Post-Stroke Shoulder Pain

Chief Complaint: A 71 year-old female with a history of stroke is seen on rounds during her inpatient rehabilitation stay. She complains of significant shoulder pain.

DOMAIN A: DATA ACQUISITION

+ What are the key components of this patient’s history and physical examination?

Relevant History:

Is the pain unilateral or bilateral? If unilateral, which side is affected?
Onset, duration, radiation, quality, intensity, aggravating/alleviating factors for the pain?
Is there injury/trauma history?
Any specific shoulder pathology history? Has this pain happened before?
Are there any neck pain, sensory or bowel/bladder changes? Any fever, chills?
Does the patient have a history of diabetes?
What is the patient’s stroke history and treatment?
Does the patient have spasticity? Is it treated?
Functional history and current functional status, including equipment usage?
Social history?
Family history?
Past Medical and Surgical History?
Medications?

Relevant Physical Examination:

Vital signs
Inspection
Palpation
Range of motion of neck, shoulders, elbows
Modified Ashworth Scale scores of upper limbs
Manual muscle testing, sensation, reflex examination of bilateral upper limbs
Special testing: Spurling, Neer, Hawkins, Empty Can, Speed, Yergason, O’Brien, Scarf

+ Challenge Question

Why look at Modified Ashworth Scale scores?

+ Challenge Answer

A patient with a history of stroke and elevated MAS scores in the setting of shoulder pain could be experiencing shoulder pain secondary to uncontrolled spasticity. In such a case, identifying and controlling the spasticity is key to improving the patient’s shoulder pain and function.

DOMAIN B: PROBLEM SOLVING

The patient is a 71 year-old female with a history of ischemic right middle cerebral artery (MCA) stroke 3 months ago, resulting in left hemiparesis, who has been residing in a skilled nursing facility until presenting to your inpatient rehabilitation unit for functional recovery. She complains of 2 months of new gradual onset left shoulder pain, worse with range of motion. There is no specific injury history. Current medications include aspirin, atorvastatin, amlodipine, and baclofen. Physical examination reveals intact neuromuscular status on the right side with 3/5 strength throughout the left upper limb and 4/5 strength in the left lower limb. There is significant pain with Neer, Hawkins, and Scarf maneuvers.

+ What is your differential diagnosis for this patient's left shoulder pain?

Rotator cuff tear, rotator cuff impingement, subacromial bursitis, glenohumeral joint arthritis, acromioclavicular joint arthritis, spasticity, adhesive capsulitis/frozen shoulder, shoulder subluxation, cervical radiculopathy, myofascial pain.

+ Further physical examination reveals the following:

She has globally impaired range of motion in the left shoulder, notably in flexion and abduction, which are both limited to 60 degrees passively and cause significant pain when attempting to range. Her MAS scores are 1/4 in left shoulder abduction and elbow flexion. You detect half a fingerbreadth of shoulder subluxation.

+ What is the most likely etiology of this patient's shoulder pain?

Adhesive capsulitis/frozen shoulder.

DOMAIN C: PATIENT MANAGEMENT

+ How would you manage this condition?

I would discuss with her nurse, physical therapist, and occupational therapist on this inpatient rehabilitation unit the likely diagnosis and treatment plan which should include aggressive range of motion of the shoulder daily along with strength and activation exercises. I would also discuss this during weekly team conference so that all team members are aware of the diagnosis and plan. We need to encourage use of the shoulder. Heat, ice, ultrasound, and massage as needed. Oral acetaminophen and NSAIDs. Topical lidocaine and/or diclofenac could be trialed. I would educate the patient on the likely diagnosis and management plan, and ensure that all questions are answered satisfactorily.

DOMAIN D: SYSTEMS-BASED PRACTICE

The patient’s inpatient rehabilitation stay and functional gains in therapy have become extremely limited due to her shoulder pain and impaired range of motion.

Glenohumeral corticosteroid injection to reduce inflammation and improve the range of motion deficit secondary to the adhesive capsulitis.

+ Take me through the steps of a glenohumeral joint injection and how you will minimize risk of harm and side effects for the patient.

I would start with education and informed consent about the risks and benefits of a glenohumeral joint corticosteroid injection. Namely, I would discuss the risk of infection, bleeding, worsened pain, lack of efficacy, inaccuracy of needle placement, and blood sugar elevation, along with the intended benefit of pain relief. If informed written consent were obtained, I would ensure that the patient does not have any allergies to the proposed medications. I would plan to inject 4 mL of 1% lidocaine and 1 mL of injectable corticosteroid. I would draw up these medications into a sterile syringe and then attach a 25-gauge 1.5-2.0 inch needle to this syringe. With the patient seated, affected arm rested at her side, I would mark the needle entry point with a marker (the sulcus between the acromion and humeral head), sterilize the skin with alcohol swabs x3 or similar skin disinfectant, and pierce the skin with the needle, directing the needle towards the coracoid process. With the needle fully inserted, I would aspirate the syringe to confirm there is no blood present within the syringe, and if negative for blood, I would inject the entire contents of the syringe. After injection, I would withdraw the needle out of the skin, dispose of it in a sharps container, apply sterile gauze to the needle entry site while holding firm pressure, and then apply a sterile bandage over the needle entry site. I would educate that it may take up to 3 days for the patient to begin noticing benefit from the steroid injection.

DOMAIN E: INTERPERSONAL AND COMMUNICATION SKILLS

The following week, the patient’s physical therapist approaches you after team conference. The patient has 1 week remaining in her inpatient rehabilitation stay and her therapist wants to maximize functional gains before patient is discharged home with family. Her therapist has read that a high-volume shoulder injection can help to distend the shoulder capsule and restore range of motion. This is not something you are familiar with until now. Pretend that I am the patient’s therapist.

Physical therapist: “Here is the paper I’m talking about. The high-volume shoulder injection seems to really help range of motion quickly, and is superior to standard shoulder injections! The best part is it’s the same exact thing as a typical shoulder injection, only you add in 5-6 mL of normal saline for the volume.”

+ How would you respond?

Thank you for bringing this technique to my attention! You are such a strong advocate for our patient, and I know you have been helping her tremendously in her functional recovery. I will happily review this paper and consider adding this procedure to my skillset in the future, but unfortunately at this time I do not feel comfortable proceeding with this procedure, though it is certainly something I will consider for her in the future.

+ The therapist responds:

“But she doesn’t need it in the future. She needs it now. You know as well as I do that her rehab progress will significantly slow once she is home, and we need to maximize every inpatient rehab day that we can while she is here. Please do this injection so that I can help her!”

+ Your response:

Unfortunately I cannot proceed with a procedure that I am uncomfortable with, having not yet learned of its details, risks, benefits, and data supporting or refuting it. I am certainly interested in reviewing this option for her, and I could indeed potentially perform this in the future for her and other patients with frozen shoulder. We will continue her physical therapy and I will of course place an order for this to continue outside our hospital. She may ultimately experience thawing of the shoulder which itself may resolve the frozen shoulder. If not, I will see her in follow-up routinely, so will keep a close eye on how the shoulder is doing and if she needs further treatments for it. Does that sound like an acceptable plan?