What causes shoulder pain after a stroke, and how is it treated?

Why does the shoulder become painful after a stroke?

The shoulder is the most mobile joint in the body and relies heavily on muscles to keep the ball of the upper arm centred in its shallow socket. When those muscles are weak after a stroke, the weight of the arm can pull the joint partly out of position. This is called subluxation, and it may show as a gap below the point of the shoulder.

Other causes often add to it: irritation of the rotator cuff tendons when the arm is lifted without the muscles controlling the joint, stiffness of the joint capsule similar to a frozen shoulder, tight muscles from spasticity pulling the arm inwards, swelling and pain of the whole hand and arm, and pain related to damaged sensory pathways in the brain. More than one of these is usually present.

How can shoulder pain be prevented?

Prevention starts in the first days. The weak arm should be supported when sitting, for example on a pillow or a table in front of the person, and positioned comfortably in bed. Nobody should lift or move the person by pulling on the weak arm or under the armpit. Staff and family can be shown how to help with transfers safely.

Guidelines advise against using overhead pulleys for stretching the shoulder after a stroke, because forcing the arm upwards can damage the joint 1. Gentle movement within a pain-free range, done by the person or a trained helper, keeps the joint mobile without straining it.

Do slings and strapping help?

A Cochrane review found insufficient evidence that slings or wheelchair attachments prevent subluxation, reduce pain or improve function. It found some evidence that strapping the shoulder with tape delays the onset of pain, although it did not reduce pain once present 2.

In practice, a sling may be used for short periods when walking to stop the arm hanging, while arm supports on a wheelchair or chair are used when sitting. None of these should keep the arm immobile for long periods, as stiffness then becomes a problem of its own.

How is established shoulder pain treated?

Treatment follows an assessment of the cause. If pain is related to stiffness, gentle mobilisation and range of movement exercises are used. If weak muscles allow the joint to slip, electrical stimulation of the shoulder muscles can be used to activate them and support the joint, combined with active practice. Pain relief is adjusted so that the person can take part in therapy.

When spasticity pulls the shoulder into a painful position, botulinum toxin injected into the tight muscles can reduce tone and pain, followed by stretching and positioning 3. Corticosteroid injections into the shoulder may be considered if the joint or tendons are inflamed. Some teams use nerve blocks for persistent pain that limits rehabilitation.

Why does shoulder pain matter for recovery?

Pain makes people avoid using the arm, which reduces the practice needed for recovery. It also disturbs sleep, lowers mood and can limit participation in the whole rehabilitation programme, including walking practice. Treating shoulder pain early is therefore part of treating the stroke, not a separate issue.

Stroke rehabilitation guidance recommends that people with shoulder pain after a stroke are assessed and offered treatment tailored to the cause, and that everyone involved in their care knows how to position and handle the arm 4.

When should shoulder pain be checked urgently?

Severe new pain after a fall, a visible deformity, or inability to move the shoulder at all may indicate a fracture or dislocation and needs prompt examination. A hot, red, swollen joint with fever needs urgent assessment for infection.

Burning pain, marked swelling of the hand, shiny skin and extreme sensitivity to touch can suggest complex regional pain syndrome, which responds better when it is recognised early. Any of these signs is a reason to ask the rehabilitation team for a review.

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