Brachial plexus neuritis is an uncommon pathology characterized by severe shoulder and upper arm pain, followed by upper arm weakness. Brachial plexus neuritis most often affects the dominant shoulder of males. This case review describes a female collegiate volleyball player with brachial plexus neuritis of the non-dominant shoulder. She was treated with medication, massage, and therapeutic exercise for a successful return to participation.
A 20-year-old female collegiate volleyball player with a history of peroneal nerve inflammation and no upper extremity pathologies presented with numbness and tingling in all fingers of her left hand after a volleyball match. There was no known etiology. The patient presented with her head laterally flexed to the left side and her elbow, wrist, and fingers in full flexion. The patient stated that she was unable to move out of this position without pain. On evaluation, the patient was tender to palpation on the upper trapezius, was in complete contracture at the biceps brachii and brachialis, and had noticeable swelling of the infraspinatus. She reported an inability to laterally flex her cervical spine or shoulder and extend her elbow or wrist. The patient reported her pain level to be 8 of 10 on the Visual Analog Scale. The patient experienced unilateral neck pain and there was notable swelling of the upper and middle trapezius. Physical examination demonstrated a loss of axillary nerve sensation and weakness in the deltoid (1 of 5) and supraspinatus (2 of 5). Moderate winging of the scapula was noted.
The initial differential diagnoses included transient brachial plexopathy, strained upper trapezius, rotator cuff tear, cervical disk injury, cervical radiculopathy, and thoracic outlet syndrome. The patient was removed from participation and underwent an anterior and posterior radiograph within 24 hours. Findings on the radiograph were inconclusive. The patient was unable to undergo a magnetic resonance imaging scan due to the amount of swelling present and the inability to relax the involved musculature. The patient was referred to an orthopedic surgeon who specializes in shoulder pathologies. Based on physical findings, the patient was diagnosed as having brachial plexus neuritis.
The surgeon prescribed naproxen, cyclobenzaprine, and hydrocodone and instructed the patient to rest the involved shoulder and not compete in physical activity until the swelling had subsided and pain levels decreased. After beginning the cyclobenzaprine and hydrocodone treatment, the patient failed to experience a change in symptoms for 2 weeks. This delay in response may be attributed to the half-life of the drug because naproxen may take up to 2 weeks to provide pain relief in severe cases.1 During these 2 weeks, the patient received a light massage once a day to reduce pain. She could not tolerate anything but minimum pressure from the clinician. At 2 weeks, the muscle spasms began to subside and the patient was gradually able to extend her elbow, wrist, and hand into a neutral position. Following this reduction in muscle spasm, the patient regained full range of motion and reported a score of 0 of 10 on the Visual Analog Scale 3 weeks after her initial evaluation.
She had a follow-up evaluation with the orthopedic surgeon and was cleared to begin shoulder strengthening exercises (Table 1), progress to functional activity, and discontinue her prescribed medication. During the strengthening portion of her rehabilitation, the patient reported numbness and tingling in the fourth and fifth digits of the affected hand. One month after the initial evaluation, she had full range of motion, full strength, normal sensation, and no pain. The patient was discharged from rehabilitation and returned to full sport participation.
Shoulder Strengthening Exercises
Brachial plexus neuritis has an incidence rate of 1 to 2 cases per 100,000 individuals and occurs predominately in males.2 Literature suggests that patients who are diagnosed as having acute brachial plexus neuritis can expect a full recovery by 3 years.2,3 However, this patient had a successful recovery after 1 month. In a retrospective study evaluating nerve injuries in 346 athletes, only 1 athlete participated in volleyball.3 The symptomology of this pathology usually includes the dominant arm3; however, this patient was right-hand dominant and hit only with her right shoulder and arm. Interestingly, she was diagnosed as having brachial plexus neuritis of the left shoulder and neck, without a mechanism. The etiology and pathogenesis of this condition are unknown; however, many cases have documented a recent vaccination, surgery, or infection prior to onset,4,5 none of which this patient experienced. Although the patient did not respond to medication initially, her pain, swelling, and muscle spasms decreased to a point at which she could begin rehabilitation after 2 weeks. She was then returned to play much faster (1 month) compared to other cases documented in the literature (up to 3 years).3 Brachial plexus neuritis is a complicated, idiopathic condition causing debilitating pain and weakness. This patient initially responded slowly to treatment, but then made a fast recovery and return to play. More research needs to be conducted to confirm the pathogenesis and etiology of brachial plexus neuritis to further enhance clinicians' knowledge of this condition.
The practicing clinician should be aware that brachial plexus neuritis may not be specific to the dominant swinging arm in volleyball players and may present without a mechanism. The goal of treatment should be to decrease swelling and increase range of motion and strength. For this particular case, the patient did not respond to medications prescribed to reduce swelling immediately and had persistent numbness and tingling in the fourth and fifth digits, affecting her strength gain. Once all goals were met, this patient progressed much faster than other cases in the literature. It is vital for the clinician to distinguish brachial plexus neuritis from common differential diagnoses (eg, impingement syndrome, glenohumeral instability, tendinitis, nerve entrapment, “burner” syndrome, and acute fractures)3 to select the appropriate intervention and plan of care.
Brachial plexus neuritis is a complex pathology with unknown etiology and pathogenesis. The condition affects the motor neurons of the brachial plexus and is characterized by an acute onset of debilitating shoulder pain, weakness, and paresthesia. Although most often affecting males and the dominant limb, this particular patient was a right-hand dominant female collegiate volleyball player. Although her initial progress was slow and she reported pain and loss of sensation, once the swelling subsided and she began strengthening and functional exercises, the patient had a successful return to participation with no complications. Clinicians must be aware of this pathology and consider the clinical features, particularly when evaluating a patient with suspected cervical radiculopathy or cervical disk injury. With early intervention including medication and therapeutic exercise, the prognosis for this patient was successful.
- Naproxen (Oral Route). Mayo Clinic Web site. http://www.mayoclinic.org/drugs-supplements/naproxen-oral-route/proper-use/drg-20069820. Updated: March 1, 2017. Accessed: March 25, 2017.
- Hubka MJ, King L, Cassidy JD, Donat JR. Brachial plexus neuropathy. The Journal of the Canadian Chiropractic Association.1992;36:213–216.
- Hershman EB, Wilbourn AJ, Bergfeld JA. Acute brachial neuropathy in athletes. Am J Sport Med. 1989;17: 655–659. doi:10.1177/036354658901700512 [CrossRef]
- Debeer P, De Munter P, Bruyninckx F, Devlieger R. Brachial plexus neuritis following HPV vaccination. Vaccine. 2008;26:4417–4419. doi:10.1016/j.vaccine.2008.06.074 [CrossRef]
- Krivickas LS, Wilbourn AJ. Peripheral nerve injuries in athletes: a case series of over 200 injuries. Semin Neurol. 2000;20:225–232. doi:10.1055/s-2000-9832 [CrossRef]
Shoulder Strengthening Exercises
|Scapular wall slides||2||12|
|Shoulder shrugs (5 lb)||2||12|
|D1/D2 patterns with TheraBand||1||15×|
|Rhythmic stabilization||3||20 seconds|