When a baby’s network of nerves in the shoulder and arm is injured during birth, families face uncertainty about movement, sensation, and the child’s future abilities. While many infants recover on their own, others need specialized care to regain arm function and prevent long-term complications.

Helping Babies Move Again After Birth Nerve Injury

When a baby comes into the world, the birth process can sometimes be more complicated than expected. During difficult deliveries, a group of nerves called the brachial plexus — which runs from the neck through the shoulder and into the arm — can be stretched, squeezed, or even torn. This network of nerves is responsible for sending signals between the spinal cord and the arm, controlling everything from shoulder movement to finger sensation. When these nerves are damaged, the result is a condition known as brachial plexus birth injury, which affects approximately one to three out of every 1,000 births.^[1]

The goal of treatment is not just to restore movement, but to help children develop as normally as possible. Treatment decisions depend heavily on how severe the nerve damage is, which specific nerves are affected, and how the baby responds in the first few months of life. Some babies will move their arm freely within weeks, while others may need years of therapy or even surgery. Medical teams focus on preventing complications like muscle tightness, joint stiffness, and bone deformities that can develop if the arm stays immobile for too long.^[4]

The treatment landscape includes both established methods that have been used for decades and newer approaches being explored in specialized centers. Understanding what options exist can help families navigate this challenging time with greater confidence. Treatment is not one-size-fits-all — it must be tailored to each child’s unique pattern of nerve injury, their rate of recovery, and their family’s ability to participate in ongoing care at home.

Physical Therapy: The Foundation of Recovery

Physical therapy forms the cornerstone of treatment for nearly all babies with brachial plexus birth injury. This approach begins remarkably early — often when a baby is just three weeks old — and continues for months or even years, depending on how the child progresses. The primary purpose of therapy is to keep joints flexible and prevent muscles from becoming permanently shortened or contracted while waiting for damaged nerves to heal and reconnect with muscles.^[1]

Parents play an essential role in this process. Physical therapists teach families specific exercises and gentle movements to perform at home multiple times each day. These exercises involve carefully moving the baby’s shoulder, elbow, wrist, and fingers through their full range of motion. The movements must be gentle enough not to cause pain, yet consistent enough to prevent the joints from becoming stiff. Massage techniques and stretching routines are also incorporated to maintain muscle flexibility and promote blood flow to affected areas.^[2]

In many cases, occupational therapy joins physical therapy as part of the treatment plan. Occupational therapists focus specifically on helping children develop skills for daily activities, such as reaching, grasping, and manipulating objects. As the child grows, therapy sessions evolve to address age-appropriate developmental milestones. For instance, a therapist might work with a toddler on tasks like holding a spoon, stacking blocks, or putting on clothing — activities that require coordination between both arms.^[2]

The duration of therapy varies widely. Most babies who will recover fully do so within the first three to four months of life. However, children who show incomplete recovery by three months often continue with therapy for much longer periods. Regular assessments by specialists help determine whether the current therapy approach is sufficient or if additional interventions might be needed.^[7]

Non-Surgical Medical Interventions

Beyond physical manipulation and exercise, some children benefit from additional non-surgical treatments designed to address specific problems that arise as nerves slowly heal. One such intervention involves the use of botulinum toxin injections, commonly known by the brand name Botox. This might sound surprising for infant treatment, but it serves an important purpose when certain muscles become too strong relative to their opposing muscles.^[16]

When nerve damage is uneven, some muscles may begin recovering and strengthening before others. This imbalance can pull joints into abnormal positions and interfere with proper development. Botulinum toxin works by temporarily weakening the overly strong muscle, giving the weaker opposing muscles a chance to catch up through targeted strengthening exercises. The medication wears off after three to four months, during which time therapists work intensively to build up the weaker muscles. This approach is particularly useful for shoulder and elbow muscle imbalances.^[16]

Splinting represents another non-surgical option. Custom-made splints or orthoses help position the wrist and hand correctly when muscles are too weak to maintain proper alignment on their own. These devices prevent the hand from dropping into awkward positions that could interfere with function or lead to permanent deformity. Splints are typically worn part-time — often at night or during rest periods — rather than continuously, allowing the child freedom to move and practice using their arm during waking hours.^[16]

Some treatment centers also employ therapeutic taping techniques. This involves applying specialized tape to the skin in patterns designed to provide gentle support to weak muscles or to encourage specific movement patterns. Unlike rigid splints, taping allows more natural movement while still providing some assistance and positioning guidance.^[16]

Surgical Interventions: When and Why

Surgery becomes a consideration when nerve recovery is inadequate despite months of dedicated therapy. The decision about whether to operate, and when to do so, is one of the most challenging aspects of managing brachial plexus birth injuries. Medical teams use careful observation, repeated physical examinations, and sometimes specialized tests to determine if a child’s nerves are healing on their own or if surgical intervention will be necessary.^[8]

The timing of surgery is critical. If nerves are completely torn or pulled away from the spinal cord, they cannot repair themselves, and waiting too long can result in permanent loss of function. Muscles that remain disconnected from nerves for more than 18 months typically weaken to the point where they may never work properly again, even if nerve connections are eventually restored. Therefore, most decisions about primary nerve surgery are made between three and nine months of age — early enough to maximize recovery potential but late enough to avoid operating on babies who might recover spontaneously.^[7]

Nerve grafting is one type of surgical procedure used to repair damaged nerves. When a nerve is torn but the tear occurs away from the spinal cord, surgeons can sometimes remove the damaged section and replace it with a piece of nerve taken from elsewhere in the body — often from the leg. This nerve graft acts as a bridge, providing a pathway along which nerve fibers can slowly regrow from the healthy nerve stump toward the muscles. The process of nerve regrowth is extremely slow, typically progressing at about one millimeter per day.^[8]

Nerve transfers represent a more complex surgical approach. When nerve roots are torn away from the spinal cord — a particularly severe type of injury called an avulsion — direct repair is impossible. In these cases, surgeons redirect functioning nerves from nearby areas to take over the job of the damaged nerves. For example, a nerve that normally controls a less critical function might be rerouted to power the biceps muscle, allowing elbow bending to be restored even though the original nerve connection was lost. The brain must eventually learn to use these rewired pathways, which can take considerable time and rehabilitation.^[8]

As children grow older, additional surgical procedures may be needed to address secondary problems that develop from incomplete nerve recovery. Muscle transfers involve moving a functioning muscle from one position to another to restore lost movement. Tendon transfers reroute the attachment point of a working muscle to compensate for a paralyzed one. Osteotomies — surgical cuts in bones — can correct skeletal deformities that develop when muscles pull unevenly on growing bones. These procedures are typically performed in older children after the extent of permanent damage becomes clear.^[16]

Diagnostic Tools That Guide Treatment Decisions

Determining the severity of nerve damage and whether recovery is occurring requires more than just watching how a baby moves. While physical examination remains the most important assessment tool — with doctors observing which movements the baby can perform and testing muscle strength at various joints — additional diagnostic tests provide valuable information in certain situations.^[2]

X-rays are often the first imaging test performed, though they don’t show nerves themselves. Instead, x-rays help rule out other birth injuries that might cause similar symptoms, such as a broken collarbone or fractured humerus (upper arm bone). These bone injuries can cause a baby to hold their arm still because of pain — a condition called pseudoparalysis — which can initially be confused with nerve damage. Unlike true nerve injury, pseudoparalysis resolves once the fracture heals, typically within a few weeks.^[7]

Magnetic resonance imaging (MRI) provides detailed pictures of soft tissues, including nerves. Specialized MRI techniques can sometimes show where nerve damage is located and whether nerve roots have been torn away from the spinal cord. However, MRI has limitations in newborns because the images can be difficult to interpret in very young infants, and the procedure requires the baby to lie completely still, often necessitating sedation.^[2]

Nerve conduction studies and electromyography (EMG) measure electrical activity in nerves and muscles. These tests can help determine whether nerve signals are reaching muscles and whether muscles are beginning to respond. However, these electrical studies are most useful in older infants and children, as results in newborns can be difficult to interpret. Many centers reserve these tests for cases where the clinical picture is unclear or when surgical planning requires additional information.^[2]

Perhaps the most powerful diagnostic tool is serial physical examination by experienced specialists. By examining a baby at regular intervals — typically monthly during the first critical months — doctors can track which muscles are beginning to show signs of recovery and which remain unresponsive. Standardized scoring systems help quantify improvement over time and identify infants whose recovery is lagging behind expected patterns, potentially indicating the need for surgical intervention.^[4]

Emerging Approaches and Ongoing Research

While the treatments described above represent standard care supported by medical evidence, research continues into ways to improve outcomes for children with brachial plexus birth injuries. Understanding that what works today may evolve as new evidence emerges is important for families and healthcare providers alike.

Some research centers are exploring the optimal timing for different types of surgical interventions. Questions remain about which babies benefit most from early surgery versus extended observation, and whether certain nerve repair techniques produce better outcomes than others. Clinical studies compare different surgical approaches — such as nerve grafting versus nerve transfer — to determine which methods restore the most function for specific injury patterns. These investigations typically involve careful tracking of children over many years to assess long-term results.^[8]

Researchers are also studying techniques to enhance nerve regeneration after surgical repair. While nerves can regrow after injury, the process is slow and often incomplete. Some experimental approaches investigate whether certain biological substances or growth factors might speed nerve regrowth or improve the quality of nerve regeneration. These studies are in early stages and not yet part of routine clinical care, but they represent potential future directions for improving treatment outcomes.

Advanced imaging techniques are being refined to better visualize nerve damage in young infants. Improved imaging could help identify which babies need surgery sooner and with greater certainty, potentially reducing the current period of watchful waiting. Similarly, better diagnostic tools might help predict which specific surgical approach would work best for an individual child’s pattern of nerve injury.

Some specialized centers are examining the role of intensive therapy protocols, exploring whether more frequent or longer therapy sessions during critical developmental windows might improve outcomes. Others are investigating complementary approaches such as aquatic therapy, where the buoyancy of water allows babies to practice movements that might be too difficult against gravity. While these approaches show promise, additional research is needed to determine their effectiveness.^[16]

Most common treatment methods

• Physical and occupational therapy
  • Range-of-motion exercises started at three weeks of age to prevent joint stiffness and muscle contracture
  • Gentle stretching and massage techniques performed by parents multiple times daily at home
  • Age-appropriate developmental activities to promote functional use of the affected arm
  • Therapeutic exercises to strengthen recovering muscles as nerve function returns
• Botulinum toxin injection therapy
  • Temporary weakening of overly strong muscles to balance muscle forces at joints
  • Most commonly used for shoulder and elbow muscle imbalances
  • Effects last three to four months, during which intensive therapy strengthens weaker muscles
  • Can prevent abnormal joint positioning and development of permanent deformities
• Splinting and orthotic devices
  • Custom-made devices to support and position the wrist and hand properly
  • Typically worn part-time, especially during sleep periods
  • Prevent drop-wrist or other positioning problems in weak limbs
  • Allow freedom of movement during therapy and active play periods
• Nerve reconstruction surgery
  • Nerve grafting to bridge torn nerve segments using donor nerve tissue
  • Nerve transfers to reroute functioning nerves to replace permanently damaged ones
  • Typically performed between three and nine months of age for optimal results
  • Requires months to years of post-surgical therapy for maximum recovery
• Secondary surgical procedures
  • Muscle and tendon transfers to restore specific lost movements
  • Osteotomies (bone cuts) to correct skeletal deformities from unbalanced muscle pull
  • Usually performed in older children after permanent deficits become clear
  • Address functional limitations and improve appearance of affected limb