletic
trainers reported a rate of 0.23 concussions per
100 player-seasons in high school baseball players, meaning that 0.23 concussions occurred
every season for every 100 athletes. The same
study found that the rate of concussion in high
school softball was 0.46 per 100 player-seasons.
Covassin and colleagues[63] studied NCAA athletic
injuries over a 3-year time span and reported that
concussions accounted for 2.9% of all injuries
that occurred in practice and 4.2% of all injuries
that occurred in games. In softball, concussions
that occurred in practice accounted for 4.1% of all
softball injuries, whereas in games, concussions
accounted for 6.4% of all injuries. A more recent
study investigated injuries in NCAA athletes over
16 years and found the rate of concussion in
baseball to be 0.07 per 1,000 athletic exposures.
[135]
This survey also revealed a concussion rate
in softball of 0.14 per 1,000 athletic exposures.
These rates of concussion in collegiate softball
are higher than those reported in a recent 1-year
study of high school softball athletes, in which
the overall concussion rate was 0.07 per 1,000
athletic exposures.[114]

Injuries to the spine are rare but can occur,
usually secondary to collisions or headfirst sliding. While the use of breakaway bases and rules
against headfirst sliding (at the youth level) have
helped to substantially reduce the occurrence of
sliding-related injuries, the risk for catastrophic
spinal cord injury still exists. With headfirst slides,
the top of the runner’s head can collide with the
body or leg of the defensive player, creating a
significant amount of axial load to the vertebral
column. Baseball and softball players also are at
risk for injury to their peripheral nervous system
in addition to injuries of the brain and spine.
A pitcher’s arms in baseball and softball withstand tremendous repetitive stress throughout
a season. Long and colleagues[189] reported that
every major league baseball pitcher, most minor
league pitchers, and a few amateur pitchers they
had studied had had reduced sensory nerve
action potentials in the throwing arm. This is
probably due to overuse and is a manifestation
of brachial plexus injury. Although they throw
underhand, fast-pitch softball pitchers withstand
maximum compressive forces at the elbow and
shoulder equivalent to 70% to 98% of their total
body weight.[15] The more common peripheral
nerve injuries in baseball and softball include
suprascapular, axillary, and ulnar nerve injuries,
although more infrequent injuries to the radial,
musculocutaneous, and median nerves have
been described.[140, 174, 301, 337]

Basketball
Originally developed in 1891 by Dr. James Naismith at the International YMCA Training School
in Springfield, Massachusetts, basketball has
grown into a tremendously popular sport enjoyed
worldwide and equally by men and women.
Approximately 13.8 million high school men,
11 million high school women, 375,000 college
men, and 328,000 college women participated
in basketball between 1982 and 2008.[225] Most
basketball injuries are musculoskeletal, affecting
primarily the lower extremity; however, neurologic injuries can occur to the head, spine, and
peripheral nerves.
Head injuries in basketball can be caused by
the sudden deceleration of the head when the
player strikes an immobile object, such as the
floor, another player, or a basketball pole or
rim. These forces can cause direct contusions to


Athletes and Neurological Injuries: A View From 10,000 Feet 

the brain or even result in tears of arteries and
bridging veins, subsequently causing epidural
and subdural hematomas. Several reports of
acute subdural and epidural hematoma related
to playing basketball are in the literature.[73, 160, 341]
In their 16-year study, Hootman and colleagues
found in college basketball that men experienced
a rate of 0.16 concussions per 1,000 athletic

exposures compared to a rate of 0.22 concussions per 1,000 athletic exposures in women.
[135]
Powell and Barber-Foss demonstrated that
in high school basketball, the rate of concussion
was 0.75 and 1.04 concussions per 100 playerseasons in men and women, respectively.[254]
Additionally, in men’s high school basketball,
concussions accounted for 4.1% and 5.0% of all
the injuries sustained during practices and games,
respectively.[114] While this was not significantly
different for men, they did note that in women’s
high school basketball, concussions accounted for
4.7% and 8.5% of the injuries sustained during
practice and games, respectively; and this was
significantly different. This subtle significant difference was also confirmed in a separate study.[261]
Injuries to the spine are more common in
basketball than other forms of neurologic injury.
Basketball involves rapid, repetitive changes in
direction and explosive movements that put
significant stresses on the spine, resulting in
a spectrum of spinal disease including lumbar
sprains, contusions, facet hypertrophy, pars
interarticularis fractures, spinal stenosis, spondylolisthesis, and disc herniations or degenerative disc disease.[4, 66, 141, 209, 213, 234, 311, 321] Cases of
cervical cord neurapraxia have been reported in
basketball players as well.[332]
Although typically thought of as a football
injury, burners or stingers have been reported
in basketball secondary to acute head, neck, or
shoulder trauma.[91, 92] Suprascapular, musculocutaneous, ulnar, median, peroneal, and sciatic
nerves are all susceptible to entrapment neuropathies.[56, 68, 92, 152, 326, 340] Compression neuropathies
of the arms are common injuries in a unique

subgroup of basketball players—those who participate in wheelchair basketball.[43]

Bowling
Bowling can be traced back more than 5,000
years ago to Egypt. In the 1930s, a British anthropologist named Sir Flinders Petrie discovered a

• • • 

11

collection of objects in a child's tomb in Egypt
that appeared to have been used for a primitive
form of bowling. A crude version of a bowling
ball and primitive pins were all sized for a child. A
similar game evolved during the Roman Empire
that entailed tossing stone objects as close as possible to other stone objects. This game became
popular with soldiers and eventually evolved
into Italian bocce (considered a form of outdoor
bowling). The game has continued to evolve and
today is a sport enjoyed by more than 100 million
people in more than 90 countries each year and
is considered a timeless sport.[97]
Although not typically thought of as a sport
with a high risk of injury, bowling can be both
physically and psychologically demanding. Tremendous force is applied to the body throughout a bowler’s stance, approach, pivot step, arm
swing, release, and follow-through. Repetitive
stress is applied to the entire upper extremity
including the fingers, wrist, and elbow. Injuries
may vary by age as well. A recent study examined bowling-related injuries presenting to U.S.
emergency departments between 1990 and 2008.

[162]
The authors analyzed data from the U.S.
Consumer Product Safety Commission's National
Electronic Injury Surveillance System and found
that children younger than 7 years had a higher
proportion of finger injuries and injuries from
dropping the ball than individuals older than 7
years. On the other hand, bowlers more than
65 years old sustained a greater proportion of
injuries related to falling, slipping, or tripping.
While the annual incidence of injury is
extremely low, the sport can cause a spectrum
of neurologic hand and upper extremity injuries, either acute or due to overuse. Injuries to
the fingers and digital nerves can occur. One
report described a bowler with a rare traumatic
dislocation of the four long fingers.[197] More
commonly, though, the repetitive nature of
bowling can lead to injuries to the digital nerve
of the thumb, which most bowlers place inside
the ball holes; this is referred to as “cherry pitter’s thumb”[337] (figure 1.2). Perineural fibrosis
of the digital nerve of the thumb[297, 351] and even
cases of thumb neuromas have been described.
[164, 165]
Dobyns and colleagues reported on one
of the largest series of these patients.[78] Patients
may present with a positive Tinel’s sign and skin
atrophy or callusing over the neuroma. The nerve
may ultimately become atrophied with fibrous