Why Does the Shoulder Hurt After a Stroke? Shoulder Pain on the Weak Side

This guide is general information, not medical advice. Always follow the advice of your loved one's doctor, physio or occupational therapist (OT).

Your mum or dad has started to wince when you help them up, or they hold their weak arm close and say the shoulder aches at night. Shoulder pain on the weak side is one of the most common problems after a stroke, and the way the family handles that arm every day can make a real difference.

This guide explains why it happens, what you can do at home, and when to get help.

Why does the shoulder hurt after a stroke?

Shoulder pain after a stroke usually comes from weak muscles that can no longer hold the shoulder joint in place, combined with tightness, stiffness or small injuries from handling. Doctors call it hemiplegic shoulder pain, which simply means pain in the shoulder on the side weakened by the stroke.

The shoulder is a shallow ball-and-socket joint that relies on muscles to keep it steady. When a stroke weakens those muscles, several things can go wrong:

• Subluxation: the weight of the arm drags the top of the upper arm bone partly out of the socket. You may feel a small gap below the bony point of the shoulder.
• Spasticity: some muscles become tight and pull the arm in against the body, which can make the shoulder stiff and sore. Our guide to spasticity and a clenched hand after stroke explains this in more detail.
• Stiffness: a shoulder that hardly moves can lose its range of movement, especially turning outwards.
• Strain and injury: pulling on the weak arm, lifting someone under the armpit or moving the arm too far can damage the soft tissues around the joint.

Often it is a mix of these, which is why a physio or doctor should check what is behind your loved one's pain.

How common is shoulder pain after a stroke?

It is very common. A 2020 systematic review by Anwer and Alghadir, published in the International Journal of Environmental Research and Public Health, pooled studies and estimated that between 22% and 47% of stroke survivors have shoulder pain on the weak side, with most cases developing within two to three months of the stroke.

The same review found that people with very little arm movement, increased muscle tone, reduced feeling in the arm or a subluxed shoulder were more likely to develop pain. The authors noted that many of the studies were of low quality, so these figures are a guide rather than an exact prediction for your family.

The practical message is simple: if your loved one's arm is weak, protect the shoulder from day one rather than waiting for pain to start.

How should you handle the weak arm at home?

Support the weak arm whenever your loved one is sitting, lying or moving, and never pull on it. Canadian Stroke Best Practice Recommendations (2019) and NHS patient guidance (NHS Fife, 2023) both put safe positioning and handling first.

1. When sitting

• Sit well back in the middle of the chair or wheelchair.
• Rest the weak arm forward on one or two pillows on a table or lap tray, so it is not hanging down by the side.
• Keep feet flat on the floor or footrests.

2. When lying in bed

• On their back: rest the weak arm on a pillow, with the shoulder supported.
• On the strong side: bring the weak shoulder slightly forward and rest the arm on a pillow in front.
• On the weak side: make sure the weak shoulder is comfortable and not squashed underneath them. Ask the physio to show you this one.

3. When helping them stand, walk or move

• Never pull on the weak arm or lift them under the armpits.
• Support from the strong side, or the way the physio has shown you, using a transfer belt if one has been recommended.
• When moving the weak arm, hold it gently at the elbow and wrist and move slowly. Movement should not cause pain.

4. During daily care

• When dressing, put the weak arm into the sleeve first, and take it out last.
• Check the skin regularly, especially if feeling is reduced, and remove rings if the hand swells.
• Make sure everyone who helps, including other family members and paid carers, knows the "don't pull the arm" rule.

Do slings and shoulder braces help?

The evidence is weak. A Cochrane review (Ada and colleagues, 2005) of four trials with 142 people found there was not enough evidence to say whether slings or wheelchair supports prevent subluxation, reduce pain or improve arm function, and no evidence that they push a subluxed shoulder back into place.

The Canadian guidelines (2019) suggest avoiding slings except while the arm is completely floppy (flaccid), because a sling can stop the arm being used and may add to tightness. Strapping or taping by a physio may help in some cases, and the same Cochrane review found it delayed the start of pain by about two weeks.

Many South African families search for a "stroke shoulder sling" or "shoulder brace" online. If you are thinking of buying one, ask the physio or OT first whether it suits your loved one's stage and how long to wear it. Our guide to hand splints and braces after a stroke covers similar questions for the hand.

What exercises and treatments can help shoulder pain?

Gentle, guided movement helps keep the shoulder from stiffening, but exercises should come from your loved one's therapist, because the wrong movement can make pain worse.

Things the treating team may suggest include:

The Canadian guidelines (2019) specifically advise against overhead pulleys and against moving the shoulder above shoulder height unless a therapist has shown you how, because these can injure the joint.

Keeping the hand and arm active within the therapist's programme also matters. Some families use a rehab glove, such as Mirra, to help with daily hand repetitions while the arm rests supported on a table. Check with your therapist first that it suits your loved one's shoulder and hand.

What if physio has ended or is hard to get?

You can still protect the shoulder at home with good positioning and handling, and ask for a review if pain starts or changes. In South Africa, many families have only a few sessions in hospital or none after discharge, especially in the public sector or outside the cities.

Before the last session, ask the physio to show you safe positions, the exact exercises to continue and how often, and take photos or a short video on your phone. If pain appears later, your local clinic, GP or a hospital outpatient physio department can refer you back. Our guide on what to do when physio ends after a stroke has more practical steps.

When should you call a doctor or therapist?

Contact your loved one's doctor, physio or OT if you notice:

• Shoulder pain that is new, getting worse or stopping them from sleeping.
• Pain whenever the arm is moved, even gently.
• A hand that becomes swollen, shiny, hot, very sensitive to touch or changes colour, which can be a sign of a pain condition called complex regional pain syndrome.
• A visible gap or change in the shape of the shoulder, or the arm suddenly hanging differently after a fall or a pull.
• Stiffness that is getting worse, so the arm is harder to dress or wash.

Call an ambulance immediately if there are new stroke signs: face drooping, sudden arm or leg weakness, slurred speech, sudden loss of balance or vision. Our BE FAST guide explains what to do in South Africa.

Frequently asked questions

Is shoulder pain after a stroke permanent?

Not necessarily. Many people improve with good positioning, careful handling and treatment from their team, although for some the pain lasts longer. Getting it checked early gives the best chance of managing it well.

Can a subluxed shoulder go back into place?

As the shoulder muscles get stronger, the joint may sit better, but supportive devices on their own have not been shown to move it back (Cochrane review, 2005). A physio can assess the shoulder and advise on taping, electrical stimulation or exercises.

Should my loved one wear a sling all day?

Usually not. Canadian guidelines (2019) suggest avoiding slings except while the arm is completely floppy, and only on a therapist's advice. Wearing one all day can stop the arm being used.

Why does the shoulder hurt more at night?

Lying in a position where the weak shoulder is unsupported or squashed can increase pain. Try supporting the arm on a pillow, and ask the physio to check your loved one's sleeping positions.

Sources

• Anwer S, Alghadir A. Incidence, Prevalence, and Risk Factors of Hemiplegic Shoulder Pain: A Systematic Review. International Journal of Environmental Research and Public Health, 2020.
• Cochrane. Ada L, Foongchomcheay A, Canning CG. Supportive devices for preventing and treating subluxation of the shoulder after stroke. Cochrane Database of Systematic Reviews, 2005.
• Heart and Stroke Foundation of Canada. Canadian Stroke Best Practice Recommendations: Management of shoulder pain following stroke, 6th edition, 2019.
• NHS Fife Occupational Therapy. How to look after your arm following a stroke, 2023.