Shoulder Pain After Stroke: What Doctors Don’t Tell You (But Should)
NeuroRehab Team
Thursday, August 21st, 2025
Shoulder pain affects up to 72% of stroke patients during their first year of recovery. This pain usually develops on the stroke-affected side of the body. The condition can lower a patient’s quality of life by a lot and leads to depression and sleep problems.
Doctors tend to focus on basic stroke rehabilitation. The treatment of post-stroke shoulder pain needs more attention since it can start just two weeks after a stroke. Most cases develop within 2-3 months. On top of that, shoulder subluxation affects three out of four patients during recovery. This condition often triggers the debilitating pain. Let’s explore what causes this pain, its types, and available treatments. We’ll also look at key prevention strategies that healthcare providers should emphasize but often miss.
What causes shoulder pain after a stroke?
Brain damage after stroke leads to several physical changes that cause shoulder pain. We can better treat stroke survivors when we understand these mechanisms of pain development and persistence.
Muscle tone changes: flaccidity vs spasticity
Stroke survivors experience distinct phases of muscle tone abnormalities in their affected arm. The limb becomes “flaccid” at first, which means it has no voluntary movement and low muscle tone (hypotonia) [1]. The shoulder muscles can’t hold the humeral head properly within the glenoid cavity during this time [2]. This original flaccidity leaves the shoulder vulnerable to damage as the unsupported limb hangs.
Many patients develop spasticity later, a condition that affects about 20-40% of stroke survivors [3]. Spasticity makes muscles abnormally stiff and resistant to stretching, sometimes causing painful muscle spasms [3]. This increase in muscle tone based on movement speed usually shows up between 1-6 weeks after stroke [3].
The change from flaccidity to spasticity substantially affects how the shoulder works. Clinical experts note that “The pattern of motor recovery and spasticity is confirmed in a recent longitudinal study” [3]. Electromyography studies show that reflex-driven increases in muscle tone peak between 1-3 months after stroke [1].
Subluxation and joint instability
Shoulder subluxation—where the humeral head moves out of its normal position in the glenoid fossa—affects up to 80% of stroke survivors [2]. Weakened shoulder muscles that can’t keep the joint lined up properly cause this condition.
The glenohumeral joint trades stability for mobility, making it vulnerable [4]. The joint capsule stretches when gravity pulls on the humerus without enough muscle activity [4]. Doctors check for subluxation by feeling the gap between the arm bone and shoulder blade—one finger width means mild subluxation, with bigger gaps showing more severe cases [2].
Experts debate the connection between subluxation and pain. Some believe subluxation causes pain when soft tissues stretch too much [4], but many studies show no real link between subluxation and pain [4]. Notwithstanding that, subluxation consistently leads to poor upper limb function [4].
Soft tissue injuries and inflammation
Soft tissue damage plays a big role in post-stroke shoulder pain. Stroke patients who can’t move their upper limb well face a higher risk of soft-tissue injuries during therapy [5].
Injuries happen most often in the biceps and supraspinatus tendons. Ultrasound studies show tendonitis in 50% of biceps tendons and 47.1% of supraspinatus tendons in affected shoulders [5]. These injuries often come with subluxation because both problems stem from weak muscles that can’t protect and stabilize the shoulder joint.
Wrong positioning, stress on the weak joint, and pulling damage can inflame the joint capsule. The shoulder might become frozen (adhesive capsulitis), getting stiffer and more painful [6]. Weak muscles, poor positioning, and repeated minor injuries create an ongoing cycle of inflammation and pain throughout recovery.
The most common types of post-stroke shoulder pain
Stroke survivors face several distinct shoulder pain conditions. Each condition needs its own specific treatment approach. Medical professionals must understand these differences to provide effective care.
Frozen shoulder after stroke
Frozen shoulder (adhesive capsulitis) occurs when inflammation tightens the tissue around the shoulder joint. This leads to painful and limited movement [7]. Stroke survivors with arm weakness or paralysis often develop this condition due to lack of movement [7]. Recovery happens in three phases. The "freezing" phase lasts 2-9 months with severe pain and increasing stiffness. The "frozen" phase follows with established stiffness but less pain. Finally, the "thawing" phase allows gradual mobility improvement [7]. Research shows frozen shoulder accounts for 41% to 88% of shoulder pain cases in stroke-affected arms [8].
Shoulder impingement
The rotator cuff tendons become irritated and swollen as they pass through a narrow space between the acromion and humeral head. This condition is shoulder impingement. Poor positioning and changed shoulder mechanics cause this problem in stroke survivors. The biceps and supraspinatus tendons remain particularly vulnerable. Studies reveal tendonitis in 50% of biceps tendons and 47.1% of supraspinatus tendons in affected shoulders [9].
Hemiplegic shoulder pain
Pain that develops on the weakened side after stroke is called hemiplegic shoulder pain (HSP). Up to 84% of stroke survivors with motor weakness and shoulder subluxation experience HSP [7]. Pain usually starts 2-3 months after stroke but can appear within two weeks [6]. Both neurological factors like paralysis and spasticity and mechanical factors such as subluxation contribute to this condition [9]. Patients with HSP stay longer in hospitals, show slower functional recovery, and face lower chances of returning home [6].
Complex regional pain syndrome (CRPS)
CRPS affects 12.5% to 50% of stroke survivors [10]. Medical professionals previously called it reflex sympathetic dystrophy or shoulder-hand syndrome. Patients experience pain along with unusual sensory, autonomic, and motor problems [10]. Symptoms include increased pain sensitivity, pain from light touch, swelling, limited movement, and warmth in the affected area [10]. Long hospital stays and shoulder subluxation increase risk [10]. Quick treatment matters. Oral corticosteroids (30-50mg daily for 3-5 days with decreasing doses) reduce swelling and pain when given early [1].
Central post-stroke pain (CPSP)
About 8% of stroke patients develop central post-stroke pain, a unique neuropathic pain syndrome [3]. CPSP stems from brain damage to sensory pathways, particularly the thalamus [3]. Pain starts within the first month after stroke but timing varies from immediately to 6 months later [3]. Patients describe burning sensations or shooting pains with unusual sensitivity to temperature and touch [3]. Treatment combines medications like antidepressants with techniques such as desensitization and relaxation [3]. Doctors must rule out other causes to diagnose CPSP [3].
Why shoulder pain is often overlooked in stroke recovery
Shoulder pain affects up to 72% of stroke patients in their first recovery year [1]. Yet many rehabilitation centers don't deal very well with this complication. Several system-wide problems lead to this oversight, and patients often end up managing this debilitating condition without much support.
Focus on mobility over pain
Rehab programs usually focus on walking ability instead of upper limb function [4]. This one-sided approach comes from practical needs - walking directly affects when patients can leave the hospital and live independently. Research shows that almost every stroke patient starts by saying walking matters more than arm function [4]. A study points out that "Walking is a fundamental part of human activity and was seen by the participants as the key to becoming more independent and having freedom and choice" [4].
Patients usually start caring about their arm function only after going home - about six months after their stroke [4]. The problem is that therapy services have mostly ended or become very limited by then. Patients who still have trouble walking keep working on their leg mobility [4]. This means their shoulder problems stay untreated.
Lack of caregiver training
Poor caregiver education creates another big gap in treating shoulder pain. Hospital rooms themselves make things harder - patients lie surrounded by tubes, catheters, and monitoring equipment that make proper movement difficult [2]. Yet caregivers rarely get complete training on how to prevent shoulder problems.
Everyone knows early movement programs help prevent hospital complications and speed up recovery [2]. When shoulder pain isn't addressed, it can limit rehab participation, lead to longer hospital stays, and cause depression and worse quality of life [11][1].
Most rehab services completely stop by twelve months after stroke. This leaves patients feeling "unsupported, ignored and abandoned" [4]. One patient in a research study felt frustrated that nobody thought about rehabilitation priorities even though they still needed therapy [4].
Underreporting by patients
Sometimes patients make things worse by not telling anyone about their shoulder pain. About 12% of stroke survivors need help from staff or family to describe their pain [12]. This suggests many can't effectively talk about their discomfort. Others keep unrealistic hopes - some completely ignore arm pain while staying "optimistic of a full recovery in a relatively short period of time" [4].
Ignored shoulder pain leads to serious problems. Studies show that patients with hemiplegic shoulder pain end up back in the hospital 84% of the time two months after stroke, compared to 62% for those without shoulder pain [13]. Patients without shoulder pain can do things like dressing, grooming, feeding, and bathing more independently [13].
Many doctors focus on studying risk factors and understanding why shoulder pain happens after it develops [14]. This reactive approach leaves many stroke survivors without proper care for this common and disabling problem.
Post stroke shoulder pain treatment options
Managing post-stroke shoulder pain needs a comprehensive approach that adapts to each patient's condition. Doctors choose treatments based on why it happens and how severe the symptoms are.
Physical therapy and range of motion exercises
Range of motion exercises are the life-blood of shoulder pain rehabilitation. Therapists usually start with gentle passive movements before moving to active exercises [5]. These movements help reduce spasticity, make mobility better, and ease pain gradually. Patients must be careful though - shoulder exercises without professional guidance can make pain worse and lead to more injuries [5]. Physical therapists work to arrange proper alignment and build strength in weak shoulder girdle muscles. This helps patients regain active range of motion step by step [1].
Botulinum toxin injections
Botulinum toxin injections into the subscapularis and pectoralis muscles show good results in patients who have spasticity-related shoulder pain [1]. Clinical trials prove these injections work better than intra-articular steroids to treat hemiplegic shoulder pain. They reduce pain more and improve motion range [15]. Treatment patterns change based on how the shoulder presents itself. Doctors usually inject the pectoralis major and teres major muscles if they see adduction with internal rotation patterns [16].
Electrical stimulation and TENS
Doctors use different types of electrical stimulation like TENS and NMES. Research shows electrical stimulation reduces shoulder subluxation well if used in the first six months after stroke [1]. This works by making muscles contract better through lower motor nerve stimulation [17]. Treatment starts with two hours each day and builds up to 4-6 hours to get the best results [1].
Pain medications and anti-inflammatories
Different medications can help with pain relief depending on its cause [5]. Subacromial corticosteroid injections combined with exercise programs cut down shoulder pain levels significantly after eight weeks [1]. Early treatment with oral corticosteroids (30-50mg daily for 3-5 days with decreasing doses) works well to reduce swelling and pain in complex regional pain syndrome [18].
Use of slings, taping, and supports
Kinesiology taping has become more popular to manage shoulder subluxation. Studies show it reduces subluxation, eases pain, and helps with active shoulder flexion [19]. This elastic, water-resistant method stimulates mechanical receptors as it compresses the skin during joint movement [20]. On top of that, shoulder braces or orthoses help support the arm's position. This reduces subluxation and eases pain [5]. Therapists must train patients properly to apply these supports correctly to get the best outcome [5].
Prevention strategies doctors rarely emphasize
Medical guidance often overlooks specific strategies that prevent hemiplegic shoulder pain. Patients can reduce their pain risk throughout recovery by implementing these approaches properly.
Proper arm positioning during rest and transfers
Joint protection strategies play a vital role during the flaccid stage of recovery [1]. Patients lying down should support their affected arm with pillows under the forearm while lying on the back. The upper arm needs to rest on the mattress [7]. Wheelchair positioning demands extra care—lap trays, arm troughs or pillows can effectively reduce shoulder subluxation [8]. The affected arm should never be pulled during transfers, dressing, or bathing [7].
Avoiding passive overhead movements
The affected arm's movement should stay within 90 degrees of shoulder flexion or abduction unless the scapula rotates upward and the humerus rotates laterally [1]. Research shows that overhead exercises without proper instruction can increase shoulder pain risk [7]. Movement patterns may worsen if range-of-motion exercises are performed incorrectly [21].
Educating caregivers and family members
The core team, patients and their families need training on correct positioning and handling techniques [1]. Research proves that proper education can reduce shoulder pain incidence after stroke substantially [22].
Early intervention to prevent contractures
Daily positioning of the hemiplegic shoulder in maximum external rotation for 30 minutes shows positive results [23]. We mobilized patients early to prevent hospital-associated complications and support recovery [23].
Conclusion
Shoulder pain is a major yet often overlooked problem for stroke survivors. Nearly 75% of patients experience this debilitating condition in their first recovery year, but healthcare providers don't give it enough attention. The mechanisms behind this pain - from changes in muscle tone and subluxation to soft tissue injuries - are crucial to understand for proper management and prevention.
Stroke survivors experience several types of shoulder pain that need specific treatment approaches. These include frozen shoulder, impingement, hemiplegic shoulder pain, CRPS, and central post-stroke pain. Most rehabilitation programs focus on helping patients walk rather than improving arm function. This leaves many people dealing with shoulder pain even after their therapy ends. Patient reluctance to report pain and lack of proper caregiver training make things worse.
Several treatment options can help. Physical therapy combined with range of motion exercises works well. Botulinum toxin injections, electrical stimulation, pain medications, and proper supports can substantially reduce pain and improve function. Prevention remains the best strategy. Standard rehabilitation practices should include proper arm positioning during rest and transfers. Patients should avoid passive overhead movements while caregivers need proper education. Early intervention helps prevent contractures.
Better management of post-stroke shoulder pain begins with greater awareness. Healthcare providers must recognize this common complication and start complete prevention strategies immediately. Patients and their families should learn shoulder protection techniques early instead of waiting until pain develops. Early intervention and proper care could help many stroke survivors avoid this painful complication. This would improve their quality of life and rehabilitation outcomes considerably.
Key Takeaways
Shoulder pain affects 72% of stroke survivors within their first year, yet it's frequently overlooked in rehabilitation despite significantly impacting recovery and quality of life.
• Prevention is critical: Proper arm positioning, avoiding overhead movements, and caregiver education can prevent most shoulder complications from developing.
• Multiple pain types require different treatments: From frozen shoulder to complex regional pain syndrome, each condition needs specific approaches like botulinum injections or electrical stimulation.
• Early intervention matters most: Shoulder problems typically develop within 2-3 months post-stroke, making immediate protective strategies essential for long-term outcomes.
• Rehabilitation priorities are misaligned: Healthcare systems focus on walking recovery over upper limb function, leaving shoulder pain undertreated until it becomes severe.
• Caregivers need proper training: Family members and healthcare staff must learn correct positioning and handling techniques to prevent inadvertent shoulder damage during daily care.
The key insight is that shoulder pain after stroke is largely preventable through proper education and early protective measures, yet most healthcare providers fail to emphasize these crucial prevention strategies until pain has already developed.
References
[1] - https://www.strokebestpractices.ca/recommendations/stroke-rehabilitation/management-of-shoulder-pain-complex-regional-pain-syndrome-crps-following-stroke
[2] - https://pmc.ncbi.nlm.nih.gov/articles/PMC8015460/
[3] - https://www.aapmr.org/about-physiatry/conditions-treatments/pain-neuromuscular-medicine-rehabilitation/central-poststroke-pain
[4] - https://www.tandfonline.com/doi/full/10.1080/09638288.2022.2120097
[5] - https://www.flintrehab.com/shoulder-pain-after-stroke/?srsltid=AfmBOorqnvtLrL6Lre2gICma0-ry2kIZMqIr8pVpANlqaaXWYTXWXBAS
[6] - https://www.elsevier.es/pt-revista-neurologia-english-edition--495-articulo-painful-hemiplegic-shoulder-in-stroke-S2173580812000478
[7] - https://www.stroke.org/en/about-stroke/effects-of-stroke/physical-effects/managing-pain/shoulder-pain
[8] - https://www.strokebestpractices.ca/-/media/1-stroke-best-practices/tacls-qrg/tacls-qrg-shoulder-care-final.pdf?rev=bab09e7849924538838c71772098e9a9
[9] - https://www.tandfonline.com/doi/full/10.2217/pmt-2018-0075
[10] - https://pmc.ncbi.nlm.nih.gov/articles/PMC9587704/
[11] - https://pmc.ncbi.nlm.nih.gov/articles/PMC7732168/
[12] - https://www.ahajournals.org/doi/10.1161/01.STR.0000254598.16739.4e
[13] - https://pmc.ncbi.nlm.nih.gov/articles/PMC9879055/
[14] - https://pmc.ncbi.nlm.nih.gov/articles/PMC8713217/
[15] - https://www.ahajournals.org/doi/10.1161/strokeaha.107.484048
[16] - https://www.frontiersin.org/journals/neurology/articles/10.3389/fneur.2022.1004629/full
[17] - https://pmc.ncbi.nlm.nih.gov/articles/PMC8406756/
[18] - https://www.medicalnewstoday.com/articles/best-pain-medication-for-stroke-patients
[19] - https://www.sciencedirect.com/science/article/abs/pii/S1052305719301168
[20] - https://pmc.ncbi.nlm.nih.gov/articles/PMC11149471/
[21] - https://pmc.ncbi.nlm.nih.gov/articles/PMC3090071/
[22] - https://www.strokebestpractices.ca/-/media/1-stroke-best-practices/tacls-qrg/tacls-qrg-positioning-final.pdf?rev=ea30e9cb314a4bba850c84e66d499d9c
[23] - https://www.strokebestpractices.ca/-/media/1-stroke-best-practices/rehabilitation-nov2019/csbpr-rehabilitation-evidence-table-5-3-shoulder-pain-crps-12nov19-final.pdf?rev=a34894d8343245de9a5e9586fe75ebb2
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