After a stroke, many people notice that their affected arm feels heavy, awkward or hard to control. Sometimes the shoulder looks “lower” than the other side, clothes hang differently, or there is a deep, dragging ache around the joint. These may be signs of shoulder subluxation, a common complication after stroke that can affect comfort, function and participation in rehabilitation.
This article explains what shoulder subluxation after stroke is, why it happens, how it relates to shoulder pain, and what rehabilitation can do to protect and support the affected shoulder in a safe, realistic way.
What is shoulder subluxation after stroke?
In a healthy shoulder, the head of the upper arm bone sits snugly in a shallow socket on the shoulder blade. Muscles around the shoulder, especially the rotator cuff and the muscles that control the shoulder blade, work together all day to keep the joint centred while we move.
After a stroke that affects one side of the body, those supporting muscles can become weak, floppy or poorly coordinated. When that happens, gravity has a stronger pull on the arm. Over time, the head of the humerus can slip slightly downward and away from the socket. This partial loss of contact is called shoulder subluxation.
In stroke, this is usually a non-traumatic, gradual change in the alignment between the upper arm and the socket, not a violent dislocation caused by a fall or accident. Studies suggest that shoulder subluxation occurs in a significant proportion of people with hemiplegia, often developing in the first few weeks after stroke.Physiopedia+1
Some people with subluxation feel no pain at first. Others notice discomfort, a dragging or pulling sensation, or difficulty using the arm. Even when it is not painful at the beginning, an unsupported, subluxed shoulder can become a source of hemiplegic shoulder pain later on if it is not handled and positioned carefully.ASRA Pain Medicine+1
Why does shoulder subluxation happen after stroke?
The main reason is the change in muscle activity around the shoulder. In the early stage after stroke, the affected arm is often flaccid or very weak. The muscles that normally hold the shoulder joint in place are not able to provide their usual support. At the same time, gravity continues to pull the arm downwards, especially when the person is sitting or standing.
If the arm is allowed to hang unsupported at the side of the body, the weight of the arm can gradually stretch the soft tissues that help hold the joint together. This is more likely if the person spends long periods in a chair without arm support, or is moved and transferred by people who are not familiar with safe handling techniques and accidentally pull on the arm.
Later on, as spasticity develops, tightness in muscles such as the pectoralis and subscapularis can alter the position of the shoulder, pulling the arm into internal rotation and adduction. This can further disturb the relationship between the ball and socket and limit pain-free movement.www.elsevier.com+1
In short, shoulder subluxation usually reflects a combination of muscle weakness, altered muscle tone, gravity and handling. It is not simply “bad posture” or a sign that the person is not trying hard enough.
How shoulder subluxation feels and looks
People describe shoulder subluxation in different ways. Some feel as if the arm is too heavy, as though it does not belong to them. Others notice a dull or aching pain deep in the joint, especially after sitting or walking without support. The pain may increase when someone lifts the arm too high or too quickly.
On visual inspection, the affected shoulder may appear lower than the other side. The gap between the top of the arm bone and the bony tip of the shoulder can seem wider. Shirts and jacket sleeves may hang lower on the affected side. A therapist may feel a “step” or space by gently supporting the arm and comparing both shoulders.
Not everyone with subluxation will have severe pain, but subluxation is considered one of the factors that can contribute to hemiplegic shoulder pain, which is one of the most common pain problems after stroke.ASRA Pain Medicine+1
Why early protection and positioning matter
The weak shoulder is vulnerable, particularly in the early weeks after stroke when muscle control is poor. Early protection has two main goals: to reduce the risk of soft-tissue strain and pain, and to give the joint the best possible mechanical alignment so that movement and rehabilitation are easier later.
Clinical guidelines consistently emphasise the importance of correct manual handling and positioning of the affected arm for stroke survivors, and recommend that not only therapists but also nursing staff, caregivers and families receive education on safe techniques.Canadian Stroke Best Practices+2Frontiers+2
Good positioning does not mean keeping the arm completely still. The aim is to support the weight of the arm, maintain a comfortable alignment of the shoulder blade and humeral head, and avoid positions that place the joint at risk, such as letting the arm hang unsupported, pulling on the hand, or forcing the shoulder above 90 degrees of elevation without proper scapular movement.
When the person is lying in bed, pillows or supports can be used to keep the arm slightly forward and away from the body, rather than tucked tightly against the side. When sitting, an armrest, pillow on the lap, table support or specially designed arm support can help share the weight of the arm and reduce the downward pull on the joint.
The role of movement and rehabilitation exercises
Although rest and support are important, a shoulder that is never moved can become stiff and painful in a different way. Gentle, well-controlled movement within a safe range is essential to maintain joint health, stimulate muscles and provide sensory input to the brain.
In the early phase, therapists often guide the arm through passive or assisted movements, paying careful attention to the position of the shoulder blade and avoiding any sudden or forced motion. Safely performed range-of-motion exercises, including flexion, abduction and rotation within a protected range, have been associated with prevention of shoulder subluxation and maintenance of joint mobility when done correctly.Physiopedia
As the person regains some active control, therapy evolves towards task-oriented practice. Reaching towards objects on a table, placing items on shelves at appropriate heights, and using the affected arm to assist with grooming or dressing are all ways to activate shoulder muscles in a functional context. The guiding principle is that controlled, purposeful movement helps build muscle support around the joint, which in turn can reduce the mechanical stress that contributes to subluxation.strokengine.ca+1
Because every shoulder is different, the exact exercises and ranges of motion should be individualised by a rehabilitation professional. Movements that cause sharp pain, sudden catching or a sense of the joint “slipping” need immediate review.
Slings, supports and other aids
One of the most visible strategies for managing shoulder subluxation after stroke is the use of slings or external supports. These devices aim to share the weight of the arm and maintain a more neutral alignment of the shoulder during sitting, standing and walking.
The research on shoulder slings is not entirely consistent. Some studies report that slings with shoulder or forearm support can help reduce the degree of subluxation and improve comfort and balance in people with acute stroke, while other studies find little difference between different sling designs.Dominican Scholar+2jpmrs.org+2 Overall, slings are often used as part of a broader management plan rather than as a stand-alone solution.
The choice of sling depends on the person’s stage of recovery, level of muscle control, skin condition, and how much they are walking or transferring. Slings that hold the arm too tightly against the body may protect the joint but can limit functional use and promote stiffness if worn all day. More open designs allow some movement while still supporting the weight of the arm. The decision about when and how long to use a sling is best made together with the rehabilitation team.
In addition to slings, other options such as supportive lap trays, arm troughs on wheelchairs, or carefully applied taping techniques may be considered. Systematic reviews suggest that taping, neuromuscular electrical stimulation and other modalities can have a role in reducing subluxation and pain for some individuals, but the quality of evidence and the size of benefit vary, and these interventions should be selected and monitored by trained clinicians.MDPI+1
Relationship between subluxation and shoulder pain
Shoulder subluxation and shoulder pain are related but not identical. Some people with clear subluxation on examination have surprisingly little pain, while others develop significant hemiplegic shoulder pain even with only mild subluxation.
Pain can arise from a number of sources, including soft-tissue strain, rotator cuff injury, capsular inflammation, altered muscle tone and poor movement patterns. Studies indicate that shoulder subluxation is one of several factors associated with hemiplegic shoulder pain and that early mechanical protection of the shoulder may reduce the likelihood or severity of pain later.ASRA Pain Medicine+2ScienceDirect+2
From a practical standpoint, this means that even if the shoulder is not currently very painful, it is still worthwhile to protect and support the joint, especially in the early months after stroke. Once pain becomes established, it can interfere with sleep, limit participation in therapy, and add to muscle guarding and spasticity, creating a difficult cycle.
Everyday strategies for people and families
For many families, the most important question is simple: what can we actually do in daily life to look after this shoulder?
A few core ideas are helpful. The affected arm should be treated as fragile but important, not ignored. During transfers and mobility, no one should pull on the arm, wrist or hand; instead, support is given at the trunk and hips. When sitting, the arm is placed on an armrest, pillow or table, rather than allowed to dangle. When walking, a sling or support may be used if recommended by the therapist.
At home, everyday tasks can be adapted so that the affected arm is gently involved. The person might rest the hand on the table during meals, support a light object with both hands, or assist with stabilising clothing while dressing. These small roles remind the brain that the arm is still part of the body’s movement system, while the shoulder remains supported.
Caregivers can also watch for early warning signs that the shoulder is not coping well: new or worsening pain, visible swelling, warmth, redness, or a sudden change after a slip or minor fall. These changes warrant prompt review by a healthcare professional.
How occupational therapy fits into shoulder subluxation care
Occupational therapists play a key role in managing shoulder subluxation after stroke. They look beyond the joint itself and consider how the shoulder is used in real-life activities such as sitting up in bed, washing, dressing, eating and moving around the home or community.
In practice, an occupational therapist may assess the degree of subluxation, shoulder range of motion, muscle tone, pain and functional use of the arm. Based on this, they can recommend a mix of strategies, which might include education on positioning and handling, selection and fitting of an appropriate sling or support, task-oriented exercises, and modifications to chairs, wheelchairs or the home environment to better support the arm.
By integrating protection, movement and function, the therapist aims to reduce the mechanical stress on the shoulder joint while still encouraging active use of the affected arm wherever possible.
When to seek professional help
If you or a family member notice that the shoulder on the affected side seems lower, feels unstable, or has developed new pain after a stroke, it is important to mention this to the rehabilitation team, doctor or therapist. An early, hands-on assessment can clarify whether subluxation is present, how severe it is, and what combination of supports and exercises might be appropriate.
It is especially important to seek help urgently if there is sudden, severe pain, visible deformity, marked swelling, fever, or a history of a fall or trauma to the shoulder, as these can indicate other conditions that need medical attention.
A realistic and hopeful outlook
Shoulder subluxation after stroke can be worrying, especially when the arm already feels weak and difficult to control. While it is not always possible to completely reverse subluxation, timely protection, thoughtful positioning and targeted rehabilitation can often reduce secondary damage, support comfort and make it easier to use the arm as part of daily life.
Recovery is rarely a straight line. Some days the shoulder will feel better, other days heavier or stiffer. Understanding what subluxation is—and what can be done about it—gives stroke survivors and families a more solid foundation for everyday decisions, and helps the rehabilitation team build a plan that protects the shoulder while still encouraging movement and participation.
This article is intended for general education and does not replace individual medical advice. For personalised assessment and recommendations, please consult your rehabilitation team or a qualified healthcare professional.
