Is Erb’s palsy noticeable at birth?

In many cases, yes. A baby may have a limp arm, show little movement on one side, or hold the arm in an unusual position. However, the full extent of the injury may not become clear until around 3 to 6 months of age, especially if the nerve damage is moderate.

Can Erb’s palsy get better on its own?

Some mild cases—especially those involving nerve stretching (neuropraxia)—can improve without surgery. Physical therapy plays a huge role in supporting natural recovery.

What is the treatment for Erb’s palsy?

Treatment options depend on the injury type. Early physical and occupational therapy is often the first step. More serious injuries like nerve ruptures or avulsions may require surgical procedures to restore function.

What is the best exercise for Erb’s palsy?

The most effective exercises for managing Erb’s palsy target strength, flexibility, and functional movement in the affected arm and hand. Early, consistent therapy can help children regain mobility and prevent long-term stiffness or muscle loss. Since every case is different, a licensed physical therapist should be enlisted to create a personalized routine based on the child’s specific condition and developmental stage.

How is Erb’s palsy diagnosed?

Doctors typically use physical exams and observe reflexes and movement patterns to diagnose Erb’s palsy. In some cases, MRI, ultrasound or nerve conduction studies (EMG) are used to determine the severity of nerve damage.

Is Erb’s palsy caused by medical error?

Not always, but it can be. If excessive force was used during delivery or the condition could have been prevented, medical negligence may be a factor. In such cases, a legal claim may help with the cost of long-term care.

Brachial Plexus Birth Injury

A parent’s guide to understanding, diagnosing, and treating a newborn’s nerve injuries

‍When a baby’s birth doesn’t go entirely smoothly, and one arm seems weak, floppy or non-responsive, it can raise alarm bells for parents. Among the conditions that may cause these symptoms is a “brachial plexus birth injury” — nerve damage to the network supplying the shoulder, arm and hand. For parents who suspect their child has such an injury, or who have already received a diagnosis, having clear, up-to-date information helps you become an informed partner in your baby’s care.

Below we’ll discuss what a brachial plexus birth injury is, how doctors diagnose it, when it can be diagnosed, what symptoms to watch for, what causes it, how it relates to other conditions, and what treatment options exist today.

Medically reviewed by:

Kelsey Pabst, Registered Nurse

A child suffers a birth injury for every 143 births in the United States

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What is a brachial plexus birth injury?

The term “brachial plexus birth injury” refers to damage to the bundle of nerves that originate in the neck (spinal nerve roots C5 through T1) and travel through the shoulder to the arm and hand. These nerves control both the movement (motor signals) and feeling (sensory signals) of the upper limb.

During birth, if the baby’s head and neck are stretched too far away from the shoulder, or the shoulder becomes stuck behind the mother’s pelvic bone (shoulder dystocia), these nerves can be stretched, torn, or in the most extreme cases avulsed (pulled from the spinal cord).

Depending on how severe the injury is, the baby may have partial weakness, loss of motion, or complete paralysis of the affected arm. Some babies recover fully with minimal intervention; others may need surgery and ongoing therapy. The condition may also be referred to by terms like “obstetric brachial plexus paresis,” “Erb’s palsy” (for upper-nerve root injuries) or birth-related brachial plexus palsy.

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How is brachial plexus injury diagnosed?

Diagnosis begins with a thorough clinical examination by a pediatrician, pediatric neurologist, or an upper-extremity specialist. The first step is noticing signs such as a limp arm, minimal movement, or an absence of normal reflexes (for example, the Moro reflex on the affected side). The doctor will assess whether the baby’s shoulder, elbow, wrist and hand move normally and whether the baby can grasp or respond to touch on the affected side.

If symptoms persist beyond the early weeks, further diagnostic tests may be used to assess nerve integrity and plan treatment. These may include:

Imaging - MRI or occasionally CT myelography to visualize nerve roots, plexus anatomy and related soft-tissue injury.
Electrodiagnostic studies - nerve conduction studies or electromyography (EMG) to evaluate how well the nerves conduct signals and which muscles are being affected.
X-rays to exclude associated fractures (e.g., clavicle or humerus) that may accompany a difficult birth.

Early assessment is important because timely interventions (especially when surgery may be needed) often correlate with better outcomes.

At what age can brachial plexus injury be diagnosed?

A suspected brachial plexus birth injury can be identified immediately after birth if a baby shows limited or absent motion in one arm, lacks normal reflexes, or has clear signs of nerve dysfunction. Parents and clinicians may notice that one arm remains down by the side and doesn’t move normally while the rest of the baby is active.

Often, however, more definitive diagnosis and treatment planning occur in the first few weeks to months of life. Pediatricians recommend close monitoring during the first 3 to 6 months to see whether spontaneous recovery is underway. If there is little or no improvement by about 3-6 months, further specialist evaluation or surgical consultation is generally advised.

In some milder cases the injury may go unnoticed until later when the child begins to reach for toys, crawl, or walk and reveals weakness or limited arm motion compared to peers. Thus, diagnosis may be refined over the first year of life. Early involvement of therapy and specialists is beneficial even when full diagnosis is pending.

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What are the symptoms of brachial plexus injury in infants?

Symptoms vary depending on which nerves of the brachial plexus are affected (upper roots, lower roots, all roots) and how severe the damage is. Typical warning signs in a newborn include:

A baby who doesn’t move one arm or uses it little compared to the other.
Holding the arm limp, hanging by the side, or “adducted” (close to the body) with the elbow extended and wrist rotated inward — often referred to as the “waiter’s tip” position in upper-root (Erb’s) injuries.
Absent or weak reflexes on the affected side (for example, biceps reflex).
Grasp reflex might be intact, but wrist or finger motion may be limited.
Reduced muscle tone, and later, failure to reach motor milestones in the affected limb.
Older infants may show weaker grip, poor coordination, muscle atrophy, shoulder joint deformity, or permanent muscle tightening.

Because nerves regenerate slowly and muscles may be affected secondary to the nerve injury, the signs may change over time — improvement, stagnation, or even worsening due to joint changes may be seen. Parents should raise concerns if the affected arm is not improving by about 3 months or if the shoulder or elbow appears stiff.

What causes brachial plexus injury in babies?

The most common cause of a brachial plexus birth injury is shoulder dystocia—a situation during vaginal birth where the baby’s shoulder is stuck behind the mother’s pubic bone after the head has delivered. As a result, excessive pulling on the head and neck, or stretching of the nerves as the baby’s shoulder is forced through the birth canal, can damage the plexus.

Risk factors include:

A large-birth-weight baby, especially in mothers with diabetes.
Prolonged labor or difficult delivery.
Use of instrument-assisted delivery (forceps or vacuum) in the presence of shoulder dystocia.
Breech presentation or unusual fetal position.
Maternal obesity or gestational diabetes.

The injury may be due to stretching (neurapraxia, the mildest form), rupture (nerve torn but still attached), or avulsion (nerve root torn from the spinal cord) — the more severe forms carry worse prognosis.

Can brachial plexus injury be caused by medical malpractice?

Yes—some brachial plexus birth injuries occur in circumstances where the standard of obstetric care may not have been met. Medical malpractice claims may arise when:

Shoulder dystocia was mishandled or appropriate maneuvers delayed.
Excessive traction or force was applied during delivery despite risk factors or recognized shoulder impaction.
Fetal size, maternal diabetes or risk of dystocia were known but not managed proactively.
Instrument-assisted delivery was used improperly in a high-risk birth.

Determining whether malpractice occurred requires detailed review of medical records, fetal monitoring, labor and delivery notes, the timing and nature of interventions, and expert opinion. It’s important to remember: not all cases of brachial plexus birth injury are preventable and occurrence alone does not prove negligence. Contact us today to speak with a birth injury attorney if you suspect negligent care.

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Conditions related to brachial plexus injury

A brachial plexus birth injury may overlap or lead to associated conditions. Some of these include:

Erb’s palsy: injury to the upper roots (C5-C6), causing shoulder and upper arm weakness.
Klumpke’s palsy: injury to the lower roots (C8-T1), affecting forearm and hand, sometimes resulting in a “claw hand.”
Horner’s syndrome: in severe avulsion injuries near the T1 sympathetic root, signs such as drooping eyelid, small pupil and reduced facial sweating may accompany the plexus damage.
Contractures and joint deformities: Without timely therapy, stiffness in shoulder, elbow or wrist may develop, limiting movement long-term.
Developmental delays or asymmetry: Because the baby may preferentially use the unaffected arm, delays in bimanual tasks or fine-motor skills may occur.
Pain or neuropathic symptoms: In older children, nerve injuries may show persistent discomfort or sensory deficits.

Parents and clinicians should monitor closely so that any secondary conditions are addressed early — better outcomes are associated with early recognition and intervention.

Is there a cure for brachial plexus injury?

There is no single “cure” that guarantees full recovery in every case, but many infants with less-severe brachial plexus injuries recover substantial or full function — particularly if treatment begins early. Mild injuries (nerve stretching) often resolve on their own without surgery.

In more severe cases (nerve rupture or avulsion), a combination of therapy and timely surgery offers the best chance of improving outcomes. Surgeries such as nerve repair, nerve grafting or nerve transfers may restore function but often take months to years for results to manifest.

The earlier (often within the first 3 to 9 months of life) the surgical intervention, the better the chances; delay reduces the potential because the muscles may atrophy and lose ability to respond.

So, while “cure” may be too strong a word in many cases, with modern therapy, surgery and early intervention, good function is achievable in many children — and early treatment dramatically improves the chances.

Treatment for brachial plexus birth injury

Treatment of brachial plexus birth injury is tailored to the severity of the nerve damage and the child’s response. It broadly falls into non-surgical and surgical approaches:

Non-surgical / conservative treatment

For many infants, especially those with milder injury, therapy begins early and may lead to full recovery. Recommended approaches include:

Physical therapy (PT) and occupational therapy (OT): These help maintain joint range of motion, prevent stiffness or contracture, and encourage use of the affected arm. Parents often learn home exercises to use daily.
Splinting or bracing: To hold the arm, wrist or hand in proper position and prevent deformity or stiffening.
Passive and active range-of-motion exercises: Starting as early as 3 weeks of age in some programs, to keep shoulder, elbow, wrist, fingers mobile.
Monitoring and observation: Many infants improve markedly in the first 3-4 months; constant tracking ensures therapy is adjusted and surgical referral is not delayed if needed.

Surgical treatment

If by about 3-6 months there is minimal or no improvement, surgical options are considered. These may include:

Nerve repair or grafting: Direct repair of damaged nerves or grafting nerve tissue from another part of the body.
Nerve transfer: Connecting a functioning donor nerve to the injured nerve to re-animate the muscle. This is often used in more severe injuries (avulsion or rupture).
Tendon or muscle transfer / osteotomy: In older infants or children with established secondary problems (joint deformity, muscle imbalance), surgeons may move tendons/muscles or reposition bones to improve function or alignment.
Timing is critical: Many centers suggest surgery between 4-9 months of age offers the greatest chance of successful recovery. Past 18 months, muscle and nerve degeneration often limit the benefit.

Long-term follow-up

Recovery takes time. Nerve growth occurs slowly, and full results of surgery may only be seen over years. Even with good recovery, children may need ongoing therapy, monitoring of shoulder development, and adjustments as the limbs grow. Supportive services (adaptive equipment, home exercises, fine motor interventions) remain important.

Parent’s role

Parents play a foundational role: ensuring therapy is consistent (often daily), maintaining appropriate splinting/bracing, monitoring the affected arm’s use, watching for signs of contracture or weakness, and ensuring referral to specialists if improvement is not seen on schedule.

Clear communication with your child’s care team about expected milestones, referral triggers, and surgical windows helps maximize the outcome.

Hope with early detection

A brachial plexus birth injury can be a frightening diagnosis for families—especially when the arm seems limp, unused, or your baby appears to favor one side. But the good news is: there’s a lot to be hopeful about. With early observation, appropriate therapy, and timely surgical intervention when needed, many children regain full or near-full use of their arm.

The key is early detection, proactive management, and a coordinated care team including a pediatric neurologist or upper-extremity surgeon, physical and occupational therapists, and you the parent as an advocate.

If your child’s delivery was difficult, birth weight high, or there were signs of shoulder dystocia, and you notice limited movement in the arm, raise the issue with your pediatrician as soon as possible. Ask for a referral to a specialist, request clear timelines for improvement, and keep careful records of therapy and movement progress. Don’t wait to see whether “it will fix itself” beyond the typical window of improvement—timely action matters.

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Disability Benefits

Sources

Brachial plexus injury. Cleveland Clinic. (October 16, 2024).

Retrieved from: clevelandclinic.org

Brachial Plexus Treatment Options. Cincinnati Children's Hospital. (November 21, 2025).

Retrieved from: www.cincinnatichildrens.org

Medically reviewed by:

Kelsey Pabst, Registered Nurse

Kelsey is an experienced surgical nurse with more than 10 years in hospital-based care, including leadership within the operating room. She has worked extensively with pediatric patients, refining her ability to support children and families during critical moments. As both a mentor and patient advocate, Kelsey is dedicated to promoting safety, communication, and compassionate care while helping families understand medical procedures, treatment options, and the realities surrounding birth injuries and pediatric conditions.

Written by:

Cerebral Palsy Center

Our nurses, patient advocates and legal experts are solely focused on bringing you the latest cerebral palsy information, options for financial assistance and access to community support.

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Last modified:

Thursday, December 4, 2025

Created on:

Friday, November 21, 2025