1410 - An Unhappy Triad of Post-Stroke Shoulder Pain: A Case Report on Concurrent Adhesive Capsulitis, Spasticity, and Shoulder-Hand Syndrome

Case Diagnosis: Adhesive capsulitis of the shoulder, pectoral spasticity, and shoulder-hand syndrome

Case Description: A 65-year-old man presented to physiatry clinic 4 months following an ischemic right corona radiata stroke. He reported progressively worsening proximal left upper limb pain and muscle tightness. He demonstrated painful restricted range of motion of the shoulder in all planes, as well as pectoral spasticity (Modified Ashworth Score 3 within available range). He received an intra-articular corticosteroid injection into the left shoulder for adhesive capsulitis and intramuscular injections with botulinum toxin A into the pectoralis major. Although he initially reported significant relief, he returned to clinic 6 weeks later with increased pain in the left shoulder and new pain in the left hand, which had become edematous. Allodynia was also noted. Slight pallor of the left upper limb was noted relative to the right, but his peripheral pulses were strong and symmetric.

Discussions: A course of oral steroids was initiated for presumed shoulder-hand syndrome. Patient reported significant improvement in pain score rating from a 9/10 to a 4/10. Further pain relief was achieved with the initiation of treatment with pregabalin. Following additional occupational therapy and botulinum toxin injections, full range of motion of the shoulder was restored.

Shoulder pain is very prevalent among stroke survivors and may hinder their progress with rehabilitation. Pectoral spasticity, adhesive capsulitis, and shoulder-hand syndrome are all common causes of post-stroke shoulder pain. When they occur concomitantly, multi-modal pain management may be necessary.

Conclusions: Post-stroke shoulder pain is often multifactorial, as demonstrated in this case of concurrent adhesive capsulitis, spasticity, and shoulder-hand syndrome. Successful treatment required a multi-modal approach incorporating botulinum toxin, steroids, neuropathic pain agents, and therapeutic exercise. This case underscores the importance of comprehensive assessment and individualized treatment strategies in managing post-stroke shoulder pain.