Shoulder pain is one of the most common complications after stroke, with an incidence ranging from 20% to 80% in different reports. The typical clinical presentation is shoulder pain on the hemiplegic side with limited shoulder joint movement. The pain occurs mostly during upper extremity activities, such as dressing and shoulder supination, and can interfere with rehab, daily living and caregiving. The pain also sometimes occurs at rest and even affects sleep. Sometimes the pain is not limited to the shoulder, but can affect the wrist and fingers, causing more pain. The shoulder joint is the most mobile three-dimensional motor joint in the body and is also the most unstable and easily damaged structure. Current research suggests that the cause of hemiplegic shoulder pain is due to a variety of factors. Subacromial impingement syndrome, rotator cuff injury, complex regional pain syndrome, myospasm, adhesive capsulitis, shoulder subluxation, and distraction brachial plexus injury have all been associated with shoulder pain. Each of these factors may cause shoulder pain alone, or they may combine to cause shoulder pain due to a mixture of factors. Hemiplegic shoulder pain not only affects the patient’s upper extremity care and functional recovery, but also leads to decreased quality of life, depression, and prolonged hospitalization. Therefore active rehabilitation and management of hemiplegic shoulder pain is needed. Correct position placement and shoulder sling In the early post-onset period of stroke patients with low muscle tone, correct position placement is clinically important to prevent shoulder injury, prevent spasm and contracture and prevent shoulder pain. Generally, when lying supine, a cushion can be placed behind the shoulder and the shoulder can be placed in an appropriate abduction and external rotation position. It is important to avoid prolonged lying on the affected side, as this can easily cause compression injury. Some physicians prefer to use a shoulder sling to protect the patient’s floppy shoulder, but this is not ideal because it puts the shoulder in a deformity-prone internal rotation position and limits upper extremity motion. Various soft shoulder rests are popularly used to correct subluxation of the shoulder, but it is questionable whether they can actually provide correction. Early shoulder movement and correct exercises The shoulder joint is a joint prone to adhesions. After stroke, hemiplegic patients often have a reduced range of motion of the shoulder joint and show a deformed state of internal rotation and internal retraction. Therefore, preventive treatment should be started as early as possible. Early and moderate movement of the shoulder joint, especially abduction, external rotation and supination of the shoulder, can prevent joint adhesion lesions caused by braking and maintain the range of motion of the joint. However, excessive range of motion may inadvertently cause injury, which is particularly likely to occur in patients with sensory impairment. Studies have found that the most popular practice of shoulder motion with a high pulley resulted in the highest incidence of hemiplegic shoulder pain. Local physical therapy Physical therapy commonly used to treat hemiplegic shoulder pain includes cold therapy, heat therapy, and electrotherapy. Studies have concluded that ice water immersion, alternating hot and cold water immersion and compressive centripetal winding have the effects of improving vasodilation and contraction, promoting venous return, reducing swelling and relieving pain, and are effective for complex regional pain syndromes. Medium- and high-frequency electrotherapy, low-power laser and ultrasound are effective for injury and can be used for the treatment of hemiplegic shoulder pain. Drug therapy Oral non-steroidal anti-inflammatory drugs can play a certain analgesic role and are the analgesic methods that can be considered as a priority. However, such drugs have certain side effects on the circulatory and digestive systems and must be used selectively. Local and systemic use of corticosteroids is a reliable method for the treatment of impingement syndrome and complex regional pain syndrome. However, patients are often unable to receive hormonal therapy due to medical problems and ideological concerns. Antispasmodic medications relax spastic muscles and also help physical therapists to perform manipulative treatments to relieve pain. The star of antispasmodic medications is botulinum toxin, which has been shown in several small samples to reduce hemiplegic shoulder pain and increase the range of motion of shoulder abduction and external rotation. Because of its dual effect of reducing muscle tone and analgesia, botulinum toxin has a promising future in the treatment of hemiplegic shoulder pain. The problem with the use of botulinum toxin is that it is expensive and requires good injection technique. Neuromuscular electrical stimulation Neuromuscular electrical stimulation improves motor control of the upper extremity in stroke patients by stimulating specific muscles, usually the superior trapezius, supraspinatus and middle and posterior deltoid muscles, which can increase the tone of the stimulated muscles and pull the humeral head back to its normal anatomical position, and the reduction of shoulder pain may be related to this. Neuromuscular electrical stimulation has been shown to be effective in preventing subluxation, relieving pain, and improving joint range of motion and upper extremity function. The UK Royal Medical Guidelines have included it as a priority treatment for hemiplegic shoulder pain. Surgery With improvements in rehabilitation techniques, surgery is rarely performed for hemiplegic shoulder pain. However, in cases of subacromial impingement syndrome or very severe rotator cuff tears, this is still one of the options to consider. The problem with surgery is that the patient no longer has a common orthopedic problem, but a dual CNS and orthopedic problem. Even with successful surgery, adverse outcomes can still result. Awareness of hemiplegic shoulder pain by the patient and his or her family can facilitate communication between the doctor and the patient so that the patient receives the most appropriate treatment. Those who disregard hemiplegic shoulder pain and emphasize pain tolerance training will seriously affect the prognosis of the affected limb.