Physiotherapy Theory and Practice, 26(7):490–496, 2010

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ISSN: 0959-3985 print/1532-5040 online
DOI: 10.3109/09593980903578872

CASE REPORT

Treatment of a brachial plexus injury using

kinesiotape and exercise
Sharon Fleming Walsh, PT, DSc, MA, PCS
The University of Findlay, Physical Therapy, Findlay, Ohio, USA, and Blanchard Valley Regional Health Center,
Findlay, Ohio, USA
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ABSTRACT
Purpose: This describes a child whose neonatal brachial plexus injury was treated with kinesiotape and exercise.
Description: The subject was a two-year-old female whose X-rays demonstrated severe inferior subluxation of the
humeral head and winging of the scapula on the left. She was fitted with a shoulder brace with surgery scheduled
in six months. The initial PT exam noted 80 degrees of shoulder abduction (trumpet sign), significant asymmetry,
and nonuse. Mallet score was 15/25. Treatment consisted of d/c of the brace and E-stimulation, parent education
on exercise and taping, and kinesiotape to facilitate rotator cuff and scapular stabilizers. Typical wear time was
2–3 days on, 1–2 days off. Outcomes: After 2 weeks, there was prominent deltoid definition. The shoulder was in
For personal use only.

20 degrees of abduction, shoulders level with less scapular winging. Scapular stabilizers were then taped.
At 4 weeks, her arm was held to her side displaying a stable symmetrical scapula. The arm displayed increased
fine motor use and initiation of activities. At 10 weeks there was a forced d/c, and a decline toward baseline levels.
After 2 weeks of reinstatement, function returned to prior level. At 20 weeks (12 total visits) she displayed full ROM,
symmetrical shoulders, Mallet score of 20/25, rare trumpet sign, and was hanging by arms during play. X-rays
displayed significant improvement in humeral head position, rib cage rotation, angle of scapula and clavicle, and
size and mineralization of humerus. Reconstructive surgery was cancelled. Discussion: Kinesiotape and parent
education made a significant difference in this child’s function.

INTRODUCTION plexus components (Dunham, 2003). Full recovery

rates are thought to be as high as 95% with conser-
Neonatal brachial plexus injuries are frequently seen in vative treatment (Malessy and Pondaag, 2009;
the physical therapy department with treatment most Pollack, Buckman, Yaffe, and Divon, 2000). How-
often beginning soon after birth (Basciani and Intiso, ever, if later monitoring of residual deficits are
2006; Malessy and Pondaag, 2009). Treatment ranges included, full recovery rates drop to 70%–80%
from periodic monitoring to neurosurgical repair (Malessy and Pondaag, 2009).
dependent upon the severity of the injury, the speed Recovery is very dependent on the severity of the
of spontaneous recovery, boney changes, and the age neural injury. A generally followed treatment strategy is
of the child (Yam, Fullilove, Sinis, and Fox, 2009). neurosurgical repair if antigravity deltoid and bicep
Neonatal brachial plexus injuries are noted in movement is not available by 2 months of age (Malessy
approximately 2 per 1,000 live births (Malessy and and Pondaag, 2009). Early surgery most often involves
Pondaag, 2009). The injury occurs at some point reconstruction of neural tissues, whereas secondary
during late pregnancy or the birth process due to a reconstruction often not done until 3 years of age or
pressure or a traction injury on any of the brachial older may involve muscle or tendon transfers or boney
osteotomies (Bain, Dematteo, Gjertsen, and Hallenberg,
2009; Dodds and Wolfe, 2000). Historically, muscles
Accepted for publication 22 November 2009.
associated with good long-term progression include
Address correspondence to Sharon Fleming Walsh, PT, DSc, MA, deltoid, triceps, biceps, and wrist extensors (Bain,
PCS, The University of Findlay, Physical Therapy, Findlay, OH, USA
and Blanchard Valley Regional Health Center, Findlay, OH, USA. Dematteo, Gjertsen, and Hollenberg, 2009; Noetzel,
E-mail: walsh@findlay.edu Park, Robinson, and Kanfman, 2001).

490
 Physiotherapy Theory and Practice 491

The last muscles to show sign of recovery are of flexible tape. Kinesio Tapes was selected for use in
typically the external rotators and supinators (Malessy this patient (KinesioTex Tape, Kinesio USA, LLC,
and Pondaag, 2009). Without these active muscles Albuquerque, NM). Kinesio Tapes was developed in
children often experience shoulder subluxation, Japan by Dr. Kenzo Kase (Kase, Martin, and
adduction and internal rotation contractures, and Yasukawa, 2006). It can be used for both muscle
resultant boney deformities. This greatly impacts relaxation and to facilitate muscle contraction
function as the typical daily demands on the upper depending on application. The theory is that by
extremities increases as the child matures. Thus, some applying the flexible taping from a muscle’s origin to
research has suggested that the external rotators and insertion that it will facilitate the muscle contraction.
supinators have the highest correlation with ultimate Because most of the evidence is anecdotal with very
long-term functional outcome (Hoeksma et al, 2004). low levels of evidence, it is difficult to determine the
Unfortunately, surgical reconstruction when these mechanism of action or its efficacy in different
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secondary complications arise has its own difficulties. populations. However, as clinicians are beginning to
Surgical reconstruction typically entails a 2- or 3-day see more and more clinical evidence of its use in
hospital stay and a shoulder spica/body brace for varying patient populations, research as to its
6–8 weeks (Bain, Gematteo, Gjertsen, and Hollenberg, effectiveness and use is increasing in the literature
2009; Dunham, 2003). Besides the pain of boney (Jaraczewska and Long, 2006; Thelen, Dauber, and
surgery and extensive medical costs, there is difficulty Stoneman, 2008; Yasukawa, Patel, and Sinsung, 2006;
with compliance in a young child and physical therapy is Yoshida and Kahanov, 2007).
still needed for 6 months after the brace is removed The purpose of the current case report is to describe
(Dunham, 2003). the treatment and subsequent progress of a 2-year-old
There is very little research examining conservative child whose brachial plexus injury was treated
treatment of obstetrical brachial plexus sequalae. successfully with Kinesio Tapes and exercise.
Basciani and Intiso (2006) studied 22 children treated
For personal use only.

with botulinum toxin and plaster casting. As a result,

active elbow range and upper extremity function was
significantly improved. In a case study, Gum (2003) was
able to display significant functional improvement when
a 27-month-old child was treated in physical therapy
with manual therapy, neuromuscular reeducation,
and therapeutic exercise. There has also been some
preliminary research indicating that threshold electrical
stimulation may show some promise (Kerr et al, 2006).
The Mallet system is a scale developed to objectively
evaluate the shoulder function of children after brachial
plexus injury (Bae, Waters, and Zurakoswki, 2003;
Gilbert, Razaboni, and Amar-Khodja, 1988). It uses a
scale of 1 to 5 with 5 being normal and 1 being no
movement. It was later modified to include internal
rotation (Gilbert, 1993) (Figure 1). Both interrater and
intrarater reliability has been demonstrated in children
with brachial plexus birth injury (Bae, Waters, and
Zurakowski, 2003). One of the components of the
Mallet system is the trumpet sign (Figure 1). When a
shoulder is subluxing, the individual will often seek a
position of comfort that holds the humerus in the
socket. This position is shoulder abduction when the
hands are in front of the body. This effectively shortens
the deltoid and gives it a better chance to work
appropriately. It is commonly a position used when an
individual plays the trumpet, thus its name, trumpet
sign (Bae, Waters, and Zurakowski, 2003; Gilbert,
1993; Gilbert, Razaboni, and Amar-Khodja, 1988).
Another treatment that has possibilities for positive
treatment of neonatal brachial plexus injuries is the use FIGURE 1 Mallet classification.

Physiotherapy Theory and Practice

 492 Walsh

Prior to the use of this case information, the neutral and supination to 458 from neutral. Her Mallet
patient’s mother received and signed an Informed score was 15/25.
Consent. IRB approval was received by both the
treating outpatient clinic and the local university where
the treating therapist was a full-time employee. There Diagnosis/prognosis
was no relationship between the author and the
manufacturer of Kinesio Tapes at any time before, The patient displayed signs and symptoms consistent
during, or after this report. with a diagnosis of 5F impaired peripheral nerve
integrity and muscle performance associated with
peripheral nerve injury. The associated ICD-9-CM
CASE DESCIPTION code was 767.6 birth trauma, injury to brachial plexus.
5F displays a prognosis of 4–8 months for optimal
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The patient was a 2-year-old female with a diagnosis of outcomes and a range of 12–56 patient visits. How-
brachial plexus birth injury. She presented at her local ever, this patient at 2 years of age was well beyond
outpatient rehabilitation facility with her mother. these parameters. The therapist determined the prog-
Referral from the physician stated, ‘‘Physical therapy nosis to be fair for increasing function due to the
evaluation and treat, electrical stimulation, range of strong support of the family, the engagement the child
motion, and exercise, return for surgical reconstruc- had with her surroundings, and her high level of
tion in 6 months.’’ communication skills. Limiting factors to her progres-
sion included the fear the child displayed for manip-
ulation of her involved upper extremity, her wariness of
History strangers, and the severity of her muscle weakness.

The child had been followed periodically at a large

For personal use only.

regional hospital and also received physical therapy Intervention

from an outpatient center closer to her home, until
1½ years of age. She had been discontinued from the Treatment at the local outpatient clinic consisted of
local physical therapy when she had reached her discontinuing use of the night resting brace because
functional goals and her progress plateaued for a
period of time. A follow-up at the regional hospital at
age 2, was considered successful until late in the
examination when x-rays demonstrated severe inferior
subluxation of the humeral head and severe winging of
the scapula. As a result, the child was fitted with a
nighttime brace to stretch shoulder internal rotators
and referred to physical therapy at her prior outpatient
center close to her home. Boney and soft tissue
reconstructive surgery was scheduled in 6 months.

Evaluation/examination

At the initial physical therapy examination the child

was observed to hold the involved shoulder in
approximately 808 of abduction (significant trumpet
sign), displayed significant asymmetry between sides,
severe winging of the involved scapula, used the arm
only as an assist, and always transferred objects to the
noninvolved hand for manipulation (Figure 2). She
was unable to catch a playground ball with both hands,
avoided weight bearing on the involved upper extre-
mity, and could not engage in playground activities
that required climbing and support of her body weight
through the involved upper extremity. Her range of
motion was limited to 108 of external rotation from FIGURE 2 Scapular winging.

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 Physiotherapy Theory and Practice 493

the child was not sleeping, and her family could no the patient’s illness. Taping began again and continued
longer deal with her crying throughout the night. through 20 total weeks of taping prior to her return for
Electrical stimulation was also discontinued because evaluation by the surgical staff.
the child refused to comply with any handling or
external devices. The primary therapist then began
active treatment with parent education. The patient
OUTCOMES
underwent a short, 3- to 4-day trial of a very small
piece of tape to ensure no allergic reaction would occur
After 2 weeks of taping (4 visits), there was significant
and to assess patient compliance. The parent was
progress. The deltoid muscle definition was promi-
taught how to apply the tape, the position of the tape,
nent. The child typically held her shoulder in
and instructed in play activities that would facilitate
approximately 208 of abduction during play. Her
shoulder external rotation, weight bearing through the
shoulders were level and her scapula was displaying
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involved shoulder, and two-handed activities. The

less winging.
parent was instructed to encourage the exercise as part
At this point the tape was then added for scapular
of play and avoid mandatory forcing of any activity.
stabilizers, At the end of 4 weeks of taping (6 visits),
The tape was placed in such a way to facilitate rotator
her involved arm was held to her side similar to her
cuff function. This was accomplished by placing one
uninvolved arm during play. She used the involved arm
piece of tape from the origin to the insertion of the
to initiate activities, no longer routinely transferred
deltoid and stretching the tape slightly before applica-
objects to the uninvolved arm, and displayed increased
tion. Primary placement was over the middle, anterior,
fine motor use with the involved hand such as picking
and posterior segment of the involved deltoid muscle.
up and using markers on an easel, turning pages in a
After the parent became proficient in positioning and
book, and putting large pegs in a board. The child’s
applying the tape, the parent was responsible for tape
involved arm also displayed a very stable scapula on the
rest days and reapplication of the tape throughout the
For personal use only.

thoracic spine with negligible asymmetry (Figure 4).

week. The tape was typically left on for 2–3 days with a
At week 10 when taping needed to be discontinued due
1- 2-day break before reapplying. The average weekly
to the child’s illness she began to decline to baseline
wear time was 4–5 days/week.
levels, losing approximately 30% of her progress by
At 2 weeks, taping was modified to include the
the time she returned to therapy 3 weeks later. After
scapular stabilizers. A second piece of tape was added
2 weeks of therapy reinstatement, her function returned
from the medial border of the scapula, just distal to the
to the prior noted level. Also, at this time due to
spinous process, to the insertion of the deltoid (Figure 3).
skin irritation, a thin coat of Milk of Magnesia was
At 10 weeks of treatment (9 total patient visits) there
placed on the skin and allowed to dry prior to every
was a forced 3-week discontinuation of taping due to
tape application.
After 20 weeks of taping (12 total patient visits) the
child displayed full range of motion, a Mallet score of
20/25, and an extremely rare trumpet sign. She was
able to support her body weight through her bilateral
upper extremities during play both in weight bearing
and hanging by playground equipment, catch a

FIGURE 3 Taping at 2 weeks. FIGURE 4 Increased use of upper extremity at 4 weeks.

Physiotherapy Theory and Practice

 494 Walsh
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FIGURE 6 Improved symmetry at 20 weeks.

For personal use only.

FIGURE 5 Improved symmetry at 20 weeks. FIGURE 7 Uninvolved upper extremity pretreatment with
patient in supine position.
playground ball when thrown to her with two hands,
and asymmetry was almost impossible to detect to losing the gained skills, and when the changes to
(Figures 5 and 6). the patient’s functional skills were permanent. The
The patient returned to the regional hospital for parent and family were elated as to the improvement
evaluation and preparation for surgery. X-rays as in their child’s function and the avoidance of surgical
compared to those taken just prior to the initial exami- intervention.
nation, displayed significant improvement in humeral Taping continued to be applied by the parent with
head position, rib cage rotation, angle of scapula a decreasing number of days per week for the next
and clavicle, and size and mineralization of the humerus 4 months. The child only came into therapy 1x/month
(Figures 7, 8, and 9). Note that Figures 7 and 8 were during this time for a quick recheck. A total of 40 weeks
taken in supine, whereas Figure 9 was taken in stand- of taping had occurred by this point. The last month of
ing. As a result of the significant change in x-rays taping, tape was only applied 1 day per week and was
and the large change in functional skills, reconstructive then discontinued. A phone interview to the parent
surgery was cancelled. 6 months after the tape was discontinued confirmed
Physical therapy continued, while efforts were made the improvements had maintained over that time. The
to determine how long the patient needed to wear the child’s activity levels and use of the involved upper
tape, how long breaks from the tape could last prior extremity continued with no decrease in use or skills.

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 Physiotherapy Theory and Practice 495

There are many issues involved in this case but one

of primary importance is patient compliance. When
treating children the whole family is the patient and
must be considered when treatment decisions are
made. In this case, the severe bracing to stretch
shoulder internal rotators was an unwise choice for this
young child and her family. It is difficult to stretch
shoulder internal rotators when the humerus is
subluxed. Subluxation in this child’s case limited the
amount of available external rotation range. Because of
the child’s fear and discomfort she was very upset and
was unable to move within the brace. Within a few
Physiother Theory Pract Downloaded from informahealthcare.com by University of Montreal on 12/01/14

minutes of donning the brace, the humeral head

subluxed, preventing any positive impact of the
brace. The family made considerable effort to
comply with its use, but after 4 weeks the child still
had to be restrained to apply the brace and cried
throughout the night for hours. This was very
disruptive for the family and led to the decision to
discontinue its use.
FIGURE 8 Involved upper extremity pretreatment with patient The child also refused several trials of electrical
in supine position. stimulation and was very resistant to any passive
handling by individuals other than her family. The use
of kinesiotape appeared to give the child some control.
For personal use only.

She was a very bright and verbal child. As a result, an

explanation of what was being done and why, was
shared with her in an age-appropriate manner. The
tape appeared to facilitate muscular seating of the
humeral head in an appropriate position. This coupled
with play activities to facilitate range and use of the
involved arm led to a successful outcome.
Also of note was that not only the rotator cuff
musculature was taped. After initial changes to the
deltoid and rotator cuff muscles were apparent, taping
to facilitate stabilization of the scapula on the thoracic
spine was initiated. Scapular stabilization is impera-
tive for appropriate shoulder biomechanics (Buchler
et al, 2002).
The significant boney changes seen in this case were
a result that was unexpected during the short time
frame. The author can only theorize that the increased
use and weight-bearing activities that frequently
FIGURE 9 Involved upper extremity posttreatment with patient occurred contributed to these very positive changes
in standing position. on x-ray.
The savings in health care costs was also a signi-
ficant issue. The cost of this treatment including the
Discussion cost of tape was under $2,500. This is only a fraction
of the cost that could be anticipated with a recons-
This child displayed significant functional change with tructive surgery, 2- to 3-day hospital stay, physician
conservative physical therapy over 5 months. Signifi- follow-up, casting/bracing, and 6 months of physical
cant boney improvements were also made during this therapy that is common for this type of reconstructive
time. Treatment costs were minimal, consisting of the surgery (Dunham, 2003).
cost of tape and 12 physical therapy visits of 30–45 There was no doubt that parent compliance was a
minutes each. Follow up visits 1x/month over the next very positive component that contributed to the
4 months were approximately 15–20 minutes each. success of this program. After the traumatic trial of

Physiotherapy Theory and Practice

 496 Walsh

bracing, the parent was very willing to be an active Basciani M, Intiso D 2006 Botulinum toxin type-A and plaster cast
participant and decision maker. In this case, the treatment in children with upper brachial plexus palsy. Pediatric
therapist acted primarily as an educator and facili- Rehabilitation 9: 165–170
Buchler P, Ramaniraka N, Rakotomanana L, Iannotti J, Farron A
tator. Decisions were made as a team consisting of 2002 A finite element model of the shoulder: Application to the
the therapist, parent, and child. In addition, after comparison of normal and osteoarthritic joints. Clinical
it became easier for the child to use the involved arm, Biomechanics 17: 630–639
her very active play and exploration of her environ- Dodds SD, Wolfe SW 2000 Perinatal brachial plexus palsy. Pediatric
ment provided all the exercise necessary. Physical Therapy 11: 202–209
Dunham EA 2003 Obstetrical brachial plexus palsy. Orthopaedic
It is possible that the child could have shown Nursing 22: 106–116
improvement with exercise alone. However, the child Gilbert A, Razaboni R, Amar-Khodja S 1988 Indications and results
had plateaued in progress for approximately 1 year of brachial plexus surgery in obstetrical palsy. Orthopedic Clinics
prior to the start of this detailed episode of care. of North America 19: 91–105l
Gilbert A. 1993 Obstetrical brachial plexus palsy. InTubiana R (ed),
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The taping appeared to be just the assist she needed

The Hand, vol 4, p 579. Philadelphia, WB Saunders
to allow normal play to facilitate muscular and boney Gum C 2003 Physical therapy management of the musculoskeletal
change. sequel from an obstetrical brachial plexus injury that did not
Because every child with neonatal brachial plexus spontaneously resolve. Abstract from Physical Therapy 2003
injury is different both in the degree and manner of National Conference PL-RR-171-F
injury, it is difficult to generalize these results to the Hoeksma AF, ter Steeg AM, Nelissen RGHH, van Ouwerkerk WJR,
Lankhorst GJ, de Jong BA 2004 Neurological recovery in
entire population of children with neonatal brachial obstetric injuries: An historical cohort study. Developmental
plexus injuries. Therefore, further study with larger Medicine and Child Neurology 46: 76–83
sample sizes and standardized protocols would be Jaraczewska E, Long C 2006 Kinesio taping in stroke: Improving
extremely beneficial. In addition, exploration of when functional use of the upper extremity in hemiplegia. Topics in
taping is most helpful in the course of the diagnosis Stroke Rehabilitation 13: 31
Kase K, Martin P, Yasukawa A 2006 Kinesio Taping in Pediatrics.
and determining how long taping must continue before
For personal use only.

Tokyo, Kinesio USA, LLC

change is permanent, would also add important infor- Kerr C, McDowell B, Cosgrove A, Walsh D, Bradbury I,
mation regarding this treatment. McDonough S 2006 Electrical stimulation in cerebral palsy:
The use of Kinesio Tapes and exercise in the A randomized controlled trial. Developmental Medicine and
treatment of this case appeared to facilitate significant Child Neurology 48: 870–876
Noetzel MJ, Park TS, Robinson S, Kanfman B 2001 Prospective
functional, muscular, and boney changes. It did so
study of recovery following neonatal brachial plexus injury.
with little trauma to the family and minimal cost. Journal of Child Neurology 16: 488–493
This treatment shows considerable promise in the Malessy MJ, Pondaag W 2009 Obstetric brachial plexus injuries.
habilitation of children with neonatal brachial plexus Neurosurgical Clinics of North America 20: 1–14
injuries. Pollack RN, Buchman AS, Yaffe H, Divon MY 2000 Obstetrical
brachial plexus palsy: Pathogenesis, risk factors, and prevention.
Declaration of Interest: The authors report no Clinical Obstetrics and Gynecology 43: 236–246
conflicts of interest. The authors alone are responsible Thelen MD, Dauber JA, Stoneman PD 2008 The clinical efficacy of
Kinesio Tape for shoulder pain: A randomized, double-blinded,
for the content and writing of the article.
clinical trial. Journal of Orthopedic Sports Physical Therapy 38:
389–395
Yam A, Fullilove S, Sinis M, Fox M 2009 The supination deformity
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