409

The Source of Shoulder Pain in Hemiplegia

Robert L. Joynt, MD

ABSTRACT. Joynt RL. The source of shoulder pain in hemiplegia. Arch Phys Med Rehabil 1992;73:409-13.
l Shoulder pain is a common problem in hemiplegia. This preliminary study attempted to identify pain-producing
structures by evaluating the results of injecting 1% lidocaine into several sites in the shoulder area. Sixty-seven patients
with shoulder problems were identified, examined, and characterized. The amount of pain was related most to loss of
motion; it was unrelated to subluxation, spasticity, strength, or sensation. Of 28 patients who received a subacromiai
injection, approximately one-half obtained moderate or marked relief of pain and improved range of motion, suggesting
that the subacromial area of the shoulder is a location of pain-producing structure in a significant number of cases.
G I992 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and
Rehabilitation

Shoulder pain, a common and serious problem in hemi-
ptegia, has been reported with an incidence ranging from
5% to 84% in stroke patients.lW6Indeed, shoulder problems
are thought to be of such importance in stroke patients that
several review articles, chapter sections, and a book3,‘-”
have been written about them. Despite the extensive inter-
est, there continues to be uncertainty about its etiology and
appropriate treatment. Most studies have speculated about
the etiology based on the presence of a physical or x-ray
abnormality in patients with pain, but they have failed to
prove a cause and effect relationship by showing that correc-
tion of the apparent causative factor has removed the pain.
Because determining the etiology of the problem would
be an appropriate first step in the planning of rational treat-
ment, this study was developed as a preliminary attempt to
locate the anatomic structure(s) producing the pain by ren-
dering them anesthetic. It was felt that if the specific ana-
tomic source of pain could be located, the cause of pain
might become more apparent, and the treatment could be
more appropriateiy directed. In addition, demographic in-
formation about the patients and their pain was collected
and compared with that of other studies with similar data.
The data were analyzed to determine any possible relation-
ships that might suggest the etiology of the pain.
METHODS
The study was reviewed and approved by the institu-
tional Human Subjects Investigation Committee. Inpa-
tients admitted to a rehabilitation facility were examined.
However, it soon became evident that the number of pa-
tients with shoulder pain in the acute population was small
and that patients with a longer poststroke history needed to
-.-
I rum the Wayne State I Jniversitv. Rehabilitation Institute of Michigan. Detroit.
This work was supponed in part by a grant from the United Way.
Submitted for publication April 1X. 199 I. Accepted in revised form July 22. 199
7x0commercial party having a direct or indirect interest in the subject matter ofthis
article has conferred or will confer a benefit upon the author or upon any organization
with which the author is associated.
Reprint requests to Robert 1.. Joynt. MD, I148 Olden Rd. Ann Arbor. Ml 48103.
( 1992 by the .\merican Congress of Rehabilitation Medicine and the American
4cademy of Physical Medicine and Rehabilitation
000~-999~/9~/‘~ns-o002$3.0010
be included. Subjects were then recruited by sending letters
to patients who had been discharged from inpatient status
and were at least three months poststroke. The letter in-
formed them of our interest in shoulder pain in stroke pa-
tients and invited their participation in a study to deter-
mine the cause of the pain.
All patients who volunteered were examined personally
by the author. A standard medical history was obtained,
including details of the stroke and its onset. and specific
information about the pain including its nature, severity,
location, radiation, onset, course, and factors influencing or
accompanying the pain. A physical examination was per-
formed and the following data were recorded: the presence
of abnormality in the shoulder such as subluxation or ten-
derness on palpation; passive range of motion (ROM) in
the shoulder in all planes: the amount of pain with motion:
the presence of any accompanying abnormalities such as
hand swelling; and a neurologic examination including the
measurement of tone, strength, sensation (light touch, pin-
prick, position sense, two-point discrimination, and stere-
ognosis in the affected upper limb), and reflexes. A clinical
diagnosis was then made regarding the shoulder problem.
If the shoulder pain by its nature or severity was felt by
the patient or physician to interfere in the patient’s normal
daily activities, an injection of 1% lidocaine into the area of
pain in the shoulder was offered in an attempt to remove
the pain. The injection was preceded by an explanation
about the procedure and its possible risks and benefits. If an
injection was given, the results regarding the improvement
in pain and ROM were rated by the patient on a scale of 0
to 5.
Because of the subjective nature of the response, attempts
were made to be as objective as possible by asking the pa-
tients, whenever possible, to use the number scale without
prompting. However, assistance was often necessary to try
to determine exactly what the patient felt. eg, was the pain
I. any better, a little better, etc. Ifthe pain had not been mark-
edly relieved by the injection after several minutes, a second
injection was offered and given into I he area of the remain-
ing pain. If given, the results were again rated as previously
described.
The data were analyzed for associ.ation among variables

Arch Phys Med Rehabil Vol73, May 1992

 410 SHOULDER PAIN, Joynt

using the x’ test and the Fisher exact test, if the sample size Table 1: Patient Demographic Information (N = 67)
was small. Significance was set at a 0.05 level. Statistics
Percent of Cases
were performed using the SPSS/PC+ programa on a desk-
top computer. For the purposes of data analysis, variables Age(YN
were sometimes transformed from an interval scale to an <55 I5
ordinal scale (eg, specific degrees of ROM in all directions 55-65 37
66-15 36
were summated from the measured ranges and transformed 275 22
to a scale indicating mild, moderate, or severe motion re- Gender
striction depending on whether the total range was <33%, Male 45
33% to 67%, or >67% of normal) or separated into conve- Female 55
History
nient groups (eg. clinical diagnosis of bursitis, capsulitis, or Hypertension 67
others). Diabetes 36
Heart disease 33
Previous stroke 9
RESULTS Side Affected
Right 36
Ninety-seven patients were examined, with the interval Left 61
from stroke onset to examination varying from a few days Bilateral 3
to a few years. The largest group were in the 6- to 9-month Physical examination
interval from the time of stroke. Seventy-seven patients had Shoulder subluxation 31
Hand swelling or pain 34
complaints of pain in the hemiplegic extremity, and 49 Tenderness on shoulder palpation 24
were complaining specifically of shoulder pain. Of the 28 Loss of shoulder motion
who were complaining of pain but not specifically of None or mild 33
shoulder pain (ie, diffuse pain or pain in the arm, hand, Moderate 46
neck, or an undeterminable area), 18 exhibited shoulder Severe 21
Pain on passive shoulder movement
discomfort on examination. Therefore. 67 patients were None or mild 45
diagnosed as having a shoulder problem by history and ex- Moderate 42
amination. Severe 13
Some of the pertinent demographic information about Increased upper limb tone 69
Strength in affected upper limb
the 67 patients is shown in table 1. Of particular note was Normal or good 29
the high percentage of patients with left hemiplegia (6 1%) in Fair II
the total sample. The onset of pain was reported within the Poor or less 61
first month after stroke by the largest number of cases, but Sensation in affected upper limb
patients frequently had communication difficulties, and Normal or minimal loss 46
Moderate loss 49
there had often been a considerable time lapse between the Marked loss 5
stroke and the evaluation: therefore, the accuracy of histori- Increased upper limb reflexes 85
cal information was sometimes questionable. The inability Clinical diagnosis
to find patients with shoulder pain in the inpatient hospital Subacromial bursitis 43
Capsulitis 33
setting in the initial part of the study also suggests that infor- Other 24
mation about the time of onset of pain may have been unre- Pain characteristics
liable. At the time of evaluation, the largest group of pa- Stroke to pain
tients (28) was six to nine months from the onset of their I month or less 30
stroke. 2-6 months 22
Corse
The following variables were found to show association Stable 25
by the x2 test, with the statistical significance (p value) Progressive I5
shown in parentheses. Patients more than 75 years old often Improving I
tended to have a nonspecific diagnosis, whereas patients 55 Vague 52
Location
to 65 years old were diagnosed more often with subacro-
Lateral shoulder 25
mial bursitis (0.05). The severity of the complaint of Shoulder (general) 22
shoulder pain was related to the amount of passive loss of Shoulder (top) I9
shoulder range (.OO1) and to the amount of pain on Radiation
shoulder movement (.002). Shoulder pain with movement Arm 33
Neck 16
was greatest when it was located laterally in the shoulder Nature
area (.007) and radiated into the arm (0.06). As might be Sharp 31
expected, a clinical diagnosis of subacromial bursitis was Achy 19
associated with pain located laterally in the shoulder area Vague 31
Severity
(.OO1) and radiating into the arm (.003). Loss of shoulder Mild 55
range was not only associated with the amount of pain pro- Moderate 31
duced on movement (.OOO),but also with pain radiating Severe 14
into the arm (0.02). Although not related significantly to Movement
strength (O.OS),patients with more strength tended to have Aggravation 64

Arch Phys Med Rehabil Vol73, May 1992

 SHOULDER PAIN, Joynt
the best ROM. Strength was related to the presence of
shoulder subluxation, with the weakest patients having the
highest incidence of subluxation (.OO1). The weaker pa-
tients tended to have a diagnosis of capsulitis, whereas the
stronger patients tended to have a diagnosis of subacromial
bursitis (0.04). Patients with better sensation also tended
to have lateral shoulder pain (0.02) with radiation to the
arm (0.03).
When the 49 patients complaining specifically of
shoulder pain were compared with the 18 patients com-
plaining of pain not specifically in the shoulder, the former
were more often diagnosed as having subacromial bursitis
(0.02). These patients also tended to have more severe pain
with movement (0.05), better sensation (0.02). and better
strength (0.05). The patients not localizing the pain to the
shoulder more often tended to be aphasic (0.04). However,
statistically. patients complaining of shoulder pain did not
complain of more severe pain, and they did not exhibit
shoulder subluxation more often than patients complain-
ing of pain elsewhere.
Of the 67 patients diagnosed as having a shoulder prob-
lem, 28 were injected with a local anesthetic. Those who
declined the injection most often did so when it was ex-
plained to them that the injection was just a test to locate
the pain and not intended as a definitive treatment. Approx-
imately 1OmL of 1% lidocaine was injected into the subacro-
mial area in all instances. In 6 patients, a second injection
was given-two instances into the anterior capsule area,
two into the posterior capsule area, and two into the
shoulder joint itself. A comparison of the injected and non-
injected patients showed that those who were injected more
often had lateral shoulder pain (.0003) with radiation into
the arm (0.04). They also had more severe complaints of
pain (.004), greater restriction of ROM (.005), and greater
pain on ROM (.OOO).The diagnosis was more often subacro-
mial bursitis than other diagnoses (0.03).
The effects of the injection on pain and ROM are shown
in table 2. It is noted that slightly fewer than half of the
patients indicated that they obtained moderate or marked
degrees of improvement, although most patients did indi-
cate that they felt somewhat better than before the injec-
tion. Interestingly, although the number of second injec-
tions was small, the results in general (table 2) were
comparable to the effects of the first injection, with approxi-
mately a 50% response to the second injection as well.
Statistical analysis was performed on the results to at-
tempt to identify factors that might contribute to the qual-
Table 2: Results of Local Anesthetic Injection*
Marked Moderate
Injection ofsubacromial area (n -= 28)
Amount of pain relief 14 29
Increase in ROM 14 29
Injection of other areas (n = 6)
Amount of pain reliel 13 17
Increase in ROM 17 17
* Numbers represent the percentage of injected cases.
411
ity of the results. ROM and pain both tended to improve in
a similar manner (.002). The improvement in ROM tended
to be better in patients with right hemiplegia than left hemi-
plegia (O.Ol), but the amount of pain relief was not signifi-
cantly better in one group than in the other. The patients
without evidence of shoulder subluxation tended to have
more improvement in ROM (0.0s). Older patients ob-
tained good results less often (0.05). The amount of pain
relief did not seem to be related to the initial severity of the
pain complaint or the severity of the pain on movement,
and there was no relationship to factors such as pain loca-
tion, sensation, strength, or clinical diagnosis. All subjects
who had a second injection had left hemiplegia.
DISCLJSSION
Although shoulder pain is common in hemiplegia, there
is considerable controversy about its etiology and appro-
priate treatment. Several investigators have suggested that
the presence of shoulder subluxation is an important factor
in the development of pain. Shai and colleagues” showed a
strong association between chronic shoulder pain and sub-
luxation. Of 19 patients with subluxation, I4 had pain com-
pared with three instances of pain in 1 I patients with nor-
mal x-rays. It was suggested that subluxation was the
principal cause of pain in the shoulder in hemiplegia. De-
Courval and associates’* reported that patients with
shoulder pain had significantly more subluxation. Van Ou-
wenaller and coworkers6 also stated that subluxation
seemed to be responsible for the greatest number of pain
complications of the shoulder.
However, in their study of 100 consecutive patients with
hemiplegia, Peszczynski and Rardin’ indicated that there
was no statistical difference in the amount of subluxation in
patients with or without pain. Kumar and colleagues4 re-
ported a 46% incidence of subluxation in their 28 cases, but
no difference was noted in the development of pain with or
without subluxation. Our study also failed to show a statis-
tical relationship between the presence of subluxation and
either the severity of the complaint or the amount of pain
on passive movement.
Najenson and Pikielny, I3 in a study of 280 x-rays of
hemiplegic patients, found 88 patients with malalignment
of the glenohumeral joint: they felt that malalignment in
itself produced moderate pain. Malalignment was also asso-
ciated with severe paralysis. Chaco and W01f’~reported that
subluxation was found in flaccid pat.ients only. Our study
showed an association between weakness and shoulder sub-
luxation, but it did not show a relationship between the
amount of tone and subluxation. Although subluxation of
the glenohumeral joint is common in hemiplegia, there is
Minimal doubt whether it is a causative factor in pain production: it
or None may merely reflect the lack of muscle function.
Trauma has been implicated as a cause of shoulder pain
51 in several reports. It has been suggested that trauma may be
57 caused by uncontrolled ROM exercise. particularly with an
overhead pulley.4.15 This could produce an impingement
50
problem or actual tear of the rotator cuff as the humerus is
67
rubbed under the acromion when the amI is passively ab-
ducted. The incidence of pain relief by local anesthetic in-
Arch Phys Med Rehabil Vol73, May 1992
 412 SHOULDER PAIN, Joynt
jection into the subacromial area in our study would tend to
support the fact that, in a significant number of patients,
discomfort is related to subacromial pathology.
Shoulder arthrography in stroke patients with shoulder
pain showed a 33% to 40% incidence of rotator cuff tears in
two studies.15*‘6However, another study” of arthrography
in 30 patients showed no evidence of rotator cuff tears or
subluxation, but it indicated that there was a reduced joint
volume evident on the arthrogram in 77% of cases. The
conclusion was that patients had adhesive capsulitis related
to lack of movement.
On arthrography in 77 stroke patients, Hakuno and asso-
ciates’* found adhesive changes in paralyzed shoulders
more often than in contralateral shoulders, but they found
no greater incidence of cuff tears on the paralyzed side. It is
possible that adhesive changes reflect a late stage of the pro-
cess when chronic irritation or injury, inflammation, and
lack of movement have eventually resulted in a frozen
shoulder with adhesions. However, in our patients there
was no statistical relationship between the amount of loss of
ROM or the clinical diagnosis and the time between stroke
onset and our evaluation.
Nerve injury to the brachial plexus or the suprascapular
nerve is another kind of trauma that has been implicated as
a possible causative factor by several investigators,‘9-2’ but it
has been disputed by others.‘7,2’
Several other factors are also reported to be associated
with shoulder pain. Most studies,‘.4 have reported a rela-
tionship between the amount of pain and the loss of
shoulder motion, but the conclusion that pain is the result
of loss of ROM does not necessarily follow. It has been
suggested that spasticity may be an important contributing
factor in pain development6,“; one study of 2 19 patients
reported an 85% incidence of pain in spastic patients versus
18% in flaccid patients.6 However, our study and others,’
failed to show a significant correlation between the amount
of pain and the amount of spasticity (increased tone or re-
flexes).
It has been stated that sensory abnormality plays a role in
development of shoulder-hand syndrome,23 and that pa-
tients with shoulder pain had less sensation to pinprick.12
Our study did not show a correlation between sensory loss
and the amount of pain. It has also been suggested that pain
was not related to the amount of weakness,“4 and our data
tend to support that assertion.
The preponderance of left hemiplegia in our sample was
of interest. DeCourval and associates’2 also found that pain
was significantly more frequent in patients with left hemi-
plegia, but there was no relationship between pain and the
presence of hemineglect. In another study of 4 1 stroke pa-
tients 23the incidence of shoulder-hand syndrome was 6 1%
if the' patients had proprioceptive deficits and visual ne-
glect. Although the side of the hemiplegia was not stated, it
might be expected that these patients had predominately
left hemiplegia. It was felt that the neglect might affect the
patient’s ability to protect the affected limb. However.
Peszczynski and Rardin’ showed more right hemiplegia
than left hemiplegia (23 vs 15) in their shoulder pain popula-
tion. Davis and associatesZ4 had 4 1 right and 27 left cases of
hemiplegia in their shoulder-hand syndrome group.
Arch Phys Med Rehabil Vol73, May 1992
In our study, of 28 patients complaining of pain in the
involved extremity but not in the shoulder specifically, 18
were found, on further evaluation, to have a shoulder prob-
lem. It has also been suggested’,’ that there are a significant
number of patients with shoulder problems who do not
complain of shoulder pain. Therefore, the incidence of
shoulder pathology may be higher than the number of indi-
viduals complaining. Identification of the presence of a
shoulder problem may require examination of the
shoulder, even in the absence of specific complaints.
Our study was a preliminary attempt to identify the ana-
tomic structure(s) producing shoulder pain to plan treat-
ment more appropriately. It was shown that an injection of
lidocaine into the subacromial area resulted in moderate to
marked relief in almost 50% of the cases, suggesting that, in
these cases at least, there was a significant pain-producing
structure in the subacromial area, possibly related to inflam-
mation or trauma and possibly caused by impingement of
the head of the humerus against the acromion because of
disturbed shoulder kinetics. Although only 50% of patients
obtained moderate or marked relief, in some cases relief of
symptoms was so dramatic that it seemed that the exact
source of pathology had been located. The inability to re-
move the pain by local anesthetic injection in all cases sug-
gests that in these cases the pain-producing structures were
located in areas not reached by the anesthetic, and because
the subacromial area was injected in all cases, it seems un-
likely that this area is always the source of pain.
CONCLUSION
The ability to follow our hypothesis to its logical conclu-
sion, ie, repeated injections until the pain was completely
relieved, was not possible because of our patients’ intoler-
ance to such efforts. However, the conclusion that the sub-
acromial area is the pain source in a significant number of
cases seems reasonable. Therefore, when clinical evaluation
points to the subacromial area as a likely source of the pain,
treatment with physical modalities, steroid injections, and
ROM exercises (administered with caution to avoid im-
pingement) would seem to be indicated as early as possible
to reduce symptoms and prevent later complications.
The higher incidence of problems in left hemiplegia and
the somewhat poorer results of injection in patients with
left hemiplegia raise the possibility that perception may also
play a role in the pathogenesis of the pain. Neglect of the
extremity may lead to increased trauma, or disturbed per-
ception of the nature of pain may cause difficulties in the
proper interpretation of the sensory input from the extrem-
ity, thereby producing a feeling of pain in the absence of the
usual pathology. The role of perceptual abnormalities in
the pathogenesis of shoulder pain requires more detailed
study.
References
1. Bohannon RW. Larkin PA. Smith MB, Horton MG.
Shoulder pain in hemiplegia: Statistical relationship with five
variables. Arch Phys Med Rehabil 1986:67:5 14-6.
3 Peszczynski M. Rardin TE. The incidence ofpainful
-. shoulder
in hemiplegia. Bull Pol Med Sci Hist 1965:8:2 1-3.
 SHOULDER PAIN, Joynt
_3 Roy CW. Shoulder pain in hemiplegia: A literature review.
C‘lin Rehabil 1988:2:35-44.
4. Kumar R, Metter EJ, Mehta AJ. Chew T. Shoulder pain in
hemiplegia: The role of exercise. Am J Phys Med Rehabil
1990:69:705-X.
5 Braun RM, West F, Mooney V. et al. Surgical treatment of
_ 17. Rizk TE. Christopher RP, Pinals RS. et al. Arthrographic stud-
painful shoulder contracture in the stroke patient. J Bone
Joint Surg [Am] 1971:53:1307-12.
6. Van Ouwenaller C. Laplace PM, Chantraine A. Painful
shoulder in hemiplegia. Arch Phys Med Rehabil 1986;67:23-
6.
I. Griffin JW. Hemiplegic shoulder pain. Phys Ther 1986;
66: 1884-93.
8. Bruton JD. Shoulder pain in stroke patients with hemiplegia
or hemiparesis following a cerebrovascular accident. Physio-
therapy 1985:7 I :2-4.
0. Brandstater ME, Basmajian JV eds. Stroke Rehabilitation.
Baltimore: Williams & Wilkins, 1987:237-4 1.
IO. Cailliet R. The shoulder in hemiplegia. Philadelphia: Davis.
1980.
I I. Shai G, Ring H. Costeff H. Solzi P. Glenohumeral malalign-
ment in the hemiplegic shoulder. Stand J Rehabil Med
1984: 16: I 33-6.
12. de Courval LP, Barsauskas A, Berenbaum B, et al. Painful
shoulder in the hemiplegic and unilateral neglect. Arch Phys
Med Rehabil 1990:7 1:673-6.
13. Najenson T. Pikielny SS. Malalignment ofthe gleno humeral
joint following hemiplegia: Review of 500 cases. Ann Phys
Med 1965;8:96-0.
14. Chaco J. Wolf E. Subluxation of the glenohumeral joint in
hemiplegia. 4m J Phys Med 197 1:50: 139-43.
413
15. Najenson T, Yacubovich E, Pikielni SS. Rotator cuff injury in
shoulder joints of hemiplegis patients. Stand J Rehabil Med
1971;3:131-7.
16. Nepomuceno CS, Miller JM III. Shoulder arthrography in
hemiplegic patients. Arch Phys Med Rehabil 1974;55:49-5 1.
ies in painful hemiplegic shoulders. Arch Phys Med Rehahil
1984;65:254-6.
18. Hakuno A, Sashika H. Ohkawa T, ltoh R. Arthrographic tind-
ings in hemiplegic shoulders. Arch Phys Med Rehabil
1984:65:706-I I.
19. Chino N. Electrophysiological investigation on shoulder sub-
luxation in hemiplegics. Stand J Rehabil Med I Y8 1;13: 17-2 1.
20. Estapk R, Ferel D, Barth R. Brachial plexus lesions in hemi-
plegics. Acta Neurol Belg 1979:79:444-g.
‘1. Kaplan PE. Meridith J, Taft G, Betts HB. Stroke and brachial
plexus injury: A difficult problem. Arch Phys Med Rehabil
1977;58:415-8.
22. Lee K-H, Khunadorn F. Painful shoulder in hemiplegic pa-
tients: A study of the suprascapular ner\‘e. Arch Phys Med
Rehabil 1986;67:8 18-20.
23. Chalsen GG. Fitzpatrick KA, Navia R.4. et al. Prevalence of
the shoulder-hand pain syndrome in an in-patient stroke reha-
bilitation population: A quantitative cross-sectional study. J
Neuro Rehab 1987:1:137-41.
24. Davis SW, Petri110 CR, Eichberg RD. C’hu DS. Shoulder-
hand syndrome in a hemiplegic population: A 5-year retro-
spective study. Arch Phys Med Rehabil I977:58:353-6.
Supplier
a. SPSS Inc.. 444 N Michigan Avenue. I:‘hlcago. IL 606 I I
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