Shoulder pain is common among stroke survivors. It usually happens on the side of your body affected by the stroke. There are many different conditions that cause shoulder pain. While some improve with targeted treatment, sometimes it becomes a long-term condition.
Types and causes of shoulder pain
Frozen shoulder
After a stroke, you may find your shoulder is very stiff and that it hurts when you move it. This is called frozen shoulder, or capsulitis. The shoulder is a ‘ball and socket’ joint, with a rounded shape at the end of the upper arm fitting into a hollow space in the shoulder blade. Muscles and ligaments hold the arm bone in place. There is a layer of tissue that surrounds this joint which is called a capsule.
If your arm muscles are very weak, stiff or paralysed, the effect of gravity puts a strain on your ligaments and your capsule. This can cause these parts of your shoulder joint to become inflamed, stretched and damaged. Having weakness in your arm muscles may contribute to the pain in your shoulder.
Subluxation
Another common shoulder problem after stroke is subluxation. This means partial dislocation, when the rounded end of the upper arm bone moves slightly out of its socket. This happens because the muscles that normally hold this joint in place are weakened due to the stroke, and the weight of the arm can pull and stretch the soft tissues and you may feel pain. Positioning the arm correctly can help.
Subluxation is usually more noticeable while you’re sitting. A physiotherapist may suggest supporting the weak arm on pillows early after stroke. Note that subluxation does not always cause pain.
How is shoulder pain treated?
Prevention
If you have weakness in your arm following your stroke, your therapist will try to prevent shoulder pain developing. They will make sure that anyone who handles your arm knows how to do so with care and without causing strain on your shoulder joint.
They should also ensure your arm and shoulder are positioned correctly.
Correct positioning is vital because it can help to reduce the strain on your ligaments and capsule, helping to prevent frozen shoulder from developing. It may also help to prevent your shoulder blade and upper arm bone from moving apart (subluxation). You may need to use foam supports to make sure your shoulder is supported in the correct position. Your arm can also be supported using a pillow.
Shoulder taping or orthotic supports may be useful. However, they should be prescribed by your therapist, with clear guidance on their use. Supports should be regularly monitored and should not stop you moving your arm.
Your physiotherapist should consider using electrical stimulation on the muscles around your shoulder, to help prevent or reduce subluxation. If this is prescribed, the device often needs to be used throughout the day, following advice from your therapist. You and your relatives or carers and clinicians should be trained to safely use electrical stimulation devices.
Reducing pain
You may be given painkillers such as paracetamol. Seek advice from a doctor or pharmacist before taking painkillers, as they can increase the risk of bleeding if you are on a blood-thinning medication.
If you also have inflammatory arthritis, a steroid may be injected into your joint to help reduce the pain.
If you have persistent shoulder pain after a stroke, you may be referred to a specialist. Other treatments may be considered, such as a suprascapular nerve block, an injection containing local anaesthetic which may help with some cases of shoulder pain.
Alternative ways of managing pain after stroke
If you find medication or physiotherapy have not helped to relieve your pain, there are some other approaches you can try.
Moving your shoulder
It is important to keep the muscles in your shoulder and arm active so any stiffness does not get worse. Your physiotherapist may use stretching exercises to move your shoulder joint in all directions. They can also give advice about how to protect your shoulder during everyday movements, such as reaching for something or getting dressed.