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Very interesting case of Axillary nerve damage in a 22-year-old rugby player

March 2, 2010

This case was sent to me from a F.A.P. trained practitioner from Vancouver, BC.  As always questions, comments, and suggestions are welcome

History: “A 22 year old rugby player sustained a concussion 8 weeks ago by a knee to the side left side of his head (from what he can recall).  He noticed about 1 week after that his deltoid was not firing.  He came in to see me and I noted no tone in deltoid and teres minor.  I graded deltoid activity (and teres minor) at 0/5.  The odd thing is that his sensory appears intact.  I know that it is axillary nerve that has been damaged, I just don’t know where.  He has been treated with IMS and acupuncture and still has not had any activation of deltoid or teres min.  I referred out for an EMG and he is going to bring me the results soon.”

Dr. Spina’s Response (before pictures were received): 

Here are a few things to consider regarding Axillary nerve damage:

- The axillary nerve’s sensory distribution is only a ‘patch’ under the deltoid muscle via the Superior Lateral cutaneous nerve of the arm. Therefore sensory compromise may be hard to detect unless you really search for it

- Obviously you want to rule out root damage considering the head/neck injury mechanism. Axillary nerve is made up of 5-6. Check the motor supply to another muscle with the same root supply, but along a different peripheral nerve…eg. Biceps. You will have to hold the contraction bilaterally for a prolonged period of time to bring out subtle differences.  What you are looking for is the amount of time that a strong contraction can be held as compared to the asymptomatic side.

- The superior trunk of the BP is susceptible to the mechanism that you describe (brachial neuritis, or a burner stinger type injury).

- It would be highly unlikely to be a problem in the quadrangular space judging by your muscle testing findings.  Quad space syndrome would present as more of a dull pain with minor sensory problems…if any.
– You can however damage the nerve at the posterior cord at the anterior inferior aspect of the subscapularis and shoulder capsule. A mechanism can be simply a blunt trauma to the anterolateral shoulder

-  Injury to the nerve due to usage of crutches is not possible here….nor is injury due to fracture of the surgical neck of the humerus…but I thought I would mention them for completion sake

-  Hematomas of the posterior circumflex artery are rare but can occur.  Recall that this artery accompanies the axillary nerve through the quadrangular space.

….One more…does he have a hx of GH hypermobility? Long shot, but a possible subluxation at the GH?

Response: “Its my best guess that that he has axonotemesis where the axillary nerve attaches to the posterior cord of the BP.  There is no significant GH instability, but it is possible that he did land on the shoulder causing anterior inferior subluxation.  The patient doesn’t remember because he was concussed.  I have checked sensory many times with crude/fine touch, sharp/dull and hot/cold and he is able to distinguish all sensation (maybe very mild impairment compared to his right/good side, but sensory loss is subtle at best).  I saw my patient today and he said that he had the EMG done, and the physiatrist seemed stumped.  He found no activation in delt or teres min.  He referred out for an MRI (I’m not sure what they are looking for with the MRI?  Can you see nerve degeneration/tears?).
    Here are the pics I have taken.  The first 3 are from one month ago.  The second 3 are from today.” 

A to P 1 month ago

Abd & Ext Rot 1 month ago

 

P to A 1 month ago

A to P now

Abd & external rot now

P to A now

Dr. Spina’s response:

Wow…that’s only after 8 weeks!

We can probably rule out quad space or any other entrapment syndrome. We can also rule out ‘root’ damage I think.

There is definitely peripheral nerve injury here. If his radial nerve distribution is intact, we might be able to rule out Posterior cord.  That means the axillary nerve proper must be damaged.

 Response: “Dre, Radial nerve distribution appears intact.  The injury seems to be limited to just the axillary nerve.  I’m just not sure exactly where the problem lies along the nerve.”

 General thoughts…

Well… judging by the rapid nature of the muscular wasting, we have tentatively ruled out proximal nerve damage, as symptoms would most likely have surface along another peripheral nerve at this point.  Thus the ddx of root, superior trunk, or posterior cord damage seems unlikely. 

Due to the mechanism of injury and the fact that the patient cannot recall what exactly occurred there is a chance that a subluxation, with relocation of the GH joint occurred which is the most common mechanism of Axillary nerve injury.  Other differentials still in play include a hematoma of the posterior circumflex artery, or even traction or compression damage to the axillary nerve proper (especially if there are any osteophytic processes on the anterior GH joint….which would be extremely unlikely given the patients age).

If the EMG shows incomplete denervation the prognosis is generally good.  Fortunately the supraspinatus and infraspinatus can compensate for the loss of abduction and external rotation.

Anatomy Review:  The axillary nerve is a terminal branch of the posterior cord of the brachial plexus (Radial nerve being the other), containing fibers from the C5 and C6 spinal segments.  It decends behind the axillary artery to the lower border of subscapularis, passing through the quadrangular space with the posterior circumflex humeral artery.  Its anterior branch winds around the posterior surface of the surgical neck of the humerus, sending branches to deltoid and a small patch of skin over its lower part.  The posterior branch supplies teres minor and the posterior aspect of the deltoid.  It descends around the posterior border of the deltoid to form the upper lateral cutaneous nerve of the arm.  This supplies the skin and fascia over the lower deltoid and lateral head of triceps.

 

I will try to keep you posted regarding this interesting case.

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22 Comments leave one →
  1. Delores Rutherford permalink
    June 12, 2010 3:50 am

    I had two 1/2 dose cortizone shots 4 weeks apart for a shoulder torn ligament. It was given in the bursa. When I left the ofice after the 2nd injection I had a pinch in my arm, like a knot the size of a small jawbreaker. Bye the end of the cay the knot nin my arm filled the entire upper arm about the elbow. By morning I could not lift my arm and stil can’t. That shot was given on April 29th. one Shoulder surgeon said he can’t help me that my pain and not lifting the arm has nothing to do with my shoulder. One neck sugeon agrees. One neuro-surgeon also believes it is Axillary Nerve damge. Another shoulder sugeon does not agree fels it is an impinged nerve and wants to send me to Physical therapy says I am babying the arm and need to get lifting it, pain or no pain, also another neck surgeon says he used to do shoulders sna saw many people come in like me not able to lift the arm.There is a spur at the c6 not too bad and they feel that it is giving me a radiation of numbness in that same upper arm and radiating down into the lower arm and thumb and pointer finger that I’ve had for over a year, but they do not feel the c6 is impinging a nerve that won’t allow the arm to raise. There is consideral pain, sharp pain, particullary when I ake any quick reach out motion with the arm, it can cause severe pain and I get a knot in the arm feeling the size of 2/3 of a golf ball. My neurologist has scheduled a 2nd nerve conductin study, because the 1st was done 3 days after not long enought after incident.Also mentioned a specail knd of MRI that wld help find an impinged nerve.

  2. Mr C permalink
    August 16, 2010 7:40 pm

    Re: interesting case of 22 year old rugby player

    I suspect there could be an injury to the posterior branch of the axillary nerve. I would also look for involvement of the long head of triceps (i.e. wasting) to determine if the posterior distal branch is involved. This branch may also but not necessary give subtle changes to sensation at the posterior proximal triceps. There is also a possibility of a double crush injury to the axillary nerve.

    Is the MRI with gadolinuim to contrast the axillary nerve? Also if you suspect a possible inferior subluxation, will they look for an inferior shoulder capsule rupture which may involve the axillary nerve?

  3. H. Raymond permalink
    September 22, 2010 10:46 am

    I am a 33 y/o rugby player who, during a match a week ago dislocated my right shoulder. The shoulder was reduced under anaesthetic in Hospital. Shoulder movement is generally good with little or no pain however the Deltoid is completely unresponsive and numbness is present across the regimental patch. I have a follow-up with a shoulder specialist in a few days. I suspect from research done, that this is a classic case of axillary nerve damage following the dislocation. Can someone give me a prognosis for this type of injury? A non-functioning deltoid would serverly affect my participation in many sports. I know it’s early days yet (9 days since injury).
    Kind Regards

    • luke permalink
      September 22, 2010 9:48 pm

      I have trama to my “regimental patch” on my right side as well.. My F Deltoid is unresponsive and the muscle is going away FAST… I have been to the best docs around, and he says my aux. nerve was damaged from the trama. NOW, after 4 weeks, he prescribed me back to PT, but this time with E-stim… is this the last draw before I become “handicapped”, because without this arm… I may have to give up everything I have worked so hard for and start over again. On monday I am going to get an EMG, so I will have a specific nerve group names and locations on what happened to me. Can anyone tell me what is going on and what I can do to make this nerve grow back quicker? I am scared to death of not having my range of motion on my primary(right) arm.

      • H. Raymond permalink
        October 4, 2010 11:58 am

        I saw a Neurologist last week who confirmed that I sustained streching
        of the axillary nerve either during the dislocation or the reduction. I
        have a follow up with him in 6 weeks. It’s been 3 weeks since the injury
        and the deltoid is still not functioning. The Neurologist said that the
        prognosis for this type of injury is favourable due to the short distance
        that the nerve must re-grow (about 25cm), however since nerves
        grow about 1mm/day, recovery could take up to eight months! In the meantime I have to keep active, and try to keep stimulating the deltoid.

      • Mr C permalink
        October 31, 2010 1:55 pm

        For stretch injuries and closed trauma injuries to the ax nerve – be patient.

        It can take several months for the nerve to function properly again in these type of injuries. It is important to remember that the healing process normally occurs on its own but therapy including the nerve stimulator you refer to may help to maintain muscle bulk. Others may suggest taking the RDA of vitamin C / calcium and reducing acholol and caffeine consumption as a means to optimise the healing process.

        However I would stress it is important that you are seen by a specialist now rather than later in order to monitor the situation. Medical evidence suggests most will improve on their own but for those who do not improve surgery is best at around 6-12 months following the injury. After 12-18 months, the outcome following surgery is often less favourable.

        This type of injury is rare. The Uk’s specialist centre for peripheral nerve injuries is Stanmore.

    • L.G permalink
      October 12, 2011 8:13 pm

      hi, i recently had the same injury and have the same problems, what is your shoulder like now, what was your recovery time?? Cheers.

  4. H. Raymond permalink
    November 8, 2010 2:55 pm

    It’s been eight weeks since my shoulder dislocation and today I finally managed to make my deltoid muscle twitch! During the eight weeks I have continued to train with weights as much as possible but the deltoid has atrophied quite markedly. However, the middle delt is responding today, hopefully the posterior and anterior will follow shortly! I guess the Axillary nerve has finally reached the motor end plates of the muscle, I just hope the contractions become stronger every day.

  5. Gord Hepner permalink
    November 28, 2010 4:18 am

    Hello. I have been living with axillary nerve damage for 16 months. I sustained an injury racing motocross. I fell off my bike and was getting up when a fellow rider hit me directly on my shoulder with his front tire coming down from a table top jump; blunt trauma impact at around 30 mph. I broke my collar bone and dislocated my shoulder. I have been to see 2 neurologists and had 3 EMG’s since injury. All of the Physicians have recommended that there is no treatment other than physiotherapy and time. My lateral deltoid is back to working; it has minor bulk. I have no posterior deltoid function at all. I cannot raise my arm to the akimbo position; elbow to ceiling movement. My anterior is faint, but must be working. I can raise my arm forward, but my pectoral muscle is doing most of the work.
    My question is this: Will the posterior deltoid eventually work since a few months back my lateral deltoid was firing. Thanks for any help, as none of the physicians seem to think surgery is an option; although I have tried to convince that I would like surgery if it is an option.

    • Robert Ferguson permalink
      December 2, 2010 8:49 am

      hello. It has been 2.5 years since i was thrown out of my pickup truck and into the woods. i am suffering from axillary nerve damage as well. i had 2 concusions and do not remember any of the wreck but something tore because i have complete deltoid atrophy. but what is weird is that i have almost complete range of motion.! but if i use any kind of weight i only can do certain set of reps. but i am in constant pain., i mean all the time. i havent had a good night sleep since the wreck. any ways im 28 years old i have been athletic all of my life and still trying not to let it beat me but i think the past 3 months it has wore on me. i would like to get involved in how ever i can to figure out how to fix our problem. i believe this injury can be corrected or improved if we can contact others and figure it out.

  6. Mr C permalink
    December 13, 2010 11:07 pm

    The problem can be addressed conservatively with physiotherapy or via surgery in some cases. Surgical options include neurolysis, neuratlization or nerve graft and for severe cases, tendon transfers.

    The options for graft maybe from the sural nerve in the lower leg or the forearm (used less often). There is some cases of the long head of triceps nerve branch transferred to innervate the deltoid. There is very few surgeons who perform this type of surgery, so my advice would be to politey ask your consultant why they are telling you that you cannot have surgery. Is this because you are not a candiate for surgery and why? Or is because your consultant cannot perform this operation, in which case it may be worth asking for a second opinion. As a rough guide this type of surgery is likely to be performed in large teaching hospitals and specialist centres and not smaller general hospitals.

    Depending on the severity of your injury and EMG results surgery may or may not be appropriate. One must stress if surgery is necessary it is best performed as soon as possible (6-18 months). Any benefit from a conservative approach should be evident between 12-18 months following the injury and any further improvement is likely to plateu thereafter using a conservative approach.

    The posterior detoid is supplied by a different branch of the axillary nerve to the mid and anterior deltoid, its recover will be determined by the level of injury to that branch. Often one can elevate the arm even after axillary palsy due to the pulll on the rotate cuff muscles. A postive test to determine if the deltoid is weak is the posterior deltoid lag sign or resist elevate the arm outwards from shoulder height.

    • Ms L permalink
      January 11, 2011 2:45 am

      My 17 year old son was injured in a football hitting drill in August 2010. His whole right arm went numb immediately after it happened. After a few days he seemed ok, except his outer deltoid felt numb. He had no pain and was able to rotate his arm 360 degrees. He continued to play for another month (doing therapy with the trainer during practice) until we noticed the atrophy in the deltoid muscle. I immediately got him an appt with an orthopedic shoulder guy. After an X-ray, MRI (no contrast), and a nerve study with a Neurologist, they sort of said it’s “probably axillary nerve – a stinger – maybe a stretch injury to the nerve”, and it will take time to repair itself. For a while, he worked at it because he wanted to play the last few championship football games for his Senior year. Since then, he hasn’t really been working at it, and it is noticeable. After pestering him, he recently showed me how if he rotates his arm so his elbow is pointing up (isolating the deltoid), he can only raise that arm about 12″ from his hip. I think he needs to be more thoroughly evaluated, and probably have some PT. Need to know who in this state (Georgia) I should consult? This could be a life impacting thing for a young person and I am frustrated by the lack of concern in the doctors. Any help would be appreciated.

      • luke permalink
        February 28, 2011 8:28 pm

        Hey I have a VERY similar situation. Please email me back, maybe we can talk. I also have a stretched axillary nerve, and atrophy of my deltoid. Thanks!

        Luke

  7. December 19, 2010 12:11 pm

    I have been experiencing left hip joint pains which goes through my left leg. An orthopedic specialist diagnosed it as Disc Herniation which could be corrected by bed rest. I did but the pains are still there so I met a neurologist who also said that a nerve in my system which also connects my left toe is weak. I will like to find out the possible means of repairing this weak or damaged.

  8. Jonnie permalink
    January 18, 2011 5:15 am

    I’ve had a very similar experience as the rugby player mentioned in the story. I went too low on a tackle during a rugby game and the other guy’s knee caught me in brachial plexus area. We were both running at full speed so the impact was pretty severe. I lost complete sensation in my entire left arm but slowly started regaining sensation after a few minutes. However that night I really noticed that it was getting difficult to raise my arm. Over the course of a year, my deltoid atrophied until it was very noticeably less than my other shoulder (also much like the picture of the rugby players deltoid pictured in the story). During this period, I saw a neurologist who seemed baffled with my injury. I tried a stim test (deltoids wouldn’t contract up to the highest setting) and an EMG test showed nothing could fire to my deltoids. I was told to wait since nerves take so long to heal. A surgical solution wasn’t presented to me – again everyone I talked to seemed baffled. So after a year, I could finally notice my deltoids “working” accompanied with some pain. It was quite the relief to regain most of my deltoid muscle mass back but my posterior deltoid didn’t fully regain function/mass/nervation(?). I only really notice the differences in the posterior deltoid between my shoulders when I bend forward and lift my arms sideways. I can see my left posterior deltoid spasm like it’s really trying to fire. Also, there’s some loss of strength and stamina in my shoulder due to that lack of function. I was very intrigued to read this article about a very similar injury but after several years I’m wondering if it’s just something I have to live with or if there’s still something I can do to regain complete function. Any suggestions if I should seek out a neurologist again for a possible surgical “fix” or too late at this point?

  9. Max Skipworth Button permalink
    February 9, 2011 12:47 am

    Over 2 years ago… I had a similar injury in Rugby, I tackled someone and jarred my neck to the side and felt an extreme pain in my right shoulder. The physio said that it was not dislocated but it could have been subluxed in the tackle, as soon as i got up after the tackle i noticed that my whole shoulder had gone numb and could not raise it to the side. Over the next few weeks I had physio to try and stimulate the nerve but nothing worked so I had scans and a nerve test and the Doctor said that the nerve was only slightly damaged and that it would heal within 2 years, and if it did not heal after 2 years then i would be able to get some sort of ‘nerve bypass surgery’ or surgery that would enable me to gain my muscle back in my middle deltoid as it has prevented me playing any sport competitively…. 2 years on and nothing has changed, so i visited a different shoulder specialist last week to hear from him that there is nothing that I can do.

    Do you think that I should try go back and see the shoulder specialist that I saw originally or anyone would know of what I have done as I do not want to believe that I will not be able to play any sport again.

    • Shawn permalink
      April 10, 2011 6:14 am

      I have also got the same problem as the other rugby players on this page, It happend over 2 years ago, I went in for a tackle afterwards my arm went numb, the feeling in my arm returned after a while but the feeling in my deltoid never did. After seeing a physio and specialist they told me the same thing that the nerve will grow back 1mm a day and that alot of rehab and physio will also help (my shoulder looks like the picture above). I can do all the movements I used to do before however my shoulder has become abit weaker than the other one and the muscle has wasted away. However accouple months after the injury I got back on the rugby field and played again at first I was worried about my shoulder but after the first few tackles my shoulder felt like it could take more impact then before even though the deltoid muscle had wasted away.I could still bench press the same amount of weight i could before and also shoulder press the same amount as before however there is still a numb patch, I even went on to play International rugby for my country with the condition but if there is surgery for this condition I would love to get my shoulder back to 100%.

  10. Gururaj permalink
    July 12, 2011 4:47 am

    Hi,

    I had an Bike Accident in 2001 and i have an axillary nerve damage since then, My right shoulder has the problem and i am not able to lift my hand above the shoulder and my Biceps has zero strength.My triceps has 75 % of the strength what i had initially and i am managing my hand with the triceps.
    My shoulder right next to the neck has a dent and my biceps is very thin.I am 28 year old now and have been doing pushups to maintain my hand.
    I have tried physiotherapy for two years and Ayurveda therapies for a year with no luck
    –Could you suggest me some treatment or exercises and let me know if the nerve damage can be cured?? your input would make a difference in my life.

    Thanks
    Gururaj

    Bangalore ,India

  11. broc newman permalink
    March 17, 2012 8:00 am

    i dislocated my shoulder in 2007 due to motocross accident and tore my axillary nerve with a dislocated shoulder…and basicaly if u leave it more than 12 months your screwed! there is sugery out there.i had paralized arm both outa fingers but eventully they came back..took about 3months after but my shoulder did not. i did have surgery where a branch to the functioning long head of the triceps was cut and attached to the nonfunctioning axillary nerve to allow this patient to once again lift their arm. this has given me more power in my tricep…following this treatment im not sure if it has worked or not as i moved away after the surgery. but at this time it hasnt realy affected me as much as i first though..i still have a complete waisted deltoid but have since raced motocross again even had kick boxing fights and won! i can still lift weights but my right arm is a little weaker. i have learned to live with this but the only problem i have with it is when people look and stare at you cause they have never seen an injury like it…and still being young does not do you much confidence. so i have decided to get a deltoid implant wich consist of soft solid silicon..this gives the symetrical look back wont be 100 percent as your other good shoulder but it will be close…this cost me $15000 au but the best 15 grand i have spent. key to this story is if you sustain this injury and doctor tells you theres nothing he can do dont take no for answer…inside 6months good chance of full recovery but dont leave it any more later than 12months for surgery.

    • Jake permalink
      March 19, 2012 11:13 pm

      I would be interested in seeing some pictures of the before and after implant surgery. I am also looking into this procedure. I injured my shoulder 15 yrs playing college football. Doctors thought I had a “stinger.” After a couple days and detoid was not “firing” and a patch on the outside was completely dumb i knew i had to go see a specialist. I went to several doctors. I had an MRI, EMG, ect. I showed up to see a nuerologist and he wanted to know why i was sent to him. He also wanted to know why I received an MRI. It was very frustrating as 18 yr old going to all these doctors and them not knowing what to do. They did’t take it seriously. Everyone told me it should come back after a couple months. Nerves grow 1 mm a day. Well after a couple months, I was told never to play football again. My deltoid was wasting away. Well, after a year i was laying in bed and felt a twitch. I continued to work the deltoid and it gradually started to come back, however, after 15 yrs living with this injury i probably gained 50% of deltoid back. Its an annoying injury, because I notice it all the time and everyone tells me they can’t tell. The pain and discomfort don’t bother me, but my shirts irritate me. My shirts don’t fill out in my bad shoulder and binds up under my armpit. Its very irritating. So that is why i am considered a implants so i can live more comfortble. I can function normally and do basically everything i have done before, however, i can’t for long. anything where i have to raise my arm for long periods of time i can’t. After 15 yrs I have been back to the doctor for other injuries, including surgery on my “good” shoulder and I always ask if anything can be done and they said NO. or they seem like they are not even interested in looking at i. There has to be something that can be done. I do lift weights, but nothing that will build muscle like i did while playing football. i wonder since i have some function and muscles are flexing, if i work hard on the deltoid would the detiod get bigger. Will this help?

      • JimmyJazz permalink
        October 27, 2012 1:03 am

        Jake take it easy on the weights mate you don’t want too severe muscle imbalances and a screwed up posture.

        I’ve had a knackered axillary nerve for just gone ten years and stretching to my brachial plexus on the right side after bouncing off a tree on two wheels when I was 21. One of the worst things are the muscle imbalances which I really hurt myself with years ago trying to keep my muscles, weights did me no good whatsoever and it took a really long time to get things better again. You need to really take care of your posture.

        Muscle wastage won’t stop at your deltoid so it’s really important you keep moving and excercising but what will be will be. I’ve worked really hard since my crash and docs say I have 80% movement back and what they class an excellent recovery. I didn’t have surgery and they’re supprised at the range of motion I have. I can lift my arm above my head, but can’t put my arm behind me or lift it up to the side correctly, everything else is ok, hard work, but considering I didn’t think I’d feed myself with my right hand again I’m happy with that.

        Deltoid has gone, Teres minor shortly followed and surrounding muscles have all shrunk despite my efforts with Physio and daily ROM, I have winging of the scapula and a screwed up Thoracic nerve as a result now which hurts like hell. All the pain seemed to get better gradually over time until I developed problems with my scapula, this hurts more than my shoulder and neck combined. This is why i think your posture is so important and you need to take care of it. I managed for years with no painkillers but gave in when my Thoracic nerve kicked in. I’m not encouraging drug use but weed does help, and I just have tramadol and naproxen now for when my back hurts.

        I’ve worked all since the crash and some days are better than others but i can manage and life’s ok. I still ride my motorbikes and mountain bikes, i can’t swim anymore but some people find swimming really helps.

        Shoulder looks really freaky but you get used to it just like you get used to things being different. I’m really lucky things should be much worse, I have days when it really bothers me but keeping busy is the best way to block out the pain, thats the best reason I have for going back to work. Best thing I did and I’m really lucky I can, some people arnt so fortunate.

        Everyone’s different, all injuries are different just like recovery will be different, I just thought I’d share a few things they don’t tell you in hospital and that this isn’t the end of the world.

        I wish you guys all the best and a speedy recovery.

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