IN FORMATION
REFERENCES and previous partially denervated shoulder muscu-
1. Kahn FH, Visscher BR: Water disinfection in the wilderness
-A simple effective method of iodination (Information). West J
Med 122:450-453, May 1975
2. Brodsky RE, Spencer HIC, Shultz MG: Giardiasis in Ameri-
can travelers to the Soviet Union. J Infect Dis 130:319-323, 1974
3. Giardiasis-Vail, Colorado. Morbidity Mortality Weekly Rep
27:155, 1978
4. Moore GT, Cross WM, McGuire D, et al: Epidemic giardia-
sis at a ski resort. N Engl J Med 281:402-407, 1969
5. Wright RA, Vernon TM: Epidemic giardiasis at a resort
lodge. Rocky Mt Med J 73:208-211, 1976
6. Barbour AG, Nicholas CR, Fukushima T: An outbreak of
giardiasis in a group of campers. Am J Trop Med Hyg 25:384-
389, 1976
7. Bingham AK, Meyer EA: Giardia excystation can be induced
in vitro in acidic solutions. Nature (Lond) 277:301-302, 1979
8. Bingham AK, Jarroll EL, Meyer EA, et al: Giardia sp:
Physical factors of excystation in *vitro, and excystation vs. eosin-
exclusion as determinants of viability. Exp Parasitol 47:284-291,
1979
9. Microbiological Methods for Monitoring the Environment:
Water and Waste. EPA Publication No. EPA 600/8-78-017, 1978
10. Stringer R, Kruse CW: Amoebic cysticidal properties of
halogen in water. Proc National Specialty Conference on Disin-
fection, 319-338, (ASCE), 1970
11. Jarroll EL, Bingham AK, Meyer EA: Giardia cyst destruc-
tion: Effectiveness of six small quantity water disinfection methods.
Am J Trop Med IHyg 29: 8-11, 1980
Refer to: Corkill G, Lieberman JS, Taylor RG: Pack palsy in
backpackers (Information). West J Med 132:569-572,
Jun 1980
Information
Pack Palsy in Backpackers
GUY CORKILL, MD
JAMES S. LIEBERMAN, MD
ROBERT G. TAYLOR, MD
Sacramento, California
UPPER EXTREMITY NUMBNESS, weakness and
atrophy associated with the use of a heavy back-
pack have been reported in military personnel1-4
and termed pack palsy or rucksack paralysis.
Compression of the upper trunk of the brachial
plexus' 2 or peripheral nerve supply to the shoul-
der girdle3 4 by backpack straps is implicated as
the causative mechanism.
In several of the cases factors were present
which could predispose a person to this type of
injury. These included nutritional deficiency,'
structural abnormalities in the neck and shoulder2
From the Departments of Neurosurgery (Dr. Corkill) and Phy-
sical Medicine and Rehabilitation (Drs. Lieberman and Taylor),
University of California, Davis Medical Center, Sacramento.
Reprint requests to: James S. Lieberman, MD, Dept. of Phy-
sical Medicine and Rehabilitation, 4301 X Street, Room 201, Sac-
ramento, CA 95817.
lature.4 The presence of these predisposing factors
and the occasional occurrence of an upper ex-
tremity neuropathy in military personnel without
backpack trauma led Weinstein5 to state that
"pack palsy does not exist as a primary entity."
A neuropathic condition similar to that seen
following routine immunizations is cited as a prob-
able mechanism for these cases.5 However, a suf-
ficient number of cases have been reported with-
out predisposing factors or recent immunizations
to suggest that pack palsy does exist.2-4
Despite the many case reports from the mili-
tary, communications regarding pack palsy in
civilians are rare. Compression of the brachial
plexus by a backpack has been reported in four
adolescent Boy Scouts,6 and in one man.7 Under-
developed musculature has been suggested as a
predisposing factor in the cases in adolescents.2
In view of the increasing popularity of back-
packing, civilian physicians should be reminded
of the occurrence of pack palsy. The present com-
munication documents our experience with three
civilian men with weakness, atrophy of shoulder
muscles, or both, associated with backpacking.
Reports of Cases
CASE 1. A 23-year-old, rght-handed man com-
plained of nonprogressive muscle wasting and
weakness of the right shoulder of a year's dura-
tion.
For three years the patient had been back-
packing frequently using an internal frame pack
and waistband, and carrying a 30-kg load. After
several hours of climbing or hiking he would ex-
perience right shoulder pain, numbness of the
entire right arm and right shoulder girdle weak-
ness. Removal of the backpack for several min-
utes led to prompt relief of symptoms, but they
would return if hiking or climbing was resumed.
Between trips the patient was asymptomatic.
A year before evaluation the patient experi-
enced similar symptoms during a backpacking
trip. However, the weakness of the 'shoulder
girdle did not respond to pack removal, although
pain and numbness disappeared. Following this
trip the patient noted persistent weakness of the
right shoulder girdle and atrophy of shoulder
musculature.
Despite the persistent weakness and atrophy
the patient made- another backpacking trip a
month later. During this trip he carded more
weight on the left side of the pack because of
THE WESTERN JOURNAL OF MEDICINE 569
 INFORMATION
weakness in his right arm. He felt bilateral arm
pain, numbness, and shoulder girdle weakness
(right greater than left). Pack removal relieved
the pain, numbness and left arm weakness. Fol-
lowing this trip the patient noted increased right
shoulder weakness and wasting and some left
shoulder wasting without weakness. No progres-
sion or improvement of symptoms occurred up
to the date of examination.
Past medical history disclosed no neck or arm
trauma, immunizations, viral illness or diabetes
before onset of symptoms.
On examination the patient was noted to be
1.78 meters (5 ft 10 in) tall and weighed 61.2 kg
Figure 1.-Four views of patient 1 showing bilateral
scapular winging and spinatus atrophy, which is greater
on the right side.
Figure 2.-Four views of patient 1 showing position of
the pack straps relative to the neck and shoulder, and
right trapezius atrophy (lower photogaphs). Note that
the backpack straps c.ross potential compression sites
for accessory, long thoracic and suprascapular nerves
as well as the upper trunk of the brachial plexus.
570 JUNE 1980 * 132 * 6
(134.9 pounds). Blood pressure was 120/70
mm of mercury in both arms and pulses were
equal. A general physical examination showed no
abnormalities.
A neurological examination showed mental
status, cranial nerve, coordination, reflex and
detailed sensory measurements to be within nor-
mal limits. On motor testing, tone was normal.
There was pronounced atrophy (Figures 1 and
2) of the right trapezius, supraspinatus and
infraspinatus. Milder atrophy was noted in the
left spinati and bilateral scapular winging was
present. Weakness of both serratus anterior mus-
cles, the right trapezius and right spinati was
present.
X-ray studies of the cervical spine and chest,
as well as a complete myelogram showed no ab-
normalities. Results of laboratory evaluation
were unremarkable.
Electromyographic abnormalities were limited
to the right trapezius, serratus anterior, supra-
spinatus and infraspinatus. In these muscles de-
creased insertional activity was seen in association
with fibrillations and positive sharp wave poten-
tials. During voluntary contraction the interfer-
ence pattern was reduced and motor units were
polyphasic and of increased amplitude and dura-
tion. The impression was partial denervation of
the involved muscles.
Nerve conduction studies from Erb point to
bilateral trapezii and spinati showed slowed con-
duction to all three muscles on the right and to
the left infraspinatus. Evoked potential ampli-
tudes on the left were six to seven times greater
than on the right.
CASE 2. A 26-year-old, right-handed man com-
plained of left shoulder wasting and weakness of
five months' duration.
Six months before evaluation the patient con-
tracted hepatitis B. During his illness he com-
plained of generalized arthralgias, myalgias and a
subjective feeling of'weakness in both shoulders.
A month later the patient went on a backpack-
ing trip 'while recovering from his hepatitis. He
used an external frame pack and carried a load of
20 kg. Following the backpacking trip he noted
painless left shoulder weakness and subsequent
atrophy of the left spinati. The weakness and
atrophy were nonprogressive after initial -discov-
ery, and strength was returning by the time of
evaluation.
Past medical history disclosed no recent viral
illnesses other than the hepatitis B. Gamma glob-
 INFORMATION
ulin had been administered six months before the
onset of weakness, at the time of known exposure
to hepatitis. There was no history of neck or arm
trauma or diabetes before onset of arm symptoms.
On examination the patient was found to be
1.75 meters (5 ft 9 in) tall and weighed 72.6 kg
(160 pounds). Blood pressure was 110/80 mm
of mercury in both arms and pulses were equal.
Results of a general physical examination were
normal.
Neurologic examination showed mental status,
cranial nerve, coordination, reflex and detailed
sensory measurements to be within normal limits.
On motor testing tone was normal. There was
atrophy of the left supraspinatus and infraspina-
tus. Muscle strength was normal except for weak-
ness of the left spinati.
X-ray studies of the cervical spine, shoulder
and chest as well as recent routine laboratory tests
showed no abnormalities.
Electromyographic abnormalities were limited
to the left supraspinatus and infraspinatus. In
these muscles slightly increased insertional ac-
tivity was seen in association with fibrillations and
positive sharp wave potentials. During voluntary
contraction the interference pattern was reduced
but motor units were otherwise normal. The im-
pression was partial denervation of the left spinati.
Follow-up evaluation was carried out ten
months after weakness began. Motor strength in
the left spinati was essentially normal while some
atrophy remained.
Follow-up electromyography of the left spinati
disclosed normal insertional activity. The left
supraspinatus showed occasional fibrillations and
positive sharp wave potentials, while the left in-
fraspinatus showed no abnormal rest activity. In
both muscles motor unit potentials of normal
amplitude, duration and configuration were seen
with a normal interference pattern during con-
traction.
Nerve conduction studies from Erb point to
the shoulder musculature showed normal laten-
cies ten months after injury.
CASE 3. A 29-year-old, right-handed man com-
plained of winging of the left scapula noted 72
hours before examination.
Nine days before evaluation the patient went
on a backpacking trip for several days. He used
an external frame pack and carried an 18-kg
load. He noted some mild discomfort from the
straps of the pack but did not feel arm pain or
numbness. On one night of the trip, his air mat-
tress partially collapsed and his sleeping position
may have been abnormal that night. Forty-eight
hours after the trip he realized his left scapula
was winging. However, the winging was nonpro-
gressive during the next 72 hours, when he was
examined.
Past medical history disclosed no recent im-
munizations, viral illnesses, history of diabetes,
or neck and arm. trauma before the camping trip.
On examination the patient was noted to be
1.83 meters (6 ft) tall and weighed 81.6 kg
(179.9 pounds). Results of a general physical
examination were unremarkable.
On neurological examination, mental status,
cranial nerve, coordination, reflex and detailed
sensory measurements were within normal limits.
On motor testing, tone was normal. The only
abnormality noted was mild left scapular winging.
The patient was reevaluated 19 days after the
onset of scapular winging. At that time no wing-
ing was noted.
Electromyographic abnormalities were limited
to the left serratus anterior. Normal insertional
activity was noted as was normal rest activity.
During voluntary contraction a reduced interfer-
ence pattern was observed but motor units were
otherwise normal. The impression was neura-
praxia or partial denervation of the long thoracic
nerve.
Discussion
Despite the fact that most pack palsy cases in
the literature are thought to be due to brachial
plexus compression," 2'6'7 peripheral nerve injury
appears to be the mechanism in the three cases
reported above. In case 1 the patient had acces-
sory nerve involvement (not part of brachial
plexus), as well as involvement of only muscles
innervated by the suprascapular and long thoracic
nerves. This is in contrast to patients with plexus
compression, in which there is more diffuse C5-
C6 involvement and almost invariable deltoid
involvement.2 Cases of compression of the acces-
sory4 and long thoracic3'4 nerve by backpacks
have been reported. Suprascapular nerve com-
pression at the scapular notch has been reported
from other causes.8 In case 2 (suprascapular
nerve) and case 3 (long thoracic nerve) the pa-
tients had only single nerve involvement. Their
conditions are also dissimilar to those involving
plexus compression.
Case 1 probably represents pure pack palsy as
no predisposing factors could be documented. Of
THE WESTERN JOURNAL OF MEDICINE 571
 INFORMATION
interest, however, is the fact that the patient
carried a heavy load compared with his own body
weight (49 percent) using an internal frame pack.
This exceeds the load recommended by many
outfitters (personal communications).
Predisposing factors may have been present in
the remaining cases. The hepatitis B in patient 2
may have rendered his peripheral nerves more
sensitive to injury, because the load he carried
appeared to be within safe limits. Patient 3 may
have had an abnormal sleep posture as a predis-
posing factor in long thoracic nerve injury be-
cause his load was also within safe limits.
Regardless of the site of compression, the
prognosis for complete recovery from pack palsy
within three months after injury approaches 87
percent.7 Recovery in patients 2 and 3 was good
and followed the expected course for this entity
although it was slow in patient 2. In the case of
patient 1, however, no improvement was noted
in his condition a year after onset. In all proba-
bility repeated trauma to affected nerves by con-
tinued backpacking adversely affected his prog-
nosis.
Treatment of pack palsy consists primarily of
removing the source of trauma by avoidance of
further backpacking during recovery. Daube2
suggests that the use of a pack should be discon-
tinued until at least a month after complete re-
covery occurs. During the recovery phase further
trauma of any type to the brachial plexus or to
nerves to the shoulder girdle should be avoided,
as should heavy lifting with an outstretched arm.
A sling may be useful when trapezius or deltoid
weakness allows shoulder separation. Heavy
therapeutic exercise programs will probably be
unnecessary and may be harmful.9 Most patients
with pack palsy will be able to do sufficient
mild exercise during their normal activities to
strengthen upper extremities as recovery occurs.
Civilian as well as military physicians should
572 JUNE 1980 * 132 * 6
consider pack palsy as a possible cause or con-
tributing factor in patients presenting with unex-
plained weakness and wasting of the arm and
shoulder girdle. Appropriate history-taking will
help to establish the possibility of this diagnosis,
and clinical and electrodiagnostic testing will help
to localize the process to the upper trunk of the
brachial plexus or to the nerves to the shoulder
musculature. While other disease processes must
still be considered and ruled out, the proper diag-
nosis of pack palsy permits appropriate treatment
for this cause of arm wasting and weakness.
Summary
Pack palsy, secondary to compression of the
upper trunk of the brachial plexus or peripheral
nerve supply to the shoulder girdle by backpack
straps, has been thought to be essentially a mili-
tary medical problem. However, this report pre-
sents three cases of pack palsy in civilian back-
packers in which peripheral nerve compression
appears to be the cause. Recovery from pack
palsy is usually good, although prolonged dys-
function may occur if the condition is not recog-
nized, thus permitting repeated trauma to neural
tissue to occur. Treatment primarily involves re-
moval of the source of the trauma.
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