On my international placement I treated a left sided stroke patient with severe left shoulder pain. He reported pain on movement in all ranges of shoulder and elbow motion. The condition had increasingly worsened over the period since his stroke. He had not undergone any investigations on the joint, it was unclear whether it was subluxed or dislocated. Upon observation the head of humerus was displaced from the glenoid cavity and his arm was supported in a sling. Shoulder active ROM was 10 degrees abd/Flx P2, elbow F 30 degrees P2. Touch and pain sensation was intact. There were no P&Ns, numbness or reduced blood flow distal to the joint. His functional ability was restricted: he required assistance x 1 to move up/down/side to side in bed, and to roll (of which he did to his affected side!).
I had seen a dislocated shoulder a number of times, and this presentation was very similar. I was almost sure of it. But I was unsure of the role I could play as a physio. I was not qualified to reposition it. And even once repositioned, it was likely to sublux or dislocate again due to increased laxity in joint structures.
My choice of treatment was firstly to reposition his sling so the weight of his upper limb was well supported, and his HOH approximated to his glenoid cavity. I educated him on sling use: to wear it consistently throughout the day, but take it off to complete his stretching program. I recommended he see his GP for an X-ray. I suggested surgery may be an option (however it was unlikely he would financially be able to do this). I taught him how to roll to his unaffected side.
I am unsure whether the course of action I took was the most appropriate, or if there were other treatments I could have performed. I was in a foreign country and did not have adequate supervision. Basically the treatment was discussed and justified between my fellow student and me. I am curious about what course of action to take, as this is a case not covered in our course, and I want to know the best way to treat such a patient in the future. Does anyone have any suggestions? Did I do anything you wouldn’t do? Do you have further suggestions on treatment or management?
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Hi,
sounds like that was a difficult one to deal with. You did the right thing discussing it with your fellow student/s. You also are likely to have assisted pt by teaching him to roll away from his painful side rather than always on to it- as the impingements caused by repeated rolling onto the
hemi shoulder are clinically talked about as a risk factor for development (and maintenance) of shoulder pain.
With regards to your diagnosis and the clinical reasoning aspects:have you previously seen a stroke pt with a significant subluxation? The evidence doesn't support the subluxation independently being the cause of pain however I have seen a number of pt with significant shoulder pain and teaching them not to roll on the shoulder is helpful.Do you recall the difference between the pt active and passive range- this would have helped you with consideration of diagnosis. The mechanism of injury , the acuteness and the range issues are quite different for acute dislocation cf subluxation due to secondary effects of stroke eg cumulative loss of joint congruity and mixed tone of trunk, scapula and rotator cuff muscles(have seen it called dislocation but usually in the literature as subluxation). Surgery is not listed as part of clinical practice guidelines for management of stroke subluxation.
On a final note- there is a reasonable amount published on the painful shoulder post stroke (which I can assume that you would not be able to access). When you get another pt like this you will hopefully be more able to access literature and support. Despite lack of access to further
information you have assisted the patient by changing his practice re the arm position and the rolling. Feel free to phone me if you would like to discuss the case further.
Cheers
Steph
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