Erb's Palsy Symptoms
Erb's palsy symptoms affect controlling movement and sensation in a child's shoulder and arm. When brachial plexus nerves are stretched, torn, or pulled away from the spinal cord, the result can be weakness, limited motion, or even paralysis in the affected arm. Learn how to recognize the symptoms of Erb's palsy.
What Are the Most Common Signs and Symptoms of Erb's Palsy?
Erb's palsy is caused when the brachial plexus nerves from the spine to the arm are injured during childbirth. This damage can cause a variety of symptoms affecting multiple areas of the body, including the shoulder, neck, arm, hand, and fingers.
Early Erb's Palsy Symptoms in Babies
For many babies, the first signs of Erb's palsy are visible shortly after birth. Parents may notice that one arm doesn't move like the other or that their baby seems uncomfortable when the arm is touched or lifted. Since newborns can't tell you what hurts, small differences in movement or posture can give parents important clues.
Common early signs of Erb's palsy include:
- One arm hangs limp or doesn't move as much as the other
- The affected arm stays close to the body and is rotated inward (often called the waiter's tip" position)
- The baby does not lift the shoulder or bend the elbow on the affected side
- The hand and fingers may move and wiggle, but the shoulder and elbow are weak or still
- Uneven startle (Moro) reflex; only one arm lifts when the baby is startled or picked up
If you notice that your baby rarely uses one arm, avoids moving it during diaper changes, or cries when it is moved, it can be an early sign of a brachial plexus injury or Erb's palsy.
How Does Erb's Palsy Change the Way an Arm Looks or Moves?
Waiter's Tip Position
One of the most recognizable symptoms of Erb's palsy is the way the arm rests. The affected arm may hang at the baby's side with the shoulder turned inward, the elbow straight, and the forearm rotated in with the palm facing backward. This is often called the "waiter's tip" position.
The "waiter's tip" position posture happens because some muscles are weak or paralyzed, while others are still pulling strongly, which creates an imbalance.
Weakness and Limited Movement
Children with Erb's palsy often have:
- Difficulty lifting the arm away from the body
- Trouble bending the elbow to bring the hand toward the mouth
- Poor ability to rotate the arm outward (for example, turning the palm up)
- Less use of the affected arm during play, reaching, or rolling
Parents may notice their baby always reaching with the same hand, leaning their body to compensate, or ignoring toys placed on the weaker side.
Sensory Symptoms
Not every child with Erb's palsy has obvious pain, but nerve injuries can affect sensation and movement.
Some sensory changes parents may notice in their baby are:
- Increased fussiness or crying when the affected arm is touched, dressed, or moved
- Pulling away, grimacing, or stiffening when the limb is handled
- Less response to gentle touch, tickling, or temperature changes on the affected arm compared to the other side
As children grow older, they might describe the arm as:
- "Tingly", "numb", or "asleep"
- Achy after activity or at the end of the day
- Sensitive to touch, stretching, or certain positions
How Do Erb's Palsy Symptoms Show Up in Daily Life?
Symptoms are often easiest to recognize when you look at what a child can or cannot do during daily routines. Families may first notice differences in how their baby reaches for toys, holds a bottle, or pushes up during tummy time.
Red Flags in Babies and Toddlers
- Not bearing weight on the affected arm when crawling or pushing up
- Always rolling or turning toward one side to avoid using the weaker arm
- Difficulty holding a bottle, toys, or finger foods with both hands together
- Trouble dressing the affected arm, such as threading it into sleeves
Red Flags in Preschool and School-Aged Children
Difficulty with tasks that require two hands, such as:
- Zipping jackets
- Buttoning shirts
- Tying shoelaces
- Carrying books or backpacks
Other challenges such as:
- Avoiding playground activities that require climbing, hanging, or catching
- Using the stronger arm to do almost everything, while the affected arm "comes along for the ride"
Over time, strength, coordination, and confidence can be affected if they are not addressed with therapy and support. It's important for parents and caregivers to recognize the signs early on so that their child gets the best treatment and support as soon as possible.
What Are the Differences Between Mild and Severe Erb's Palsy Symptoms?
In most mild cases of Erb's palsy, the nerves are stretched but not torn. These babies often have good potential for recovery, especially with early therapy and close monitoring. In more severe cases, symptoms and long-term effects can linger but are often managed with physical and occupational therapy.
The tables below show the differences between mild and severe symptoms of Erb's palsy:
Mild Symptoms (Stretch Injuries and Neurapraxia)
- Slight weakness in the affected arm - The arm may move, but not as strongly or smoothly as the other side.
- Subtle differences in movement quality - Your baby might lift the arm more slowly or have trouble fully bending the elbow or lifting the arm up to shoulder height.
- Mild "waiter's tip" positioning - The arm may rest with the palm turned inward or the elbow slightly straightened, but you still see some active motion.
- Decreased but present reflexes - The Moro (startle) reflex on the affected side may be weaker but not completely absent.
- Minimal differences in arm size - Over time, the affected arm might appear slightly smaller or less muscular, although the differences can be subtle.
Families will often notice that their baby “uses one arm more than the other,” especially during feeding, reaching for toys, or pushing up during tummy time. In many mild cases, symptoms gradually improve over the first several months with stretching, positioning, and physical or occupational therapy.
Severe Symptoms (Rupture and Avulsion Injuries)
- Little to no movement in the arm - The arm may hang at your baby's side with almost no active motion at the shoulder, elbow, or hand.
- Pronounced "waiter's tip" posture - The arm is rotated inward, the elbow is straight, and the wrist may be flexed, with very limited ability to change this position.
- No reflexes on the affected side - The Moro and other newborn reflexes may be completely missing in the injured arm.
- Weakness or paralysis - Your baby may be unable to bend the elbow, lift the arm, or grasp objects, even as they get older.
- Significant asymmetry over time - As your child grows, the injured arm may look noticeably shorter, thinner, or smaller. This is due to muscle atrophy and abnormal growth patterns.
- Early joint and shoulder problems - Stiffness, contractures, shoulder dislocation, and even joint deformities are more common if nerve function does not return.
Even in severe cases, early therapy, bracing, and guidance from a brachial plexus specialist can make a big difference in your child's comfort, mobility, and independence as they grow.
If little or no improvement is seen within the first 3 to 6 months, specialists may recommend nerve grafts, nerve transfers, or other surgical procedures to restore function and prevent long-term complications.
How Can I Tell if My Child Has Erb's Palsy?
While all babies have times when they seem sleepy or less active, understanding the difference between "just being a little weak" and Erb's palsy is important.
The key signs of Erb's palsy include:
- Weakness is limited to one arm and shoulder, not the whole body
- The same abnormal posture (like the waiter's tip position) shows up repeatedly
- Consistently avoids using the affected arm, even when excited or reaching for something they have a strong interest in
- Reflexes, muscle tone, and responses to touch are clearly different between sides
You should contact your child's doctor if you notice any of these signs, as they may indicate possible injury from Erb's palsy:
- No movement in one arm within the first 24–48 hours after birth
- A persistent “hanging” arm or “waiter’s tip” position
- Asymmetrical startle reflex (one arm moves, the other doesn’t)
- Ongoing fussiness or crying when the arm is moved or dressed
- Little to no improvement in arm movement over the first few weeks
Signs of Erb's palsy during childbirth:
- If your baby's birth weight was over 8 lbs 13 oz (macrosomia)
- You had a prolonged or difficult delivery
- Your child had a breech delivery (feet-first position)
- The delivery team used vacuum extractors or forceps
- Your child was stuck in the birth canal
Early referral to specialists such as pediatric neurologists, orthopedists, or brachial plexus clinicians is crucial to improve your child's function. In many cases physical therapy can start in the first month of life.
If therapy alone isn't enough, nerve specialists can determine whether surgery may be needed to improve recovery and increase mobility.
What Are the Long-Term Effects of Erb's Palsy?
Many children with Erb's palsy have full recoveries, especially if the nerve injury is mild and treated early. In fact:
According to an NIH study, 80-96% of babies with Erb's palsy will make a full recovery within the first year of life. Additionally, nearly 100% of children who are diagnosed make a full recovery if recovery starts within the first 4 weeks of birth.
However, in cases where nerve damage is more severe or treatment is delayed, long-term symptoms can potentially develop, such as:
Contractures: Muscles and soft tissues around the shoulder, elbow, or wrist can tighten and become stiff over time. This makes it hard to move the joint through its full range. Without stretching and therapy, contractures can make simple daily tasks like getting dressed, reaching a shelf, or combing their hair more difficult.
Muscle Atrophy: When a muscle is not used fully, it can become smaller and weaker and the affected arm may look thinner or less muscular than the other side. Muscle atrophy also makes the difference between arms more visible as a child grows.
Abnormal Limb Growth: Reduced nerve input and limited use can slow growth in the injured arm and it may appear shorter, with a smaller hand or thinner bones compared to the other side. Over time, the body might compensate with trunk leaning or neck tilting, creating secondary strain. Limited motion can interfere with sports, self-care (like washing hair), and participation in school activities.
Shoulder Instability and Joint Deformity: Due to weak or imbalanced muscles, the shoulder joint might sit out of its normal position. Children may feel or sense that the shoulder is not secure during movement. In more severe cases, the shape of the shoulder socket and upper arm bone can change, possibly requiring orthopedic surgery to improve alignment.
Chronic Pain and Fatigue: Some children develop ongoing discomfort in the neck, shoulder, and upper back from overuse of certain muscles. Pain may also increase after participating in sports, therapy, or after a long day of activity. Fatigue and pain can also affect sleep, mood, and social participation.
Emotional and Social Effects: Visible differences in arm size or movement can impact self-esteem and confidence later in childhood or adolescence. Children may avoid wearing short sleeves, doing certain sports, or taking photos due to feeling self-conscious. Having supportive conversations, counseling, and inclusive activities can help reduce emotional burdens and encourage social participation.
Luckily, the majority of children with Erb's palsy make a full recovery, and those who have more severe injuries can improve symptoms with ongoing therapy and treatment.
How Do I Help My Child with Erb's Palsy?
Parents play a powerful role in supporting their child's recovery and preventing complications. Most care plans include a combination of help from professional physical therapists and gentle, guided home activities.
Things parents can do at home (under a therapist's guidance) may include:
- Gentle daily stretching to maintain range of motion in the shoulder and elbow
- Positioning your baby so that both of their arms are encouraged to participate in play
- Incorporating the affected arm into feeding, toy play, and reaching tasks
- Watching for signs of pain or resistance and reporting them to your care team
The goal is not to force movement but to create safe, frequent opportunities for the nerve and muscles to work together as they heal. Parents should trust their instincts, seek a specialist evaluation, and build a care team that understands brachial plexus injuries.
With early and consistent care, many children with Erb's palsy grow into active, confident adults who find ways to adapt, participate, and thrive.
Erb's Palsy Symptoms FAQs
Written and Medically Reviewed by:
Cerebral Palsy Hub Team
Cerebral Palsy Hub was founded to help support children and their families with cerebral palsy and to create a safe space for those affected. We strive to provide the most accurate, up-to-date information, and tools to help give your child the life they deserve.
Last Updated: December 6, 2025
