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History
A 53-year-old female patient presented with weakness that had progressed over six months, gradually involving her entire left upper limb.
She experienced needle-like intermittent pain in her left upper limb, with a Visual Analog Scale (VAS) score of 7 points. The pain episode lasts for 1–2 seconds, occurring several times a day, mostly at night. Three months ago, her symptoms worsened. The VAS score increased to 9 points, and the frequency of pain episodes also increased. She was unable to lie on her back. Three months prior to presentation, she was unable to lift her left arm, and the pain radiating from her left shoulder blade to her fingers worsened.
Evaluation
A clinical examination revealed decreased muscle strength and muscle atrophy in the left upper limb.
Manual muscle testing (MMT) was performed on the upper limb. The strength of shoulder flexion, shoulder abduction, and shoulder external rotation was impaired, graded as 2+ on the MMT scale. The patient was unable to lift the upper limb through its full range in a gravity-eliminated position. Additionally, compensatory shoulder shrugging was observed during movement.
Left biceps and radial reflexes were normal. Sensory examination revealed diminished sensation in the lateral shoulder region, corresponding to the deltoid and teres minor distribution. The remainder of the neurological examination was unremarkable.
Electrophysiological studies were conducted to assess the brachial plexus. Nerve conduction studies demonstrated normal motor and sensory nerve function in the right upper limb. However, findings indicated an injury to the left brachial plexus, predominantly affecting the axillary nerve, with features suggestive of axonal injury and left brachial plexopathy.
Treatment
Acute phase (Weeks 1-3)
Pain management was prioritized using ice therapy, NSAIDs, and transcutaneous electrical nerve stimulation (TENS). The patient was advised to avoid overhead activities.
Passive range of motion (ROM) exercises, assisted ROM exercises including pendulum swings and assisted shoulder flexion, were initiated to prevent stiffness. Isometric contractions for the deltoid and rotator cuff were introduced to minimize muscle atrophy.
Subacute phase (Weeks 4-8)
The focus shifted to restoring ROM and initiating muscle activation. Active-assisted ROM exercises, such as pulley-assisted flexion and wall walks, were incorporated. Scapular stability training, including prone retractions and serratus anterior activation drills, was introduced to support shoulder mechanics.
Progressive resistance training using therabands was started, targeting the rotator cuff and periscapular muscles. Neuromuscular re-education techniques, including proprioceptive neuromuscular facilitation (PNF) and mirror therapy, were implemented to improve movement awareness.
Strengthening phase (Weeks 9-12)
The patient demonstrated improved ROM but continued to experience mild deltoid weakness. Strength training was advanced with isotonic exercises using light weights and resistance bands. Closed-chain exercises, such as wall push-ups and quadruped rocking, were included to enhance shoulder stability. Functional movement training, including overhead reaching tasks and controlled lifting, was introduced to simulate daily activities.
Final recovery phase (Weeks 12-16+)
The patient exhibited near-full shoulder function with residual mild weakness. Strength and endurance training were intensified, incorporating weighted shoulder exercises. The rehabilitation program concluded with a focus on injury prevention through regular scapular stabilization, core strengthening, and mobility exercises. At the 16-week follow-up, the patient demonstrated full functional recovery, with restored strength and ROM. Regular monitoring was recommended to ensure long-term stability and prevent re-injury.
History
Three months ago, her symptoms worsened. The VAS score increased to 9 points, and the frequency of pain episodes also increased. She was unable to lie on her back. Three months prior to presentation, she was unable to lift her left arm, and the pain radiating from her left shoulder blade to her fingers worsened.
Evaluation
A clinical examination revealed decreased muscle strength and muscle atrophy in the left upper limb.
Manual muscle testing (MMT) was performed on the upper limb. The strength of shoulder flexion, shoulder abduction, and shoulder external rotation was impaired, graded as 2+ on the MMT scale. The patient was unable to lift the upper limb through its full range in a gravity-eliminated position. Additionally, compensatory shoulder shrugging was observed during movement.
Left biceps and radial reflexes were normal. Sensory examination revealed diminished sensation in the lateral shoulder region, corresponding to the deltoid and teres minor distribution. The remainder of the neurological examination was unremarkable.
Electrophysiological studies were conducted to assess the brachial plexus. Nerve conduction studies demonstrated normal motor and sensory nerve function in the right upper limb. However, findings indicated an injury to the left brachial plexus, predominantly affecting the axillary nerve, with features suggestive of axonal injury and left brachial plexopathy.
Treatment
Acute phase (Weeks 1-3)
Pain management was prioritized using ice therapy, NSAIDs, and transcutaneous electrical nerve stimulation (TENS). The patient was advised to avoid overhead activities.
Passive range of motion (ROM) exercises, assisted ROM exercises including pendulum swings and assisted shoulder flexion, were initiated to prevent stiffness. Isometric contractions for the deltoid and rotator cuff were introduced to minimize muscle atrophy.
Subacute phase (Weeks 4-8)
The focus shifted to restoring ROM and initiating muscle activation. Active-assisted ROM exercises, such as pulley-assisted flexion and wall walks, were incorporated. Scapular stability training, including prone retractions and serratus anterior activation drills, was introduced to support shoulder mechanics.
Progressive resistance training using therabands was started, targeting the rotator cuff and periscapular muscles. Neuromuscular re-education techniques, including proprioceptive neuromuscular facilitation (PNF) and mirror therapy, were implemented to improve movement awareness.
Strengthening phase (Weeks 9-12)
The patient demonstrated improved ROM but continued to experience mild deltoid weakness. Strength training was advanced with isotonic exercises using light weights and resistance bands. Closed-chain exercises, such as wall push-ups and quadruped rocking, were included to enhance shoulder stability. Functional movement training, including overhead reaching tasks and controlled lifting, was introduced to simulate daily activities.
Final recovery phase (Weeks 12-16+)
The patient exhibited near-full shoulder function with residual mild weakness. Strength and endurance training were intensified, incorporating weighted shoulder exercises. The rehabilitation program concluded with a focus on injury prevention through regular scapular stabilization, core strengthening, and mobility exercises. At the 16-week follow-up, the patient demonstrated full functional recovery, with restored strength and ROM. Regular monitoring was recommended to ensure long-term stability and prevent re-injury.