Can Archery Cause Brachial Plexus Injury?

Myron S. Cohen, MD


December 27, 2000


Is there an association between brachial plexus injury and the sport of archery?

Mark Trott, PA-C

Response from Myron S. Cohen, MD

Archery, due to its reliance on upper extremity muscle control, can plague its participants with injuries that few outside of the sport appreciate. As a result, archers must be in top condition to counteract the extreme forces involved in the sport.

The most common acute injuries in the sport of archery include arrow laceration of digital nerves and arteries, contusions of forearm skin and subcutaneous tissue, and compression neuropathy of digital nerves from the bowstring. Chronic injuries included bilateral medial epicondylitis and median nerve compression at the wrist, de Quervain's tenosynovitis, and median nerve compression at the elbow.[1] Overuse injury of the coracoid process has also been reported.[2] In addition, a case of long thoracic nerve palsy has been reported, complete with winged scapula, as a result of prolonged exertion due to archery practice.[3]

Shoulder injury in archers has also been described. This injury involves mostly supraspinatus impingement, tendonitis and infraspinatus, or teres minor traction tendonitis.[4] Another common injury, Archer's shoulder, or the recurrent posterior subluxation and dislocation of the shoulder due to the repetitive forces of the archer, can cause shoulder instability.[5]

Brachial plexus injury may occur, usually in the form of thoracic outlet syndrome. The formation of the brachial plexus begins just distal to the scalene muscles and emerges, from contributing nerve roots, at the base of the neck between the anterior and median scalenes. The pectoralis and subclavius muscles are also in intimate association with the distal plexus just past the clavicle.

The term "thoracic outlet syndrome" was coined by Peete and colleagues in 1956 to encompass all the forms and causes of neurovascular compression in the base of the neck. Histochemical studies of scalene muscles have shown important changes at the cellular level of the scalene muscles with trauma leading to outlet syndromes.[6]

What many clinicians call the thoracic outlet is really the scalene triangle divisible into a lower portion or thoracic outlet (for subclavian vessels and nerve roots C8 and T1) and an upper portion or cervical outlet (for nerve roots C5, C6, and normally C7). Compression of the upper roots of the brachial plexus between the anterior and middle scalene muscles is really then cervical outlet syndrome.[7]

More common in swimmers and throwing athletes, thoracic or cervical outlet syndrome comprises a constellation of symptoms that result from compression of the subclavian artery and vein, as well as the brachial plexus, within the outlet.[8]

Archery expertise is based on constancy of neuromuscular control of the musculi trapezius, biceps brachii, and extensor digitorum[9] and tightening or control of the scalene, sternocleidomastoid, pectoralis, and subclavius muscles. Specific causes of outlet compression include injury to the scalene or scapular suspensory muscles, anomalous fibromuscular bands, cervical ribs, clavicular deformity, and pectoralis minor tendon hypertrophy.[10] All of these muscles are involved in the performance of archery. Thoracic outlet may also be seen as a result of postural abnormalities of the shoulder girdle.[11]

The symptoms of thoracic outlet or inlet syndrome are most often caused by compression of the nerves of the brachial plexus.[12] Clinical manifestations can include upper extremity pain, paresthesias, numbness, weakness, fatigability, swelling, discoloration, and Raynaud's phenomenon. Four symptom patterns have been described: upper plexus, lower plexus, vascular, and mixed. The lower brachial plexus pattern is the most common.

A condition called "burners" may also occur in archers. Burners are often the result of a brachial plexus stretch injury and are often seen in football players. Nerve root compression causing a burner can also occur with nerve root compression in the intervertebral foramina secondary to disk disease and must be ruled out in archers. This condition is more chronic than acute in presentation, however.[13]

The physical demands of archery and the need for constant muscular control, coupled with the repetitive stress of practicing and competing, may certainly predispose archers to brachial plexus injury.