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Axillary Neuropathy Cheat Sheet by

Presentation, management, etc

Axillary Nerve

- Posterior cord of the brachial plexus, anterior to the subsca­pularis muscle
- Travels inferior to the glenoh­umeral joint capsule
- Passes through quadra­ngular space
- Axillary nerve splits into anterior and posterior division
- Anterior division = motor innerv­ation to anterior and middle heads of deltoid
- Posterior division = motor innerv­ation to posterior deltoid and teres minor
- Terminates as the superior lateral cutaneous nerve (inner­vates lateral shoulder)
- C5-C6

Causes

- Skiiers, footba­llers, rugby, baseball, hockey, soccer, weight lifting, wrestling
- Chronic compre­ssion occurs in young adults who are overhead throwers
- Carrying a heavy backpack/ misuse of crutches
- Overde­veloped or hypert­rophic muscles forming quadra­ngular space
- Gangli­on/­par­alabral cyst
- More common in the dominant shoulder
- Brachial Neuritis (Parso­nag­e-T­urner Syndrome)
- Rare in isolation
- Older people with GH disloc­ation more predis­posed

Presen­tation

- Dull, poorly localises shoulder ache
- Can be after sporting event or blunt force to the shoulder (shoulder disloc­ation can be related to AN)
- Vague deltoid numbness or parast­hesia
- Sensory symptoms often worse at night
- Deltoid weakness may be present ( rapid fatigue with overhead throwing)
- Excaer­bated by arm abduction and external rotation
- Point tenderness of quadra­ngular space
- Weakness in abduction, external rotation
- Deltoid atrophy if chronic
- Assess for changes in limb (cyanosis, pallor, splinter haemor­rhages) for lesions pressing on posterior circumflex artery as it exits the quadra­ngular space (Quadr­angular space syndrome (QSS)
- Assess ipsila­teral neck and upper extremity
- Assess other nerves (Spinal accessory, supras­cap­ular, long thoracic, muscul­ocu­tan­eous, radial)

DDx

- Cx radicu­lopathy
- TOS
- Rotator cuff tear
- Brachial plexopathy
- QSS
- Brachial neuritis
- GH f#/dis­loc­ation
- Subacr­omial imping­ement syndrome
- Herpes Zoster

Imaging

- X-ray rule out bony pathology/ if trauma
- MRI to rule out lesions and look for atrophy of teres minor/­­de­ltoid
- EMG gold standard
- MRI if compre­­ss­i­v­e/­­inf­­la­m­m­atory causes

Management

Selective rest and modifi­cations
ROM exercises
Cross friction massage / myofascial release to muscles of quadra­ngular space
- GH mobili­sation
- Cross body and posterior capsule stretching
- Rotator cuff streng­thening
- Avoidance of positions that place axillary nerve in traction
- NSAIDs
- If failure to restore function in 3-6 months , consider surgical referral
- Traumatic cases can be managed non-su­rgi­cally (reduc­tion, immobi­lised for 4-6 weeks in the young and 7-10 days in the elderly then a rehab program - muscle strength and shoulder mobility) but there is a risk of permanent paralysis
-Neuro­praxic patients expect recovery within 6-12 months
- Axonot­mesis recovery is high, but can take many months, if no signs of recovery within 6-9 months, consider surgery
- Neurot­mesis patients should have surgery

Prognosis

- Low grade + GH disloc­ation recovery within 7 months
Compli­cat­ions: Permanent numbness to the lateral shoulder region, atrophy of the deltoid and teres minor muscles and chronic neurop­athic pain
 

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