Brachial Plexus Injury
Upper LimbOverview
Brachial plexus injury involves damage to the nerve network (C5-T1) that controls upper limb function, resulting from trauma, stretching, or compression. Injuries range from mild neurapraxia to complete nerve root avulsion, presenting with varying degrees of motor weakness, sensory loss, and pain. Prognosis depends on injury severity, mechanism, and timing of intervention.
Pathophysiology
The brachial plexus can be damaged through traction injuries (shoulder depression with neck extension), compression injuries (cervical rib, scalene muscle hypertrophy, fibrous bands), penetrating trauma, or nerve root avulsion from the spinal cord. Nerve injury triggers inflammatory cascades, axonal degeneration, and disruption of motor and sensory signals. In traction injuries, nerve fibers may be stretched beyond their elastic limit, causing demyelination (neurapraxia) or axonal disruption (axonotmesis), or complete nerve root avulsion (neurotmesis). Chronic cases may develop neurogenic inflammation, muscle atrophy, and complex regional pain syndrome.
Patient Education
Brachial plexus injuries require prompt assessment and specialist neurological evaluation; early intervention, gentle mobilisation, and structured rehabilitation maximise recovery and prevent secondary complications like muscle contracture and chronic pain.
Typical Presentation
Site
Upper limb including shoulder, arm, forearm, hand; pain may radiate from neck to fingers; distribution depends on which nerve roots are involved
Quality
Sharp, burning, shooting, or electric pain; numbness and tingling; heaviness or weakness sensation
Intensity
Highly variable (0-10/10) depending on injury severity; acute injuries often severe; chronic injuries may present with dull ache
Aggravating
Neck movement away from injury side, shoulder depression, arm elevation, certain work activities, sustained postures, Adson's test position (neck extension with arm abduction)
Relieving
Arm support in sling, neck lateral flexion toward injury, rest, ice in acute phase, gentle arm movements
Associated
Motor weakness (variable by nerve root: C5 shoulder abduction/external rotation, C6 elbow flexion, C7 elbow extension, C8-T1 hand grip), sensory loss in dermatomal pattern, swelling, muscle atrophy (develops over weeks), colour changes, temperature changes, Horner's syndrome if T1 root involved, hand weakness and clumsiness
Orthopaedic Tests
Test descriptions are written with AI assistance from standard clinical texts. Where a test lists Sources, its description has been checked against them; those sources are independent and do not endorse OsteoKit. Accuracy figures and grades (A–D) appear only when checked against the published study; tests without one are marked “No accuracy study”.
Further reading: full test procedures are described in standard clinical examination texts, e.g. Magee & Manske, Orthopedic Physical Assessment (7th ed.), and Cook & Hegedus, Orthopedic Physical Examination Tests: An Evidence-Based Approach (2nd ed.).
Upper Limb Tension Test (ULTT) / Nerve Stretch Test
Procedure
Patient supine. With the shoulder girdle held down, abduct and externally rotate the shoulder, supinate the forearm, extend the wrist and fingers and then the elbow. Add neck side-flexion away from and towards the test side. Do not perform soon after a traction injury.
Positive Finding
Reproduction of the familiar arm symptoms that changes with neck side-flexion and differs from the other side.
Sensitivity / Specificity
Reference: Wainner RS et al., Spine 2003; PMID 12544957
Interpretation
Shows that the nerves of the arm are irritable. It cannot tell a plexus problem from a cervical root problem. A negative test makes cervical radiculopathy less likely. Note: these figures derive from cervical radiculopathy populations (Wainner 2003); not validated specifically for brachial plexus injury.
Sources
- Educational sitePhysiopedia. Neurodynamic Assessment.
Spurling's Test (Cervical Compression & Extension)
Procedure
Patient seated. Extend the neck and side-bend it towards the painful side, then apply gentle downward pressure through the head. Stop if symptoms are severe.
Positive Finding
Reproduction of the familiar radiating arm pain or tingling on the tested side.
Sensitivity / Specificity
Reference: Wainner RS et al., Spine 2003; PMID 12544957
Interpretation
Supports a cervical nerve-root source rather than a plexus source, which helps with differential diagnosis. A negative test does not exclude a root problem. Note: these figures derive from cervical radiculopathy populations (Wainner 2003); not validated specifically for brachial plexus injury.
Sources
- Educational sitePhysiopedia. Spurling's Test.
Adson's Test (Thoracic Outlet Syndrome / TOS Screen)
Procedure
Patient seated. Find the radial pulse with the arm slightly abducted and extended. Ask the patient to extend the neck, turn the head towards the tested side and take a deep breath and hold it.
Positive Finding
The pulse weakens or disappears with reproduction of the familiar arm symptoms.
Sensitivity / Specificity
Reference: Gillard J et al., Joint Bone Spine 2001; PMID 11707008
Interpretation
Screens for thoracic outlet compression as a differential diagnosis. A pulse change alone is common in healthy people; reproduction of symptoms matters more.
Tinel's Sign at the Brachial Plexus
Procedure
Tap gently over the plexus above the clavicle and in the axilla, and along the main nerves of the arm.
Positive Finding
Tingling spreading into the arm from a particular point.
Interpretation
Helps locate the level of a nerve injury. After a traction injury, a Tinel's sign that moves further down the arm over weeks suggests regrowth. A strong Tinel's sign just above the clavicle with no distal recovery can suggest a neuroma. It does not diagnose plexus injury alone.
Sources
- Educational sitePhysiopedia. Tinel's Test.
Phrenic Nerve Involvement Screen (Breathing Pattern)
Procedure
Observe breathing with the patient supine: watch whether both sides of the lower chest and abdomen rise together. Ask about breathlessness, especially lying flat. Diaphragm imaging (ultrasound or fluoroscopy) is arranged by the doctor.
Positive Finding
Reduced movement on one side, or paradoxical breathing, with breathlessness lying flat.
Interpretation
The phrenic nerve comes from C3–C5, so involvement suggests a very proximal (root-level) injury, which affects prognosis and surgical planning. Breathlessness needs medical assessment.
Sources
⚠ Red Flags
- •Acute severe trauma with sudden complete arm paralysis requiring emergency referral
- •Signs of Horner's syndrome including ptosis, miosis, and anhidrosis suggesting T1 avulsion with poor prognosis
- •Severe progressive neurological deficit or rapidly worsening weakness
- •Penetrating wound with visible nerve damage
- •Fracture-dislocation of cervical spine or shoulder girdle
- •Severe vascular compromise including cold limb, absent pulses, or severe swelling
⚡ Yellow Flags
- •Significant psychological distress or catastrophising about permanent disability
- •Fear of using affected limb leading to learned non-use and muscle atrophy
- •Concurrent substance abuse potentially affecting compliance with rehabilitation
- •High comorbidity of depression, anxiety, or chronic pain syndrome
- •Unrealistic expectations regarding recovery timeline
- •Poor motivation for rehabilitation exercises
- •Occupational demands incompatible with injury severity
- •Litigation or compensation claims that may perpetuate symptom focus
Osteopathic Techniques
Refer first
This condition needs medical assessment and management first. Do not use neck-directed manual techniques. Any osteopathic care is supportive, away from the injured area, and only once the treating team has cleared it. Many low-energy injuries recover with time and are followed with serial examinations; some need surgery.
- Journal articleRushton et al. · J Orthop Sports Phys Ther 2023
- Reference bookStenersen & Bordoni · StatPearls 2024
- Reference bookBazzi & Sergent · StatPearls 2023
- Reference bookDean et al. · StatPearls 2026
Rehabilitation Exercises
Pendulum Swings (Codman's Exercise)
Passive Arm Elevation with Opposite Hand
Neck Lateral Flexion Stretch (Away from Affected Side)
Scalene Muscle Stretch with Upper Trapezius
Scapular Retraction and Depression
Isometric Shoulder Abduction
Supine Shoulder External Rotation with Pillow
Prone Shoulder Flexion (Y-position)
Rotator Cuff Strengthening: Side-Lying External Rotation
Proprioceptive Upper Limb Positioning and Weight Shifting
Seated Posture Correction with Cervical Alignment
Progressive Grip Strengthening with Therapy Ball
Referral Criteria
- •Acute severe injury with complete arm paralysis: refer immediately to emergency department and neurosurgeon
- •Suspected nerve root avulsion: urgent specialist imaging (MRI, EMG/NCS) and neurosurgical assessment
- •Horner's syndrome or T1 involvement: specialist assessment for potential nerve transfer surgery
- •Penetrating injury with nerve involvement: immediate surgical exploration
- •Vascular compromise with limb at risk: immediate vascular surgery assessment
- •Lack of improvement after 3 months of conservative care: refer to nerve specialist for advanced imaging and electrodiagnostic testing (EMG/NCS)
- •Development of complex regional pain syndrome: pain specialist and physiotherapy with proven CRPS protocols
- •Progressive muscle atrophy with functional decline: reassessment for possible surgical intervention (nerve grafts, transfers)
- •Severe psychological impact or depression affecting recovery: referral to psychologist or counsellor
- •Occupational/functional demands requiring specialist vocational assessment: occupational therapist for work conditioning