Erb's Palsy and Obstetric Brachial Plexus Injury: Complete Pediatric Physiotherapy Guide
Medically Reviewed by Dr. Ponkhi Sharma, PT - 19 Years Clinical Experience | 3 Clinics in Bangalore | 11 Lakh+ YouTube Subscribers
Last Updated: April 2026
Overview
Obstetric brachial plexus injury occurs when the network of nerves supplying the arm is stretched during birth, most commonly affecting the upper roots C5-C6 and producing the classic pattern known as Erb's palsy. The infant typically shows reduced shoulder abduction, reduced external rotation, weak elbow flexion, and the characteristic waiter's tip posture. Pediatric physiotherapy begins early to maintain joint range, prevent contracture, stimulate active movement, support sensory awareness, and train the family in safe handling and home therapy. Recovery varies widely depending on whether the nerve injury was mild stretch injury, axon injury, or more severe root avulsion, which is why close monitoring is essential.
Common Symptoms
- One arm moving much less than the other in the newborn period.
- Shoulder held in internal rotation with elbow extended and forearm pronated.
- Reduced ability to bring the hand toward the mouth on the affected side.
- Weak Moro reflex or absent active shoulder and elbow movement on one side.
- Progressive stiffness if the shoulder and elbow are not moved regularly.
- Delayed hand use, bimanual play, or reaching symmetry later in infancy.
Primary Causes
- Traction injury to the brachial plexus during difficult delivery or shoulder dystocia.
- Upper plexus stretch affecting C5-C6 roots most commonly.
- Variable nerve injury severity from neurapraxia to more serious nerve disruption.
- Secondary weakness leading to imbalance around the shoulder joint.
- Loss of active movement causing joint stiffness and muscle shortening if untreated.
- Sensory changes that reduce the child's awareness and use of the affected limb.
1. Why Early Range Preservation Is Critical
In Erb's palsy, the danger is not only the nerve injury. The imbalance between stronger internal rotators and weaker external rotators can quickly lead to shoulder stiffness, internal rotation contracture, and later joint deformity if range is not maintained carefully.
This is why parents are taught gentle passive range exercises very early. The aim is to preserve shoulder external rotation, abduction, elbow flexion, and forearm supination while the nerve is recovering.
The program must be accurate and calm. Rough stretching is not helpful, but lack of movement is equally risky.
2. Active Recovery and Developmental Integration
As nerve recovery begins, physiotherapy shifts from passive protection to active facilitation. The therapist uses play, positioning, and developmental tasks to encourage the baby to recruit the recovering muscles.
This includes bringing the hand to midline, hand-to-mouth play, supported reaching, shoulder alignment, rolling, propping, and eventually bilateral play. Recovery is not only about isolated muscle power; it is about integrating the arm back into normal development.
Sensory stimulation is also important because children tend to neglect a limb they do not feel or use normally. The affected arm must become part of the child's natural play world again.
3. Monitoring Recovery and Surgical Decision Windows
Pediatric therapists monitor return of antigravity biceps, shoulder control, and quality of spontaneous use. These milestones help determine whether recovery is proceeding well or whether brachial plexus surgical review may be needed.
The timing of referral matters because some children benefit from nerve grafting or nerve transfer if recovery is insufficient within critical early months. Physiotherapy does not delay surgery when surgery is needed; it helps identify that need and protects the limb while decisions are made.
Even after surgery, physiotherapy remains essential for range preservation, motor re-education, and developmental use of the recovering arm.
4. Long-Term Function and Parent Expectations
Many infants recover very well, especially in milder injuries, but recovery quality is not judged only by early movement return. Shoulder alignment, elbow control, bimanual function, and participation in later childhood all matter.
The family should understand that regular home input is central. The therapist provides technique and progression, but daily positioning, movement, and play practice drive recovery.
When physiotherapy begins early and monitoring is consistent, the child has the best chance of minimizing stiffness, asymmetry, and long-term limitation.
Frequently Asked Questions
Can Erb's palsy recover completely?
Many mild cases recover very well, especially when early movement return is seen. More severe injuries may leave residual weakness or require surgical intervention. Early physiotherapy improves outcomes in all cases.
Why is shoulder stretching important in Erb's palsy?
Because muscle imbalance can rapidly create internal rotation contracture and limit future arm use. Maintaining shoulder range is one of the most important goals of early therapy.
When should physiotherapy start for brachial plexus injury?
Very early, once the baby is medically stable and the treating team has advised on handling. Early range preservation and parent training are crucial.
Does physiotherapy still matter if surgery is needed?
Yes. Physiotherapy remains essential before and after surgery to preserve movement, guide recovery, and integrate the arm into normal development.
Stop living with Erb's Palsy and Obstetric Brachial Plexus Injury
Our targeted physiotherapy protocols typically resolve this in Mild injuries may recover over weeks to months; more severe injuries require prolonged rehab and sometimes surgery.
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