Shoulder Pain After Stroke: Causes and Treatment

Pain in the shoulder of the weak arm (hemiplegic shoulder pain) is one of the most common complications after stroke. It can make rehabilitation harder, disturb sleep and lower mood [4].

Causes

Several mechanisms often coexist [1]:

• Subluxation: weak muscles can no longer hold the head of the arm bone in the socket
• Spasticity of the shoulder muscles
• Soft-tissue injury, such as rotator cuff problems or inflammation, often from incorrect handling
• Frozen shoulder (adhesive capsulitis)
• Complex regional pain syndrome and central pain

Risk factors include severe arm weakness, sensory loss and reduced shoulder movement [4].

Further reading: the guide “Stroke” and the articles Stroke Rehabilitation: Ischaemic and Haemorrhagic Stroke and Hand and Arm Recovery After Stroke.

Prevention

• Correct positioning and support of the arm in bed and in the chair
• Never pulling the patient by the weak arm
• Gentle range-of-motion exercises
• Supports or taping where appropriate to reduce subluxation [2]

Treatment

Treatment depends on the cause [3]: physiotherapy, electrical stimulation of the shoulder muscles, management of spasticity (including botulinum toxin injections), injections into the shoulder in selected cases, and pain medicines.

How common is it and why does it matter?

Shoulder pain is one of the most frequent complications after stroke, especially when the arm is weak. It can disturb sleep, reduce participation in therapy and slow arm recovery, so prevention and early treatment are important. Common contributors are subluxation (the upper arm bone slipping partly out of the shoulder socket because the muscles are weak), spasticity (muscle tightness), inflammation of the shoulder tendons, frozen shoulder (stiffness of the joint capsule) and complex regional pain syndrome (a painful condition with swelling and skin changes of the hand and arm).

How it is assessed

The PM&R physician examines the range of movement, muscle tone, the position of the shoulder joint, sensation, swelling of the hand and signs of nerve-related pain. Ultrasound or X-ray may be used to look at the joint and tendons. Identifying the main cause guides treatment.

Treatment options in general terms

• Correct positioning and support of the arm in bed, in the chair and in the wheelchair
• Gentle, pain-free range-of-motion exercises guided by your physical medicine and rehabilitation specialist and the physiotherapist
• Electrical stimulation of the shoulder muscles in selected patients
• Treatment of spasticity, including injections when indicated
• Pain medicines and, where appropriate, injections into the shoulder, decided by the physician
• Taping or supports as part of an individual plan

What families can do

• Never pull on the affected arm when helping the patient move or stand up
• Support the arm on a pillow or armrest when sitting and lying
• Avoid overhead pulley exercises unless the team has advised them
• Dress the affected arm first and undress it last
• Report new pain, swelling of the hand or skin colour changes promptly

When to see your physical medicine and rehabilitation specialist

After acute hospital care, the rehabilitation process is best led and advised by a physician specialised in physical medicine and rehabilitation (PM&R, also called physiatry). At home, too, it is worth consulting a PM&R specialist, who examines the patient, sets goals and guides therapy and supportive treatments together with the physiotherapist and the wider team. Ask for a review if:

• function is getting worse instead of better, or progress has stalled for several weeks
• new pain, stiffness, swelling or falls appear
• mood, sleep, swallowing or bladder control change
• you are wondering whether a robotic or other advanced therapy might be suitable

Whether robotic or other advanced therapies are suitable is decided by a PM&R specialist focused on neurorehabilitation. Prof. Dr. Engin Çakar works in this field and can be consulted online or in person; otherwise, consult a PM&R specialist near you.

Call emergency services immediately for sudden new weakness, facial drooping, difficulty speaking, a severe headache or loss of consciousness: these can be signs of a new stroke.

Frequently asked questions

Is a shoulder sling useful? A support may help when sitting or walking, but long-term immobilisation can cause stiffness. The choice is individual.

Can shoulder pain appear months after the stroke? Yes. It often develops in the first months, but it can start later. See also Spasticity after stroke.

Should the patient avoid moving a painful shoulder? Complete rest can lead to stiffness. Gentle, guided movement within a pain-free range is usually recommended, while forceful stretching should be avoided.

Can shoulder pain be prevented? Not always, but correct handling, positioning and early treatment of tightness reduce the risk.

Assessment and contact

You can request an appointment or a second-opinion review of existing reports and imaging: Contact & second opinion (WhatsApp). This page is general health information. Diagnosis and treatment decisions are made individually after examination.

Sources

1. Kalichman L, et al. Underlying pathology and associated factors of hemiplegic shoulder pain. Am J Phys Med Rehabil. 2011. PMID: 21430513
2. Arya KN, et al. Rehabilitation methods for reducing shoulder subluxation in post-stroke hemiparesis: a systematic review. Top Stroke Rehabil. 2018. PMID: 29017429
3. de Sire A, et al. Efficacy of rehabilitative techniques in reducing hemiplegic shoulder pain in stroke: Systematic review and meta-analysis. Ann Phys Rehabil Med. 2022. PMID: 34757009
4. Anwer S, et al. Incidence, Prevalence, and Risk Factors of Hemiplegic Shoulder Pain: A Systematic Review. Int J Environ Res Public Health. 2020. PMID: 32660109