Shoulder Hand Syndrome Diagnosis and Treatment

Clinical Presentation

Shoulder Hand Syndrome (CRPS) is characterized by pain and tenderness of metacarpophalangeal and proximal interphalangeal joints, associated with edema over the dorsum of the fingers, trophic skin changes, hyperaesthesia, and limited range of motion in both the hand and shoulder 1, 2
Edema over the dorsum of the fingers is a common symptom of Shoulder Hand Syndrome 1, 2
Trophic skin changes in the affected hand are a characteristic of Shoulder Hand Syndrome 1, 2
Hyperaesthesia (increased sensitivity to touch) is a symptom of Shoulder Hand Syndrome 1, 2

Diagnosis is primarily based on clinical findings 1, 2
Triple phase bone scan can assist in diagnosis, demonstrating increased periarticular uptake in distal upper extremity joints 1, 2

Active, active-assisted, or passive range of motion exercises should be used to prevent CRPS 1, 2
Protecting the hemiplegic limb from trauma and injuries can reduce the frequency of shoulder-hand syndrome 3
Avoid overhead pulleys, which encourage uncontrolled abduction and may increase risk of developing hemiplegic shoulder pain 3, 4

Treatment of hemiplegic shoulder pain related to limitations in range of motion includes gentle stretching and mobilization techniques, focusing on increasing external rotation and abduction 1, 2
Active range of motion should be increased gradually in conjunction with restoring alignment and strengthening weak muscles in the shoulder girdle 1, 2
Local application of heat before exercise can provide symptomatic relief 5
Splints and orthoses should be considered for thumb base involvement 5

If there are no contraindications, analgesics such as acetaminophen or ibuprofen can be used for pain relief 1, 2
Topical NSAIDs should be considered as first pharmacological treatment for mild to moderate pain 5
Topical capsaicin may be effective for hand involvement 5

An early course of oral corticosteroids, starting at 30-50 mg daily for 3-5 days, and then tapering doses over 1-2 weeks can be used to reduce swelling and pain 1, 2
For shoulder pain related to spasticity, injections of botulinum toxin into the subscapularis and pectoralis muscles could be used 1, 2
Subacromial corticosteroid injections can be used when pain is related to injury or inflammation of the subacromial region 1, 2

Shoulder pain can delay rehabilitation and functional recovery as it may mask improvement of motor function or inhibit rehabilitation 3, 6
Hemiplegic shoulder pain may contribute to depression, sleeplessness, and reduced quality of life 1, 2

Patients should be reassessed periodically to evaluate their response to treatment 5
Long-term follow-up should be adapted to the patient's individual needs 5

The American Heart Association recommends that stroke patients with combined motor, sensory, and visuoperceptual deficits are at high risk for developing Complex Regional Pain Syndrome (CRPS), with an incidence rate of 67% 7
The American Academy of Neurology suggests that spasticity contributes to CRPS genesis, though a definitive causal relationship remains unconfirmed, with a study showing a correlation between spasticity and CRPS onset 8
Improper handling during rehabilitation, particularly overhead pulley exercises, increases the risk of CRPS, according to the American Heart Association 7, 9
About one-third of acute stroke patients show shoulder tissue injury on ultrasound (effusion, tendinopathy, rotator cuff tears) that may contribute to CRPS, as reported by the American Heart Association 8
Sympathetic dysregulation plays a proposed role in CRPS development, though its central importance is debated, with studies suggesting a subgroup of CRPS patients exists with predominant sympathetic nervous system hyperactivity 10, 11

Failure to protect the hemiplegic limb from trauma is a critical error, and using overhead pulleys encourages uncontrolled abduction and dramatically increases hemiplegic shoulder pain incidence, according to the American Heart Association 7, 9, 12
Inadequate staff education about proper handling of the hemiplegic shoulder allows preventable trauma, highlighting the need for education and training, as recommended by the American Heart Association 7, 12

CRPS specifically involves the hand with characteristic metacarpophalangeal and proximal interphalangeal joint involvement, distinguishing it from isolated shoulder pathology like adhesive capsulitis, rotator cuff tears, or bursitis, according to the American Heart Association 7, 9, 12