Axillary Nerve Injury
Original Editor - Kimberley Anlauf
- 1 Definition/Description
- 2 Epidemiology/Etiology
- 3 Characteristics/Clinical Presentation
- 4 Differential Diagnosis
- 5 Examination
- 6 Clinical Diagnosis
- 7 Medical Management (current best evidence)
- 8 Physical Therapy Management (current best evidence)
- 9 Clinical Bottom Line
- 10 References
Axillary nerve injury is characterised by trauma to the axillary nerve: from either a compressive force or a traction injury following anterior dislocation of the shoulder. Axillary nerve injury referred to neuropathy of the axillary nerve. It describes a loss of movement and/or lack of sensation in the shoulder area of the body. Stress or damage to the axillary nerve, which serves the deltoid muscles and skin of the shoulder, causes this dysfunction.
Since this is a problem with just one nerve, it is a type of Peripheral neuropathy called mononeuropathy. Of all brachial plexus injuries, axillary nerve palsy represents only 3% to 6% of them.
- Anterior shoulder dislocation is the most common occurring dislocation at the shoulder.
Men and women 3:1
23% have combination neuropathies, all involving the axillary nerve
The incidence of brachial plexus and axillary nerve injury increases dramatically following shoulder dislocation in patients ≥50 years of age, if fracture is associated with the dislocation, and if the duration of the dislocation lasts >12 hours
The incidence of nerve injury doubled with the presence of an associated fracture
Propagated tension due to overstretching of the axillary nerve over the humeral head during shoulder dislocations may cause elongation of the free portion of the axillary nerve and the increased tension may even result in axillary nerve avulsions from the posterior cord of brachial plexus.The axillary nerve is susceptible to injury at several sites, including the origin of the nerve from the posterior cord, the anterior inferior aspect of the subscapularis muscle and shoulder capsule, the quadrilateral space, and within the subfascial surface of the deltoid muscle.
Nerve Injury Overview
Nerve regeneration takes place at a rate of ~1mm/day
Seddon's Classification of Nerve Injury
The axon and all 3 connective tissue layers (endoneurium, perineurium, and epineurium) remain intact with a decrease in conduction
Comparable to a 1st-degree nerve injury (Sunderland's Classification of Nerve Injury)
Axonal damage is present with preservation of the endoneurium
The endoneurium acts as a guide for axonal regeneration
Comparable to a 2nd degree degree nerve injury
Axonal damage is present
Connective sheath damage ranges from partial disruption of the endoneurium to complete disruption of the involved nerve
- 3rddegree nerve injury= axon and endoneurium are damaged with preservation of the perineurium
- 4thdegree nerve injury= axon, endoneurium, and perineurium are damaged with preservation of the epineurium
- 5thdegree nerve injury= complete disruption of the nerve
It is important to note that the clinical presentation of axillary nerve dysfunction is variable and can go undetected, as the concomitant dislocation or fracture may mask the symptoms. Nerve injury should be considered as part of the differential diagnosis process when a patient reports pain, weakness, or paresthesias.
- Generalized mild, dull, and achy pain to the deep or lateral shoulder, with occasional radiation to the proximal arm 
- Numbness and tingling of the lateral arm and/or posterior aspect of the shoulder  in some cases, persisting 2-4 weeks post-injury
- Feeling of instability
- Weakness, especially with flexion, abduction, and external rotation 
- Fatigue, especially with overhead activities, heavy lifting, and/or throwing 
- May/or may not reveal a history of trauma to the shoulder region 
- History of dislocation with soreness persisting ~1week post-injury 
- Easing Factors include: rest, ice, analgesics, and anti-inflammatory medications 
1. Unhappy Triad
The “Unhappy Triad” consists of a shoulder dislocation that results in both a rotator cuff tear and axillary nerve injury.
- Occurs in 9-18% of anterior shoulder dislocations
- Risk of an “unhappy triad” with anterior shoulder dislocation increases after the age of 40
2. Quadrilateral Space Syndrome
QSS is an “uncommon condition that involves the compression of the posterior humeral circumflex artery and the axillary nerve within the quadrilateral space,” secondary to an acute trauma or from overuse, especially with overhead sports like throwing and swimming.
- Cardinal Features
- Generalized shoulder pain
- Paresthesias in a nondermatomal pattern
- Point tenderness to the quadrilateral space
- (+) arteriogram findings with the shoulder in abduction and external rotation
- Symptoms are typically present with the arm in an overhead position, especially in late cocking or the early acceleration phases of throwing
3. Posterior Cord of the Brachial Plexus Injury
4. C5-6 Cervical Radiculopathy
PTS is an uncommon, idiopathic condition, characterized by an acute onset of intense pain, without a mechanism of injury, that subsides within days-weeks, leaving behind residual weakness/paralysis in upper extremity muscles.
- Symptoms are NOT related to neck movements.
- Aka: Acute brachial neuritis
Physical examination should begin with a screening consisting of an evaluation of the head and neck which shouldn’t reveal any abnormalities. If the patient presents with a recent shoulder dislocation, presence of a radial pulse and sensation and movement of the digits should also be assessed as part of the initial screening.
It is important to note that the physical examination findings are dependent on the extent of the axillary nerve damage. Furthermore, there is a lack of consensus regarding the ability of a patient to retain normal range of motion and function when presenting with axillary nerve injury. 
Accurate manual muscle testing is necessary as 60% of athletes may be able to elevate the effected arm by compensating with and recruiting the pectoralis major and supraspinatus muscle groups, and prevent subluxation by utilizing the supraspinatus and long head of the biceps muscles.  However, there is no evidence to translate this statistic to the general population.
The sensory examination of the axillary nerve has been calculated to have a poor sensitivity (7%) in detecting the presence of axillary nerve injury, emphasizing the need for electrodiagnostic evaluation for a patient with persistent weakness and decreased shoulder function following shoulder dislocation. 
The best means to confirm a concomitant axillary nerve injury with shoulder dislocation includes detailed subjective and objective clinical examinations, along with electromyogram (EMG) studies.
The diagnostic test of choice to identify nerve conduction loss is EMG However, significant nerve damage may not be identified until 2-3 weeks post-injury. EMG can distinguish between atrophy secondary to pain or that of nerve injury. EMG studies also serve as means to track the patient’s progression or regression throughout the recovery phase, ultimately indicating whether a surgical or conservative treatment approach is needed.
- Neuropraxias (1st degree) nerve injury 
Full recovery occurs 85% to 100% of the time with conservative management within 6 to 12 months. Muscle weakness due to the axillary nerve lesion may recover spontaneously as the tissues from the shoulder dislocation heal.
- Axonotmesis (2nd degree) nerve injury
The recovery rate is near 80% secondary to the short distance between the site of injury and the muscle endplates.  Recovery should be evident between 3-4 months post-injury  EMG re-evaluations should be preformed at monthly intervals for signs of regeneration. By 6 months post-injury, if there are no signs of functional return, surgical exploration and possible nerve grafting are recommended. 
- Neurotmesis (3rd-5th degree) nerve injury
Without surgical intervention, there is typically no recovery. 
MRI is rarely used for initial evaluation of a typical nerve injury. It may be useful if the diagnosis is unclear or if there is evidence of abnormal recovery. A normal MRI does not rule out nerve injury. The duration of recovery from axillary nerve injury is prolonged, lasting as long as up to 35 weeks.
Medical Management (current best evidence)
There is uncertainty among clinicians as to the appropriate time for surgical exploration following isolated axillary nerve injury, with some authors recommending exploration at 3 months post-injury while others recommend at 6 to 12 months post-injury. The site of the axillary nerve injury is variable, making both anterior and/or posterior surgical approaches appropriate. If the axillary nerve cannot be repaired without tension, cable grafts are required. Indications for surgery are rare but must be understood by clinicians in order to maximize outcomes and minimize complications.
Indications for surgery:
- Suspicion of osteophyte formation or compression in the quadrilateral space.
- No axillary nerve recovery observed by 3 to 4 months following injury.
- No improvements were seen after 3 to 6 months of conservative treatment.
- No EMG/NCV evidence of recovery by 3 to 6 months after injury.
Surgery for shoulder instability in young active patients reduces the likelihood of recurrent anterior shoulder dislocations, therefore reducing the possibility of axillary nerve compromise.
In the rare occasion that surgery is indicated, there are several types of surgeries which can be considered by the patient and his surgeon.There is a better prognosis if the surgery is performed within 6 months of the injury but functional improvements can be expected with surgical intervention up to 12 months year after the injury. The clinician should be aware of these prognostic correlations between time of injury and time of surgery to maximize the patient's outcome. Prognosis is good in 90% of patients 
- Nerve grafting The sural nerve is commonly used during nerve grafting, not only of the axillary nerve, but in other peripheral nerves injuries as well. Prognosis for the axillary nerve with graft repair is better than other peripheral nerve repairs secondary to its short length. 
Reduction eliminates the need for surgical intervention, and is followed by immobilization and physical therapy management.
Immobilization for young adult males 4-6 weeks  Immobilization for older patients 7-10 days  Precaution should be taken during manipulative reduction of a dislocation, in which traction together with rotation or abduction are applied simultaneously, creating extra distraction and increasing the risk of axillary nerve damage.  Other treatments include: NSAIDS, rest, ice 
Physical Therapy Management (current best evidence)
Current research encompassing treatment and intervention of axillary nerve injuries following shoulder dislocation is limited. The research suggests that the management of the axillary nerve damage following shoulder dislocation is treated in the same manner as treating an isolated dislocation, with an emphasis on strengthening and stimulation of the deltoids and teres minor muscles.There should be a great amount of importance placed on allowing ligamentous, capsular, and nervous tissues time to heal while preventing joint stiffness, which could ultimately hinder function greater in the long run.
Non-Surgical Physical Therapy Treatment
- Shoulder immobilization via sling after reduction. There is insufficient evidence to support whether physical therapy should be initiated during or after immobilization. 
- Isometric Strengthening; Dosing: 10 seconds X 6 repetitions X 2 day within limits of pain
Shoulder(Flexion, Extension, Abduction, Adduction, Internal Rotation)
- Joint Mobility:
Active Range of Motion(AROM); Dosing 10 repetitions X 2 day
Elbow(Flexion, Extension,Pronation, Supination)
Wrist (Flexion, Extension, Radial/Ulnar deviation)
Hand (Opening/Closing Fist)
- Joint Mobility
Passive/Active Assisted Range of Motion(PROM/AAROM); Dosing 10 repetitions X 2 day: Shoulder (Flexion, Internal Rotation, Adduction)
Avoid end-range ER/Abd until later stages of treatment!
Active Range of Motion (AROM); Dosing 10 repetitions X 2 day: Elbow(Flexion, Extension ,Pronation, Supination); Wrist (Flexion, Extension, Radial/Ulnar deviation); Hand (Opening/Closing Fist)
Pendulum Exercises 3 sets x 30 seconds
- Strengthening of Target Muscles:
PRECAUTION: against shoulder abduction & flexion beyond 90 degrees, and ER beyond neutral in the first 3 weeks.
Older individuals have lower rates of re-occurrence of shoulder dislocation and an increase in incidence of joint stiffness. Therefore, progressive strengthening and proprioceptive training should be initiated sooner than in younger individuals, who usually begin around week 6. 
- D/C sling
- Strengthening Program light resistive exercises 
- Closed Chained Activities:
Wall push-ups -->Table-->Floor
- Continue ROM, glenohumeral and scapulothoracic stabilization/strengthening exercises, proprioception, and joint mobility, while maintaining optimal conditions for tissue healing
- Begin to initiate sport/job specific activities, progressing to full return as patient’s functional status allows. There is no consensus of when return to sport/work is appropriate following an axillary nerve injury. In general, improvement on the EMG and at least 80% return of deltoid muscle strength is recommended. . It has been suggested that return to activity for shoulder dislocation is approximately 12 weeks, and 16 weeks for competitive sports. 
- Conservative physical therapy treatment can last between 3 to 6 months. It is essential that the physical therapist continuously monitor the progression of axillary nerve reinnervation during treatment and contact the patient’s physician if there are no signs of improvement between 3 to 4 months. Note: Progression of these interventions with increased weight or resistance should be based on each individual patient and their level of pain and perceived joint stability throughout a controlled movement.
For examples of therapeutic exercises, see Examples of Therapeutic Exercises in Axillary Nerve Injury Rehabilitation.
Post-Surgical Physical Therapy
There is a lack of research to support how long a patient should be immobilized after surgical repair of the axillary nerve. Current recommendations report that the shoulder should be immobilized for 4 to 6 weeks, after which rehabilitation should focus on increasing shoulder range of motion and strengthening. 
Clinical Bottom Line
A standardized treatment is not yet known for patients with axillary nerve injury secondary to shoulder dislocation. However, immobilization based on age, treatments focused on ROM, strength, neuromuscular re-education, and function all seem to be a recurrent theme. With early detection, prognosis for the injured axillary nerve is good due to its short length needed to regenerate.
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