Brachial Plexus Injuries.
What is a brachial plexus injury?
The brachial plexus is the complex network of nerves that originates from the spinal cord at C5 through T1 in the lower cervical and upper thoracic spine, and supplies motor and sensory function to the shoulder, arm, forearm and hand. It forms from the ventral rami of these nerve roots, which combine and divide to form the trunks, divisions, cords and terminal branches — the musculocutaneous, median, ulnar, radial and axillary nerves — that ultimately innervate the entire upper limb.
When this network is damaged — by stretch, compression, traction or laceration — the result is a spectrum of motor and sensory deficits in the arm that can range from transient weakness to complete and permanent loss of function. Brachial plexus injuries are among the most complex and challenging nerve injuries in rehabilitation.
Types and causes of brachial plexus injury
Brachial plexus injuries can result from a variety of causes, with trauma being a primary culprit. High-impact incidents such as motor vehicle accidents, falls, or sports-related injuries can exert force on the shoulder causing damage to the delicate nerve network. During childbirth the brachial plexus may be stretched or compressed, particularly if there are difficulties delivering the baby's shoulders. Tumours, inflammation, or repetitive stress injuries can also contribute.
The most clinically important distinction is between preganglionic and postganglionic injuries — a distinction that fundamentally affects prognosis and surgical options.
Preganglionic injuries — root avulsions, where the nerve root is torn from the spinal cord itself — are the most severe and carry the worst prognosis because the proximal nerve stump is unavailable for surgical repair or nerve grafting. They are identified by the absence of Horner's syndrome, paralysis of the serratus anterior and rhomboids, and specific MRI and EMG findings. Surgical options for avulsion injuries focus on nerve transfer procedures — redirecting other expendable nerves to restore priority functions.
Postganglionic injuries — ruptures, neurotmesis, axonotmesis or neuropraxia distal to the dorsal root ganglion — carry a better prognosis for recovery, either spontaneously or with surgical nerve repair or grafting. The Sunderland classification grades these from neuropraxia (temporary conduction block with full recovery expected) through to complete nerve disruption (requiring surgical repair and variable recovery).
Upper vs lower brachial plexus injuries
Upper brachial plexus injuries (C5-C6, sometimes C7) — Erb's palsy — produce the characteristic "waiter's tip" posture with weakness of shoulder abduction, external rotation and elbow flexion. This is the most common pattern in both birth injuries and adult trauma from shoulder depression with neck lateral flexion.
Lower brachial plexus injuries (C8-T1) — Klumpke's palsy — produce intrinsic hand muscle weakness and sensory loss along the medial forearm and hand, with Horner's syndrome when T1 root avulsion is present. This pattern is seen in forceful arm traction and some birth injuries.
Pan-plexus injuries involving all roots produce complete loss of function of the entire upper limb — the most severe and most demanding rehabilitation presentation.
What are the symptoms?
Symptoms include pain, numbness and tingling or other sensory disturbances, and weakness in the shoulder, arm or hand — the specific distribution of these deficits depends on which roots, trunks or cords are affected. Neuropathic pain — burning, electric, shooting pain — is common in severe brachial plexus injuries and can be one of the most debilitating aspects of the condition. A flail arm — completely denervated and without any voluntary movement — represents the most severe motor deficit.
How is it diagnosed?
Nerve conduction studies and electromyography evaluate the electrical activity in nerves and muscles, providing insights into the functionality of the brachial plexus and associated muscles. MRI of the cervical spine and brachial plexus identifies root avulsions, pseudomeningoceles (fluid collections at avulsion sites), and structural nerve damage. CT myelography provides additional information about the spinal cord and nerve root anatomy. These investigations guide the surgical decision-making process and inform rehabilitation prognosis.
How can physiotherapy help?
Physiotherapy is essential in brachial plexus injury rehabilitation regardless of whether surgical intervention is performed. The goals and approach differ depending on the severity and type of injury.
For neuropraxia and milder axonotmesis injuries where spontaneous recovery is expected, physiotherapy focuses on maintaining joint range of motion and preventing contractures while the nerve recovers, gentle strengthening as motor function returns, sensory re-education, and pain management. Nerve recovery is slow — axons regenerate at approximately one millimetre per day — and the rehabilitation process requires patience and consistent monitoring of recovery progress.
For severe injuries requiring surgical nerve repair, grafting or nerve transfer, the post-operative rehabilitation is more structured and prolonged. The first priority after surgery is protecting the repair while maintaining passive range of motion. As nerve regeneration proceeds and motor function begins to return — typically months after surgery for proximal repairs — active strengthening of recovering muscles begins. Neuromuscular electrical stimulation (NMES) supports muscle activation in partially reinnervated muscles.
For permanent or severely incomplete injuries, rehabilitation pivots toward maximising function with remaining innervation, compensatory strategies, orthotic management, and where appropriate, preparation for secondary surgical procedures such as tendon transfers or arthrodesis.
Throughout all stages, prevention of shoulder subluxation — where the weight of the paralysed arm pulls the humeral head out of the glenoid — is important and is addressed through supportive positioning, slings, taping and strengthening of any functioning periscapular muscles.
Neural mobilisation — gentle nerve gliding techniques — helps manage neuropathic pain and maintains nerve mobility through the upper limb, reducing the mechanosensitivity that contributes to pain in these injuries.
Our physiotherapist Yulia Khasyanova has specialist experience in complex nerve conditions and upper limb rehabilitation. Bethany Kippen also has experience in upper limb nerve injury management. Both are members of the Australian Physiotherapy Association. For patients whose brachial plexus injury occurred in a motor vehicle accident or workplace incident, CTP and WorkCover funded rehabilitation is available.
To book or find out more, call us on 07 3706 3407 or book online below. We see patients from across Brisbane's southside including Tarragindi, Coorparoo, Holland Park, Greenslopes and Mt Gravatt.
The brachial plexus is the complex network of nerves that originates from the spinal cord at C5 through T1 in the lower cervical and upper thoracic spine, and supplies motor and sensory function to the shoulder, arm, forearm and hand. It forms from the ventral rami of these nerve roots, which combine and divide to form the trunks, divisions, cords and terminal branches — the musculocutaneous, median, ulnar, radial and axillary nerves — that ultimately innervate the entire upper limb.
When this network is damaged — by stretch, compression, traction or laceration — the result is a spectrum of motor and sensory deficits in the arm that can range from transient weakness to complete and permanent loss of function. Brachial plexus injuries are among the most complex and challenging nerve injuries in rehabilitation.
Types and causes of brachial plexus injury
Brachial plexus injuries can result from a variety of causes, with trauma being a primary culprit. High-impact incidents such as motor vehicle accidents, falls, or sports-related injuries can exert force on the shoulder causing damage to the delicate nerve network. During childbirth the brachial plexus may be stretched or compressed, particularly if there are difficulties delivering the baby's shoulders. Tumours, inflammation, or repetitive stress injuries can also contribute.
The most clinically important distinction is between preganglionic and postganglionic injuries — a distinction that fundamentally affects prognosis and surgical options.
Preganglionic injuries — root avulsions, where the nerve root is torn from the spinal cord itself — are the most severe and carry the worst prognosis because the proximal nerve stump is unavailable for surgical repair or nerve grafting. They are identified by the absence of Horner's syndrome, paralysis of the serratus anterior and rhomboids, and specific MRI and EMG findings. Surgical options for avulsion injuries focus on nerve transfer procedures — redirecting other expendable nerves to restore priority functions.
Postganglionic injuries — ruptures, neurotmesis, axonotmesis or neuropraxia distal to the dorsal root ganglion — carry a better prognosis for recovery, either spontaneously or with surgical nerve repair or grafting. The Sunderland classification grades these from neuropraxia (temporary conduction block with full recovery expected) through to complete nerve disruption (requiring surgical repair and variable recovery).
Upper vs lower brachial plexus injuries
Upper brachial plexus injuries (C5-C6, sometimes C7) — Erb's palsy — produce the characteristic "waiter's tip" posture with weakness of shoulder abduction, external rotation and elbow flexion. This is the most common pattern in both birth injuries and adult trauma from shoulder depression with neck lateral flexion.
Lower brachial plexus injuries (C8-T1) — Klumpke's palsy — produce intrinsic hand muscle weakness and sensory loss along the medial forearm and hand, with Horner's syndrome when T1 root avulsion is present. This pattern is seen in forceful arm traction and some birth injuries.
Pan-plexus injuries involving all roots produce complete loss of function of the entire upper limb — the most severe and most demanding rehabilitation presentation.
What are the symptoms?
Symptoms include pain, numbness and tingling or other sensory disturbances, and weakness in the shoulder, arm or hand — the specific distribution of these deficits depends on which roots, trunks or cords are affected. Neuropathic pain — burning, electric, shooting pain — is common in severe brachial plexus injuries and can be one of the most debilitating aspects of the condition. A flail arm — completely denervated and without any voluntary movement — represents the most severe motor deficit.
How is it diagnosed?
Nerve conduction studies and electromyography evaluate the electrical activity in nerves and muscles, providing insights into the functionality of the brachial plexus and associated muscles. MRI of the cervical spine and brachial plexus identifies root avulsions, pseudomeningoceles (fluid collections at avulsion sites), and structural nerve damage. CT myelography provides additional information about the spinal cord and nerve root anatomy. These investigations guide the surgical decision-making process and inform rehabilitation prognosis.
How can physiotherapy help?
Physiotherapy is essential in brachial plexus injury rehabilitation regardless of whether surgical intervention is performed. The goals and approach differ depending on the severity and type of injury.
For neuropraxia and milder axonotmesis injuries where spontaneous recovery is expected, physiotherapy focuses on maintaining joint range of motion and preventing contractures while the nerve recovers, gentle strengthening as motor function returns, sensory re-education, and pain management. Nerve recovery is slow — axons regenerate at approximately one millimetre per day — and the rehabilitation process requires patience and consistent monitoring of recovery progress.
For severe injuries requiring surgical nerve repair, grafting or nerve transfer, the post-operative rehabilitation is more structured and prolonged. The first priority after surgery is protecting the repair while maintaining passive range of motion. As nerve regeneration proceeds and motor function begins to return — typically months after surgery for proximal repairs — active strengthening of recovering muscles begins. Neuromuscular electrical stimulation (NMES) supports muscle activation in partially reinnervated muscles.
For permanent or severely incomplete injuries, rehabilitation pivots toward maximising function with remaining innervation, compensatory strategies, orthotic management, and where appropriate, preparation for secondary surgical procedures such as tendon transfers or arthrodesis.
Throughout all stages, prevention of shoulder subluxation — where the weight of the paralysed arm pulls the humeral head out of the glenoid — is important and is addressed through supportive positioning, slings, taping and strengthening of any functioning periscapular muscles.
Neural mobilisation — gentle nerve gliding techniques — helps manage neuropathic pain and maintains nerve mobility through the upper limb, reducing the mechanosensitivity that contributes to pain in these injuries.
Our physiotherapist Yulia Khasyanova has specialist experience in complex nerve conditions and upper limb rehabilitation. Bethany Kippen also has experience in upper limb nerve injury management. Both are members of the Australian Physiotherapy Association. For patients whose brachial plexus injury occurred in a motor vehicle accident or workplace incident, CTP and WorkCover funded rehabilitation is available.
To book or find out more, call us on 07 3706 3407 or book online below. We see patients from across Brisbane's southside including Tarragindi, Coorparoo, Holland Park, Greenslopes and Mt Gravatt.
