Oxycodone 5 mg orally every 4 to 6 hours as needed
Limit to 3 to 5 days in acute setting
Neuropathic pain management
Gabapentinoids
Gabapentin
Start 100 to 300 mg orally at bedtime
Titrate by 300 mg every 3 to 7 days
Target 900 to 1800 mg per day in divided doses
Pregabalin
Start 75 mg orally twice daily
Titrate to 150 to 300 mg twice daily
Renal dose adjustment required if creatinine clearance below 60 ml per minute
Antidepressants for neuropathic pain
Amitriptyline
10 to 25 mg orally at bedtime
Titrate slowly over weeks
Use with caution in elderly due to anticholinergic effects
Duloxetine
30 mg orally daily for 1 week then 60 mg daily
Evidence base for neuropathic pain (Class IIa)
Rehabilitation phase (4 weeks onward)
Physical therapy program
Passive and active-assisted ROM
Prevent shoulder contracture
Loss of mobility permanently affects outcome even if nerve recovers
Progressive strengthening
Rotator cuff, deltoid, and periscapular musculature
As reinnervation progresses
Functional activity retraining
Return to overhead activities
Sport-specific rehabilitation when applicable
Serial monitoring
Clinical assessment every 4 to 6 weeks
Motor function trends
Sensory recovery mapping
EMG/NCS at 12 weeks
Reinnervation evidence evaluation
Guides decision for surgical referral
Surgical management
Indications
No clinical or electrophysiologic recovery by 3 to 4 months
Class IIa recommendation based on expert consensus
Best outcomes when surgery performed within 3 to 6 months of injury
High-energy trauma or penetrating injury at presentation
Early exploration may be indicated
Suspected neurotmesis pattern
Surgical options
Neurolysis
For nerve-in-continuity lesions
Removes scar tissue compressing viable nerve
Nerve grafting
Sural nerve graft for nerve gaps
Average MRC grade 4.3 achieved in one series
Nerve transfer (triceps motor branch to axillary nerve)
Increasingly preferred technique
87.6% of isolated axillary nerve injury patients achieved MRC grade 3 or above
All patients regained 90 degrees or greater abduction in one series
Neurotization options
Triceps branch transfer: 80% success rate
Subscapular nerve transfer: 79% success rate
Fascicle transfer from ulnar or median nerve: 74% success rate
Data from 206-patient series
Factors affecting surgical outcome
Delay from injury to surgery (most important prognostic factor)
Earlier intervention improves outcomes
Beyond 6 months success rates decline
Patient age
Younger patients have greater regenerative capacity
Older age associated with poorer outcomes
BMI
Higher BMI associated with worse outcomes
Mechanism unclear but may relate to nerve length requirements
Brachial neuritis management
Parsonage-Turner syndrome
Corticosteroids
May reduce duration of acute pain phase
Evidence limited (Level C recommendation)
Prednisone 60 to 80 mg orally daily for 10 days then taper
Supportive care
Pain control priority in acute phase
Shoulder sling for comfort
Recovery typically over months
Special Populations
Pregnancy
Pregnancy-specific considerations
Mechanism differences
Axillary nerve injury less common as isolated traumatic event
Positioning-related stretch during labor or delivery rare but reported
Imaging approach
MRI without gadolinium preferred in first trimester
Gadolinium contraindicated in pregnancy unless benefits clearly outweigh risks
Medication safety
Acetaminophen preferred first-line analgesic
NSAIDs avoid after 20 weeks gestation
Gabapentin: FDA Category C, use with caution
Amitriptyline: relatively contraindicated in third trimester
Surgical timing
Defer elective nerve surgery until postpartum when possible
Emergency intervention for vascular injury proceeds regardless
Anesthesia risk-benefit discussion required
Geriatric
Age-related considerations
Higher incidence of nerve injury with glenohumeral dislocation
More common in patients 60 years and older
Associated with greater energy required for re-dislocation
Poorer nerve regeneration capacity
Recovery timeline extended
Lower rate of full functional recovery
Rotator cuff tear coexistence
Very high prevalence in older patients with dislocation
Both conditions may coexist and require separate investigation
Medication adjustments
Reduced acetaminophen maximum dose
3000 mg per day maximum in elderly
Lower if hepatic impairment
NSAIDs use caution
Renal impairment risk
GI bleeding risk
Cardiovascular risk
Gabapentin in elderly
Start at lower dose 100 mg at bedtime
Increased fall risk and sedation
Renal dose adjustment critical
Rehabilitation considerations
Aggressive early ROM to prevent contracture
Higher rate of adhesive capsulitis in elderly
Especially important given prolonged recovery
Functional goals focus
Activities of daily living prioritized
Return to pre-injury function as primary target
Pediatrics
Pediatric mechanism differences
Traumatic dislocation less common than adults
Requires higher energy in children due to bone elasticity
Growth plate injuries may accompany nerve injury
Birth-related axillary nerve injury
Occurs with brachial plexus birth palsy
Shoulder dystocia associated mechanism
Assessment adaptations
Age-appropriate motor testing
Play-based assessment in young children
Observation of spontaneous arm use
EMG tolerance
May require sedation in younger children
Coordinate with pediatric anesthesia when necessary
Weight-based medication dosing
Ibuprofen
5 to 10 mg per kg orally every 6 to 8 hours
Maximum 40 mg per kg per day
Acetaminophen
15 mg per kg orally every 4 to 6 hours
Maximum 75 mg per kg per day
Gabapentin in children 3 to 12 years
Starting dose 10 to 15 mg per kg per day in 3 divided doses
Titrate over 3 days to target dose
Recovery prognosis
Children generally have better nerve regeneration capacity than adults
More favorable prognosis for recovery
Longer follow-up required given ongoing growth
Birth palsy axillary nerve component
Recovery often observed in first 3 months
Early intervention if no spontaneous recovery by 3 months
Background
Epidemiology
Incidence and prevalence
Most common peripheral nerve injury of the shoulder
Axillary nerve most frequently injured nerve after glenohumeral dislocation
Reported incidence 5% to 65% after anterior shoulder dislocation depending on detection method
Glenohumeral dislocation association
Anterior dislocation accounts for 90% to 95% of all shoulder dislocations
Nerve injury frequency underdiagnosed due to clinical detection limitations
Iatrogenic incidence
Shoulder arthroplasty nerve injury rate 0.7% to 4%
Axillary nerve most commonly affected in arthroplasty series
Demographics and risk
Bimodal age distribution
Young athletes (contact sports) and older patients (low energy falls)
Older patients have higher nerve injury rate and worse recovery
Sex distribution
Male predominance in traumatic mechanism group
Sport-related injuries predominantly male
Recovery statistics
Majority recover with nonoperative treatment
20% to 30% of axonotmetic injuries may have incomplete recovery
Pathophysiology
Anatomic vulnerability
Axillary nerve origin
C5-C6 nerve roots
Posterior cord of brachial plexus
Quadrilateral space traversal
Bounded by teres minor superiorly, teres major inferiorly, long head triceps medially, surgical neck humerus laterally
Fixed anatomical tunnel creates compression risk
Surgical neck wrapping
Nerve wraps around surgical neck of humerus
Tethered position limits mobility during joint displacement
Injury mechanisms
Traction injury
Inferior humeral displacement stretches nerve
Most common mechanism in anterior dislocation
Direct contusion
Proximal humerus fracture fragment
Direct deltoid impact
Compression entrapment
Quadrilateral space syndrome
Fibrous bands or hypertrophied teres minor
Nerve injury spectrum
Neurapraxia
Focal demyelination without axonal loss
Conduction block resolves with remyelination
Axonotmesis
Axonal disruption with intact connective tissue framework
Wallerian degeneration distal to injury
Axonal regeneration at approximately 1 mm per day
Neurotmesis
Complete nerve disruption
No spontaneous functional recovery without surgical repair
Therapeutic Considerations
Conservative management rationale
Most injuries are neurapraxic or mild axonotmetic
Spontaneous recovery expected
No specific pharmacologic intervention accelerates nerve regeneration
Rehabilitation prevents secondary complications
Shoulder contracture is preventable
Muscle atrophy minimized with active engagement
Electrodiagnostic timing
EMG optimal after 3 to 4 weeks
Fibrillation potentials require this interval to appear
Early EMG may underestimate severity
Repeat at 12 weeks critical decision point
Reinnervation potentials guide surgical decision
Absence of voluntary MUAPs is concerning
Surgical decision framework
Time-sensitive intervention window
Surgical outcomes best within 3 to 6 months
Muscle fibrosis beyond this window reduces benefit
Nerve transfer advantages over grafting
Shorter reinnervation distance with triceps branch transfer
Avoids donor site morbidity of sural nerve harvest in selected cases
Evidence base
Nerve transfer achieves MRC 3 or above in approximately 88% of isolated cases
Sural nerve grafting achieves average MRC 4.3 in comparable series
Patient Discharge Instructions
copy discharge instructions
What happened and what to expect
Axillary nerve injury diagnosis explained
The nerve controlling shoulder muscles was injured
Most people recover with time and rehabilitation
Recovery timeline
Mild injuries recover within weeks to 3 months
More severe injuries may take 6 to 12 months
Regular follow-up appointments are essential to track recovery
Home care instructions
Sling use
Wear sling as directed for comfort
Remove for gentle exercises as instructed by physiotherapist
Medications
Take pain medications as prescribed
Complete any prescribed medication courses
Exercise instructions
Perform only exercises taught by physiotherapist
Gentle pendulum exercises help prevent shoulder stiffness
Do not lift heavy objects until cleared by your doctor
Warning signs to return to emergency
New or worsening weakness in the arm or hand
Inability to move fingers or elbow
Rapid change in function
Arm or hand becomes cool, pale, or blue
Blood vessel injury possible
Emergency assessment required immediately
Severe or uncontrolled pain not responding to medications
Do not wait until next clinic visit
Return to emergency department
Swelling of the arm that is rapidly increasing
May indicate vascular complication
Requires urgent evaluation
New numbness or tingling spreading beyond the shoulder
May indicate worsening injury
Document which areas are affected
Follow-up plan
Orthopedic or nerve specialist clinic
Appointment within 1 to 2 weeks
Bring any imaging results
Nerve conduction study and EMG
Scheduled approximately 4 weeks after injury
Important test to measure nerve function
Physiotherapy
Begin gentle ROM program as directed
Regular sessions to maintain shoulder mobility
Activity guidance
Driving restriction
Do not drive until adequate arm strength returns
Confirm with specialist before resuming
Work and sport
Light duties only until cleared
Contact sport return requires full strength and specialist clearance
References
Guidelines and key sources
Primary clinical guidelines
Perlmutter GS - Axillary Nerve Injury - Clinical Orthopaedics and Related Research 1999
Foundational reference for mechanism, diagnosis, and management
PMID 10613150
Steinmann SP, Moran EA - Axillary Nerve Injury Diagnosis and Treatment - JAAOS 2001
Comprehensive clinical management review
PMID 11575912
Hagert E, Hagert CG - Upper Extremity Nerve Entrapments Axillary and Radial Nerves - PRS 2014
Surgical anatomy and treatment options
PMID 24622568
Surgical outcomes evidence
Lee JY et al - Factors Affecting Outcome of Triceps Motor Branch Transfer - Journal of Hand Surgery 2012
Nerve transfer outcomes analysis
PMID 23044480
Baltzer HL et al - Comparison of Outcomes Triceps Motor Branch vs Sural Nerve Grafting - PRS 2016
Comparative surgical technique outcomes
PMID 27465187
Haninec P et al - Nerve Transfers for Axillary Nerve Repair - Journal of Neurosurgery Spine 2025
Largest series with 206 patients
PMID 40053939
Diagnostic studies
Bertelli JA, Ghizoni MF - Abduction in Internal Rotation Test - Journal of Hand Surgery 2011
Clinical test validation for axillary nerve palsy
PMID 22051233
Lui I et al - MRI Features of Axillary Nerve Injuries Following Glenohumeral Dislocation - Skeletal Radiology 2025
MRI diagnostic criteria
PMID 41145831
Lorente A et al - Nerve Injuries After Glenohumeral Dislocation Systematic Review - Journal of Clinical Medicine 2023
Incidence and risk factor review
PMID 37445581
Epidemiology and classification
Silver S et al - Peripheral Nerve Entrapment and Injury in the Upper Extremity - American Family Physician 2021
Clinical overview and epidemiology
PMID 33630556
Gutkowska O et al - Brachial Plexus Injury After Shoulder Dislocation Literature Review - Neurosurgical Review 2020
Brachial plexus context
PMID 29961154
Bateman EA et al - Assessment Management and Rehabilitation of Traumatic Peripheral Nerve Injuries - Muscle and Nerve 2025
Non-surgeon management reference
DOI 10.1002/mus.28185
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