Hemiplegic shoulder pain (HSP) is a common and clinically significant complication after stroke that negatively affects rehabilitation outcomes. It is associated with shoulder subluxation, capsular contracture, spasticity, and central pain mechanisms, leading to pain, limited range of motion, and reduced quality of life. The suprascapular nerve (SSN) block has been shown to be effective for shoulder pain management; however, the glenohumeral joint (GHJ) receives innervation from multiple nerves including the axillary, subscapular, and lateral pectoral nerves. The recently described pericapsular/periarticular nerve group (PENG) block targets these articular branches and may provide analgesia with minimal motor impairment.

This study aims to evaluate the effects of adding an ultrasound-guided PENG block to conventional physical therapy in patients with post-stroke hemiplegic shoulder pain, focusing on pain intensity, range of motion, and quality of life outcomes.

Pericapsular/Periarticular Nerve Group (PENG) Block Procedure:

The procedure is performed with the patient in the supine position, the affected arm externally rotated and abducted approximately 45 degrees. A high-frequency linear ultrasound probe is placed longitudinally between the coracoid process and the humeral head. After identifying the humeral head, the subscapularis muscle tendon, and the overlying deltoid muscle, an in-plane approach is used to advance a 100-mm needle between the deltoid muscle and the subscapularis tendon under real-time ultrasound guidance.

After confirming the needle tip position, a total of 10 mL of 0.25% bupivacaine hydrochloride combined with 4 mg of dexamethasone is injected slowly, ensuring appropriate spread within the targeted pericapsular space. The goal of the block is to provide analgesia for the glenohumeral joint by targeting the articular branches of the axillary, subscapular, and lateral pectoral nerves with minimal motor impairment.

No major complications have been reported for this technique in the literature. However, minor complications such as local bleeding, infection, or transient vasovagal reactions may occur.

Inclusion Criteria:

• Age between 18 and 85 years

Stroke onset less than 1 year

Presence of hemiplegic shoulder pain with limited shoulder range of motion confirmed by clinical examination

Numeric Rating Scale (NRS) pain score ≥ 4

Exclusion Criteria:

• Severe deformity or pathology of the shoulder region

Complex regional pain syndrome type I

Modified Ashworth Scale score ≥ 3

Presence of neglect syndrome

Grade 4 glenohumeral joint degeneration

Coagulopathy or bleeding disorders

Fracture on the affected side

Secondary pathology on MRI (malignancy or infection)

Presence of pacemaker

History of allergic reaction to local anesthetic agents or dexamethasone

Shoulder intervention or injection within the past 3 months

Major psychiatric illness

Refusal to participate in the study

Patients aged 18 to 85 years with post-stroke hemiplegic shoulder pain and limited shoulder joint range of motion will be recruited from the Pain Medicine and Physical Therapy Departments of Marmara University Pendik Training and Research Hospital. All participants will have experienced a stroke within the past year and will present with a Numeric Rating Scale (NRS) pain score of 4 or higher at baseline.