Anatomy and Evaluation of

the Brachial Plexus

San Jose State University
Undergraduate Athletic Training
Educational Program
 Contents
 Anatomy of the Brachial Plexus

 Mechanisms of Brachial Plexus Injury

and Pathologies

 Neurological Evaluation for the Brachial

Plexus and Related Special Tests
Anatomy
 Levels

 Roots  Real
 Trunks  Athletic Trainers
 Divisions  Drink
 Cords  Cold
 Branches  Beer
 Brachial Plexus Branches &
Muscular Innervations
Dorsal Scapular N. Suprascapular N.
 Levator Scapulae  Infraspinatus
 Rhomboid Major/Minor  Supraspinatus

Lateral Pectoral N. Musculocutaneous N.

 Pectoralis Major/Minor  Biceps Brachii
 Brachialis
 Coracobrachialis
 Brachial Plexus Branches &
Muscular Innervations
Axillary N. Middle Subscapular or
 Deltoid Thoracodorsal N.
 Teres Minor  Latissimus Dorsi

Upper Subscapular N. Lower Subscapular N.

 Subscapularis  Subscapularis
 Teres Major
 Brachial Plexus Branches &
Muscular Innervations
Median N.
 Abductor Pollicis
Brevis/Longus
 Flexor Carpi Radialis
 Flexor Digitorum
Superficialis
 Flexor Digitorum Profundus
(Lat. 2)
 Flexor Pollicis Brevis (Lat.)
& Longus
 Lumbricales (Lat. 2)
 Opponens Pollicis
 Palmaris Longus
 Pronator Quadratus
 Pronator Teres *
Radial N.
 Abductor Pollicis Brevis
 Anconeus
 Brachioradialis
 Extensor Carpi Radialis
Brevis/Longus
 Extensor Carpi Ulnaris
 Extensor Digiti Minimi
 Extensor Digitorum
Communis
 Extensor Indicis
 Extensor Pollicis
Brevis/Longus
 Supinator
 Triceps Brachii
 Brachial Plexus Branches &
Muscular Innervations
Ulnar N. Long Thoracic N.
 Abductor Digiti Minimi  Serratus Anterior
 Adductor Pollicis
 Dorsal Interossei Medial Pectoral N.
 Flexor Carpi Ulnaris  Pectoralis Major
 Flexor Digiti Minimi
 Flexor Digitorum
Profundus (Med. 2)
Medial Brachial
Cutaneous N. (sensory)
 Flexor Pollicis Brevis
(Med.)
 Lumbricals (Med. 2) Medial Antebrachial
 Opponens Digiti Minimi Cutaneous N. (sensory)
 Palmar Interossei
 Mechanisms of
Injury to the Brachial Plexus
Brachial Plexus Injury Overview
 Sports most commonly associated with brachial
plexus injuries include: football, baseball,
basketball, volleyball, fencing, wrestling, and
gymnastics
 Nerve injuries can result from blunt force trauma,
poor posture, or chronic repetitive stress
 Patients generally present with pain and/or
muscle weakness
 Over time, some patients may experience
muscle atrophy
(Duralde, 2000)
Brachial Plexus Injury Overview
 Before performing special tests, rule out fractures
and dislocations
 Brachial plexus injuries resolve quicker than spinal
cord injuries
(Prentice, p.846)

 Evaluation for return-to-play should take into

consideration symptoms, resolution time, and prior
injuries to this region
(Gorden, et al., 2003)
 Evaluate athletes immediately after injury and again
after the game/practice
(Kuhlman & McKeag, 1998)
 Three Mechanisms of Injury
 Percussion

 Traction

 Cervical Nerve Compression

 Percussion
Occurs with direct blow to the
supraclavicular fossa over Erb’s point
(Troub, 2001)

Example: Cross-check to a hockey

player
 Traction
Occurs with a direct blow to the
shoulder with the neck laterally flexed
toward the unaffected shoulder
(Troub, 2001)

Example: Gymnast falls on beam

 Cervical Nerve Compression
Occurs when the neck is flexed laterally
toward the patient’s affected shoulder

Caused by compression or irritation of the

nerves, resulting in point tenderness over
involved vertebrae of affected nerve(s)
(Troub, 2001)

Example: Football player tackles an

opponent
A. Traction
B. Percussion
C. Cervical Nerve Compression
 Brachial Plexus Pathologies

 “Burners” or “Stingers”
 Associated with traction and/or compression

 Thoracic Outlet Syndrome

 Burners or Stingers
 Mechanisms of injury include cervical flexion
away from the limb and hyperextension of the
cervical spine

 May present with pain, numbness, burning,

and/or tingling from the shoulder to the fingers

 Possible loss of function in arm and hand for

several minutes up to several days
(Prentice, p.846)
 Thoracic Outlet Syndrome
 Caused by pressure on the brachial plexus
and/or subclavian artery and/or vein

 May present with numbness, paresthesia, pain,

cool and pale skin, cyanosis or edema in upper
extremity, and swollen veins
(Prentice, pp. 683-684)

 Patient may also develop unilateral atrophy

and/or lowered shoulder on affected side
(Duralde, 2000)
 Three Grades of Injury
 Grade 1 – Neuropraxia

 Grade 2 – Axonotmesis

 Grade 3 – Neurotmesis
 Grade 1 - Neuropraxia
 Results in a disruption in the function of a
nerve that produces numbness and
tingling

 Most common grade within athletics

 Symptoms usually resolve within several

minutes
(Duralde,2000)
 Grade 2 - Axonotmesis
 Damage to the nerve’s axon

 Symptoms include numbness, tingling,

and affected function (may last several
days)

 Long nerves have a greater healing time

than short nerves

 Rare within athletics

(Duralde,2000)
 Grade 3 - Neurotmesis
 Permanent nerve damage occurs

 Very rare within athletics

 “Occurs with high-energy trauma,

fractures, and penetrating injuries”
(Duralde, 2000)
 C5-C6 Affected

 Motor Deficits:
Shoulder abduction, shoulder flexion,
elbow flexion, and wrist extension

 Sensory Loss:
Lateral arm, 1st digit, and 2nd digit
 C7 Affected
 Motor Deficits:
Elbow extension weakness and wrist flexion

 Sensory Loss:
Pad of index finger
 C8-T1 Affected (very rare)
 Motor Deficits:
Finger abduction/adduction and thumb
flexors/extensors

 Sensory Loss:
4th digit, 5th digit, medial forearm, and
medial arm
 C5-T1 Affected
 Motor Deficits:
Scapular motion and entire arm

 Sensory Loss:
Entire arm, forearm, and hand
Process of Evaluation
 Dermatomes
 C5 – Lateral arm

 C6 – Lateral forearm, thumb, index finger

 C7 – Posterior forearm, middle finger

 C8 – Medial forearm, ring and little finger

 T1 – Medial arm
 Myotomes
 C5 – Shoulder abduction

 C6 – Elbow flexion or wrist extension

 C7 – Elbow extension or wrist flexion

 C8 – Grip strength, shake hands

 T1 – Interossei, spread fingers and resist

finger adduction
 Peripheral Nerve Tests
Axillary N. Musculocutaneous N.
• Sensory – Lateral • Sensory – Anterior
arm arm

• Motor – Shoulder • Motor – Elbow

abduction flexion
 Peripheral Nerve Tests
Radial N. Median N.
• Sensory – 1st Dorsal • Sensory – Pad of
web space Index finger
• Motor – Wrist • Motor – Thumb pinch
extension and thumb and abduction
extension
Ulnar N.
• Sensory – Pad of little
finger
• Motor – Finger
abduction
 Reflex Tests
 C5 – Biceps brachii reflex (anterior arm
near antecubital fossa)

 C6 – Brachioradialis reflex (lateral aspect

of forearm)

 C7 – Triceps brachii reflex (at insertion of

tricep brachii)

 C8 and T1 do not have reflex tests

 Related Special Tests
Brachial Plexus Thoracic Outlet Syndrome
• Cervical Compression • Adson’s Test
Test
• Allen’s Test
• Cervical Distraction
Test
• Military Brace Position
• Spurling’s Test

• Brachial Plexus
Traction Test
 References
Duralde, X. A. (2000). Neurologic injuries in athlete’s shoulder. Journal
of Athletic Training, 35(3), pp.316-318.
Gorden, J. A., Straub, S. J., Swanik, C. B., & Swanik, K. A. (2003).
Effects of football collars on cervical hyperextension and lateral
flexion. Journal of Athletic Training, 38(3), pp. 209-218.
Hoppenfeld, S. (1976). Physical Examination of the Spine & Extremities.
Upper Saddle River: NJ: Prentice Hall. pp.93-127.
Kuhlman, G. S. & McKeag, D. B. (1999). The “burner”: A common nerve
injury in contact sports. American Family Physician, 60(7). Retrieved
April 5, 2006 from the American Academy of Family Physicians
database.
Martini, F. H., Timmons, M. J., & Tallitsch, R. B. (2003). Human
Anatomy. Upper Saddle River, NJ: Pearson Education, Inc.
Starkey, C. & Ryan, J. (2002). Evaluation of Orthopedic and Athletic
Injuries. Philadelphia, PA: F. A. Davis Company.
Troub, M. (2001). Brachial plexus injuries in athletics:
“Burners”. Northwest Texas Sports Medicine Clinic. Retrieved March
5, 2006 from the Northwest Texas Sports Medicine Clinic website.
 Project Participants
 Presenters: Heather Terbeek, Hank House, Cesar
Cardenas, and Rachel Sorris

 Models: Becky Roark & Kevin Geiger

 Researchers: Caitlin Wall, Heather Terbeek, Hank

House, Cesar Cardenas, and Becky Roark

 Special Thanks to Our Faculty: Jeff Roberts,

Dr. Leamor Kahanov, and Chris Warden