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Hemiplegic Shoulder Subluxation

Original Editor - Fasuba Ayobami Top Contributors - Vaibhav Panchal, Manisha Shrestha, Fasuba Ayobami, Yesmine Gouddi, Caroline Stone, Lucinda hampton, Kim Jackson, Mohamed Abdelraof Mohamed, Alexandra Stead, Candace Goh, Vidya Acharya, Shreya Pavaskar, Amanda Ager, Lauren Lopez, Naomi O'Reilly, Robin Tacchetti, Dinu Dixon and Mariam Hashem

Page Summary

  • Hemiplegic shoulder subluxation affects up to 80% of stroke survivors, occurring when hypotonic shoulder muscles cannot anchor the humeral head within the glenoid cavity.
  • Glenohumeral subluxation often develops in the first 3 weeks of hemiplegia, typically presents after 2–3 months, and may lead to adhesive capsulitis.
  • The fingerbreadth palpation method grades the acromion to humeral head gap on a 0–5 scale, defining subluxation as a gap of ½ fingerbreadth or more.
  • Neuromuscular electrical stimulation of supraspinatus and posterior deltoid can prevent subluxation in the acute phase, although benefits are not maintained after treatment withdrawal.

Introduction

Post stroke shoulder dislocation

Shoulder subluxation or Glenohumeral subluxation (GHS) is a common post-stroke complication affecting up to 80% of patients who have experienced stroke[1]. The glenohumeral joint (GHJ) is a commonly dislocated joint, due to the lack of stable bone structure that allows for its increased range of motion[2]. Under normal circumstances, stability is achieved through muscle force[2]. A change in normal muscular function that may occur after a stroke presents a potential risk for subluxation[2].

In periods of flaccidity or hypotonicity, the shoulder muscles cannot anchor the humeral head within the glenoid cavity, resulting in a high risk of shoulder subluxation[3][2]. The weight of the upper extremity may be enough to cause subluxation[2]. Glenohumeral subluxation may also occur as a result of adopting incorrect sleeping postures, lack of support when the patient is in a vertical position or tension on the hemiplegic arm when the patient is being moved from one place to another.[2]

In the long term, GHS may lead to adhesive capsulitis or reduced proprioception, which may delay the recovery of upper extremity function [4][5].

Epidemiology

The incidence of shoulder subluxation in patients following a stroke varies from 17%–81%[6]. 73% of shoulder subluxations occur in the acute stage[6]. The development of shoulder subluxation often occurs during the first 3 weeks of hemiplegia[7]. However, the condition typically presents after 2–3 months[8][9]. In a 10-month follow-up study, shoulder subluxation was shown to be further aggravated in 67% of patients over time[5].

Pathomechanics and Risk factors

Supraspinatus and posterior deltoid muscles play a crucial role in maintaining glenohumeral alignment and preventing downward subluxation of the humerus[10][11]. Spasticity in subscapularis reduces abduction, flexion and external rotation range of motion, which may contribute to a shoulder subluxation[2]. These muscles may be affected by hemiplegia post-stroke, affecting the normal action of the shoulder. Other factors contributing to subluxation include:

  • Improper positioning and lack of support in the upright position[2]
  • Prolonged downward pull of gravity and lack of counterforce by muscles
  • Pulling on the hemiplegic arm when the patient is transferred[11]
  • Severe loss of motor function and apparent absence of supraspinatus muscle contraction[11]

Another possible explanation for the development of GHS involves impairments in tone within the periscapular musculature, though little evidence has been found in recent years to support the relationship between development of GHS and a downward orientation in the scapula[11]. The trapezius and the serratus anterior become flaccid, the pectoralis major and minor, rhomboids, levator scapulae and latissimus dorsi become hypertonic, and the trunk may lean or shorten toward the hemiplegic side[11]. Without a normal tone, the rotator cuff can no longer maintain the integrity of the glenohumeral joint, and combined with the impairments in scapular positioning, may contribute to the development of GHS.[11]

Assessment

Radiographic measurements (X-ray and ultrasound) are considered a standard measurement and have been used in several studies to assess the effectiveness of therapy or development of GHS over time[11]. Radiography can be difficult to put into practice in many settings due to cost, exposure to radiation, specialised equipment or delayed feedback for therapeutic choices[11].

Fingerbreadth Palpation Method

A clinically feasible test for shoulder subluxation is the Inferior Sulcus Test[12]. The sulcus sign is a gap or slight depression felt when palpating over the glenohumeral joint labrum and head of humerus and when present, indicates a shoulder subluxation[12]. It can be graded through fingerbreadth palpation method[13].

Technique for the fingerbreadth palpation method

Patients should sit in a chair or wheelchair with both feet flat on the ground or footrest. The physical therapist assesses the unaffected side to palpate the gap between the acromion and the humerus head and repeats on the affected shoulder. Shoulders should be positioned in neutral rotation, with the arm hanging by the side, thumb pointing forward, and close to the body with no abduction[13].

Grading

Glenohumeral subluxation is defined as a palpable gap between the inferior aspect of the acromion and the superior aspect of the humeral head that is ½ fingerbreadth or more[13]. A 0–5 grading scales are as follow:

Table: Fingerbreadth grading scale
0 No subluxation
1 ½ fingerbreadth gap
2 1 fingerbreadth gap
3 1½ fingerbreadth gap
4 2 fingerbreadth gap
5 2½ fingerbreadth gap

Physical Therapy Management

Education

Caregivers, health professionals and relatives should be informed on the importance of proper handling of the arm. Patients who have their arm unsupported and/or handled inappropriately by caregivers, specifically pulling on the arm, are at a higher risk for traction neuropathy and injury.[14][15][4][16]

Mechanical Approaches

Shoulder support or orthosis could reduce the subluxation temporarily[17]. Manual approaches such as positioning, the use of slings or strapping/taping are options that can be used to reduce subluxations.

Positioning

Lap trays, pillows and foam support help to keep the arm and shoulder supported in the correct position. Good positioning can help reduce strain on ligaments and prevent frozen shoulder from occurring.[14][15][4][18]

Slings

Supports from slings have various purposes: realigning scapular symmetry, supporting the forearm in a flexed arm position, improving anatomic alignment with auxiliary support, or supporting the shoulder with a cuff.[11]

The use of slings may increase flexor tone and synergistic patterns, cause reflex sympathetic dystrophy, restrain functional recovery, obstruct arm swing during walking, and for some, impair body image.[11] Some clinicians considered these as contraindications. On the other hand, slings are generally simpler for caregivers than functional electrical stimulation (FES) or strapping, and they can be combined with the other treatments. Reviewing the literature and knowing the structural characteristics of slings can help identify the best treatment for preventing and treating GHS.[11]

Strapping/Taping

Shoulder strapping is helpful in the first period after stroke to help reduce subluxations. Multiple options for taping exist, and can be beneficial for patients.

Longitudinal strapping method: Application of two to three strips of strapping with upward tension along the anterior, middle, and posterior deltoid, extending to cover the shoulder complex, occasionally incorporating an anchor strip[19].

Circumferential strapping method: The application of strapping around the shoulder joint. It originates from the clavicle, wrapping around the deltoid to go under the axilla (over a protective pad) and ending on the spine of the scapula. Longitudinal strapping of the shoulder in patients with stroke seems to positively influence shoulder subluxation and pain[20].

California tri-pull taping method
California tri-pull taping method

The California Tri-pull Taping Method: This taping has been shown to reduce pain, improve active shoulder flexion, and improve distal upper extremity functional ability[21]. This appears to be a promising early adjunct treatment for patients who have suffered a stroke and demonstrate pain in a subluxed shoulder[21]. This taping method allows the patients to participate in all active UE exercises as well as all ADL's. However, there was no follow-up to determine if the effects demonstrated were maintained.[21]

Kinesio tape: Kinesio taping may be beneficial for reducing shoulder subluxation, improving motor function of the UE and activities of daily living in patients with hemiplegic shoulder pain post-intervention[22]. Kinesio taping was associated with reduced pain for patients with chronic stroke.[22]

Neuromuscular electrical stimulation

Electrical stimulation can prevent shoulder subluxation and decrease shoulder pain in acute phase, but this effect was not maintained after the withdrawal of treatment in later follow-ups[10][17][23]. Conventional transcutaneous electrical nerve stimulation (TENS) can be applied to relieve pain[23].

Table 1: Recommendations for the use of NMES in Hemiplegic Shoulder Subluxation[24]
Indication Patient Position Electrode Placement Parameter Recommendations
Prevention or treatment of

shoulder sublux resulting

from UE flaccidity poststroke

Patient sitting with arm support One channel over the muscle belly of supraspinatus

and posterior deltoid. Avoid upper trapezius fibres and excessive shoulder shrug. Applying a second channel to stimulate the long head of the biceps can be beneficial in correcting humeral head alignment.

NMES waveform: symmetric or asymmetric biphasic PC

Frequency: 30–35 Hz

Pulse duration: 250–350 ms

Current amplitude: sufficient to produce a smooth,sustained muscle contraction and reduction of shoulder sublux

Work–rest cycle: ON:OFF 10–15 s ON time with progressively

shorter rest time (30 s ON time, 2 s OFF time). Rampup time (1–4 s) is set to ensure patient comfort; longer ramp-down time may be required to prevent pain or tissue

stretching when the arm sags due to gravity.

Treatment schedule: progress to 2–4 h/d on the basis of

muscle fatigue

Session frequency: 7 d/wk for 4–6 wk or until voluntary

control has been restored

Manual Therapy

Orthopaedic manual therapy techniques, such as mobilisation of joints and shortened muscles, neuromuscular activation and control of stabilising musculature, and endurance training can help reduce decrease pain and increase range of motion[25]. In the early rehabilitation phase, passive range of motion exercises have been shown to effectively prevent shoulder subluxation among stroke patients[15]. Range of motion exercises for the shoulder joint should include flexion-extension, abduction-adduction and external-internal rotation. If improperly performed, it can cause injury to the shoulder and increase the stroke patient’s risk for shoulder subluxation[15].

Possible interventions include:

  • Transverse friction massage[25]
  • Passive stretching[25]
  • Glenohumeral, thoracic and rib joint mobilisations[25]

One of the common therapeutic techniques is Bobath. This method is centered on the idea that patients should be moved and positioned into reflex inhibiting positions[26]. The hemiparetic limb should be positioned away from abnormal increases in muscle tone. [26]

Exercise

Weight-bearing and shoulder stabilisation exercises can help reduce incidence of shoulder subluxations in patients with hemiplegia[27]. Quadruped weight shifting onto the affected limb, both anterior/posterior and lateral, is a simple weight-bearing exercise to help improve shoulder stability and reduce incidence of subluxations[27].

Active shoulder exercise with a sling suspension system may effectively reduce shoulder subluxation, and improve proprioception and upper extremity function in patients following acute stroke[5][27]. Sling suspension systems facilitate movements in a gravity-minimised position, which allows for performance of exercise to address underlying neuromuscular deficits contributing to subluxations[27]. Active assisted exercises, with or without a sling suspension system, can also be beneficial[27].

See video below for further exercise examples

[28]

Robotic Therapy

Robotic therapy includes use of an exoskeleton for performance of exercise[29]. Use of an exoskeleton has been shown to reduce pain and degree of spasticity in the upper extremity, which can help increase the range of motion in the joint and the improve muscle tone[29]. The use of robotic rehabilitation can be beneficial both within the acute and chronic phases post-stroke[29].

Pharmacological Treatment

In addition to physiotherapy, electrotherapy and other various methods to reduce pain in Hemiplegic Shoulder Pain (HSP), the use of Analgesic, anti-inflammatory and corticosteroid injections have been used to treat and reduce pain[30].

Resources

Summary

Glenohumeral shoulder subluxation is a common post-stroke complication[6][5]. Loss of muscle activation in the rotator cuff, poor upper extremity positioning and the downward pull of gravity without counteracting muscle force may contribute to the development of GHS[10][2][11]. Management options include taping, positioning with external supports, orthopaedic manual therapy, strengthening exercises, and robotic therapy. Providers and caregivers should be educated on proper handling to reduce risk of subluxation.

References

  1. ↑ Arya KN, Pandian S, Vikas, Puri V. Rehabilitation methods for reducing shoulder subluxation in post-stroke hemiparesis: a systematic review. Topics in stroke rehabilitation. 2018 Jan 2;25(1):68-81.
  2. ↑ 2.0 2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8 Murie-Fernández M, Iragui MC, Gnanakumar V, Meyer M, Foley N, Teasell R. Painful hemiplegic shoulder in stroke patients: causes and management. Neurología (English Edition). 2012 May 1;27(4):234-44.
  3. ↑ Kim, M.G., Lee, S.A., Park, E.J., Choi, M.K., Kim, J.M., Sohn, M.K., Jee, S.J., Kim, Y.W., Son, J.E., Lee, S.J. and Hwang, K.S., 2022. Elastic Dynamic Sling on Subluxation of Hemiplegic Shoulder in Patients with Subacute Stroke: A Multicenter Randomized Controlled Trial. International Journal of Environmental Research and Public Health, 19(16), p.9975.
  4. ↑ 4.0 4.1 4.2 Stroke-rehab.com [Internet]. Shoulder subluxation.
  5. ↑ 5.0 5.1 5.2 5.3 Jung KM, Choi JD. The Effects of Active Shoulder Exercise with a Sling Suspension System on Shoulder Subluxation, Proprioception, and Upper Extremity Function in Patients with Acute Stroke. Med Sci Monit. 2019 Jun 30;25:4849–4855
  6. ↑ 6.0 6.1 6.2 Praveen Kumar, Marianne Mardon, Michael Bradley, Selena Gray, Annette Swinkels, Assessment of Glenohumeral Subluxation in Poststroke Hemiplegia: Comparison Between Ultrasound and Fingerbreadth Palpation Methods, Phys Ther. 2014 Nov;94(11):1622-31. doi: 10.2522/ptj.20130303. Epub 2014 Jul 24
  7. ↑ Stolzenberg D, Siu G, Cruz E. Current and future interventions for glenohumeral subluxation in hemiplegia secondary to stroke. Top Stroke Rehabil 2012; Sep-Oct;19(5):444-56
  8. ↑ Poduri KR. Shoulder pain in stroke patients and its effects on rehabilitation. J Stroke Cerebrovasc Dis. 1993;3(4):261-6.
  9. ↑ 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 Jul;17(14):4962.
  10. ↑ 10.0 10.1 10.2 Linn SL, Granat MH, Lees KR. Prevention of shoulder subluxation after stroke with electrical stimulation. Stroke. 1999 May;30(5):963-8.
  11. ↑ 11.00 11.01 11.02 11.03 11.04 11.05 11.06 11.07 11.08 11.09 11.10 11.11 Paci M, Nannetti L, Rinaldi LA. Glenohumeral subluxation in hemiplegia: An overview. J Rehabil Res Dev. 2005 Jul-Aug;42(4):557-68.
  12. ↑ 12.0 12.1 Tzannes A, Murrell GA. Clinical Examination of the Unstable Shoulder/links/02bfe5114217fb55e0000000/Clinical-Examination-of-the-Unstable-Shoulder.pdf|Clinical examination of the unstable shoulder. Sports Medicine. 2002 Jun;32:447-57.
  13. ↑ 13.0 13.1 13.2 Kumar P, Mardon M, Bradley M, Gray S, Swinkels A. Assessment of glenohumeral subluxation in poststroke hemiplegia: Comparison between ultrasound and fingerbreadth palpation methods. Phys Ther. 2014 Nov 1;94(11):1622-31.
  14. ↑ 14.0 14.1 Kumar P, Fernando C, Mendoza D, Shah R. Risk and associated factors for hemiplegic shoulder pain in people with stroke: a systematic literature review. Physical Therapy Reviews. 2022;27(3):191–204.
  15. ↑ 15.0 15.1 15.2 15.3 Seneviratne C, Then KL, Reimer M, Then KL, Reimer M. Post-stroke shoulder subluxation: a concern for neuroscience nurses. Axone. 2005 Sep 1;27(1):26.
  16. ↑ Duncan PW, Zorowitz R, Bates B, Choi JY, Glasberg JJ, Graham GD, Katz RC, Lamberty K, Reker D. Management of adult stroke rehabilitation care: a clinical practice guideline. Stroke. 2005 Sep 1;36(9):e100-43.
  17. ↑ 17.0 17.1 Arya KN, Pandian S, Vikas, Puri V. Rehabilitation methods for reducing shoulder subluxation in post-stroke hemiparesis: a systematic review. Top Stroke Rehabil. 2018 Jan 2;25(1):68-81.
  18. ↑ FlintRehab [Internet]. Shoulder Exercises for Stroke Patients from an Expert Occupational Therapist; 2021 feb 1.
  19. ↑ Comley-White N, Mudzi W, Musenge E. Effects of shoulder strapping in patients with stroke: A randomised control trial. S Afr J PhysioTher. 2018 May 7;74(1):1-1.
  20. ↑ Comley-White N, Mudzi W, Musenge E. Effects of shoulder strapping in patients with stroke: A randomised control trial. S Afr J Physiother. 2018;74(1).
  21. ↑ 21.0 21.1 21.2 Chatterjee S, Hayner KA, Arumugam N, Goyal M, Midha D, Arora A, Sharma S, Kumar SP. The California tri-pull taping method in the treatment of shoulder subluxation after stroke: a randomized clinical trial. N Am J Med Sci. 2016 Apr;8(4):175.
  22. ↑ 22.0 22.1 Deng P, Zhao Z, Zhang S, Xiao T, Li Y. Effect of kinesio taping on hemiplegic shoulder pain: A systematic review and meta-analysis of randomized controlled trials. Clin Rehabil. 2021 Mar;35(3):317-31.
  23. ↑ 23.0 23.1 Zhou M, Li F, Lu W, Wu J, Pei S. Efficiency of neuromuscular electrical stimulation and transcutaneous nerve stimulation on hemiplegic shoulder pain: a randomized controlled trial. Arch Phys Med Rehabil. 2018 Sep 1;99(9):1730-9.
  24. ↑ Nussbaum EL, Houghton P, Anthony J, Rennie S, Shay BL, Hoens AM. Neuromuscular electrical stimulation for treatment of muscle impairment: critical review and recommendations for clinical practice. Physiotherapy Canada. 2017;69(5):1-76.
  25. ↑ 25.0 25.1 25.2 25.3 Lindgren I, Lindgren A, Carlsson H, Lundgren T, Borgardh C. Orthopedic manual physical therapy for post-stroke shoulder pain: two case reports including clinical assessments and participants experiences. J Rehabil Med Clin Commun. 2025 Jun 3;8:43201.
  26. ↑ 26.0 26.1 Bender L, McKenna K. Hemiplegic shoulder pain: defining the problem and its management. Disabil Rehabil. 2001;23:698–705.
  27. ↑ 27.0 27.1 27.2 27.3 27.4 Killedar MT, Kanase SB. Effect of sling suspension-based active shoulder joint exercises on shoulder subluxation in subacute stroke patients. Cureus. 2026 May 21;18(5):e109397
  28. ↑ Bob and Brad Top 3 Exercises for Weak Arm after Stroke (Simple Do-it-yourself).
  29. ↑ 29.0 29.1 29.2 Serrezuela RR, Quezada MT, Zayas MH, Pedrón AM, Hermosilla DM, Zamora RS. Robotic therapy for the hemiplegic shoulder pain: a pilot study. J Neuroeng Rehabil. 2020 Dec;17(1):1-2.
  30. ↑ Van Ouwenaller C, Laplace P,Chantraine A (1986) Painful shoulder in hemiplegia. Arch Phys Med Rehabil. 1986 Jan;67(1):23-6.
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