In this episode of the No Plateau Podcast, host Henry Hoffman sits down with Dr. Clay Guynn, a board-certified PM&R physician with fellowship training in sports medicine, to tackle one of the most common and frustrating complications after stroke: hemiplegic shoulder pain. Dr. Guynn breaks down why shoulder pain after stroke is rarely a single diagnosis; it can arise from spasticity, musculoskeletal issues, neuropathic pain, or any combination of the three. He explains his "onion" approach to evaluation, where each layer of pain must be identified and addressed individually. The conversation covers diagnostic workups, the role of ultrasound-guided procedures, and how interventions like hydrodilation, diagnostic nerve blocks, Botox, and cryoneurolysis fit into the treatment puzzle. Henry and Dr. Guynn also explore why early physiatry involvement matters, the critical role of therapists in both identifying pain generators and maximizing the benefits of medical interventions, and why communication between providers is the single most important factor in successful outcomes. Dr. Guynn shares practical insights from his practice, from performing suprascapular nerve blocks to using hydrodilation for frozen shoulder to leveraging cryoneurolysis for longer-lasting spasticity relief. The episode underscores that hemiplegic shoulder pain isn't just about treating pain; it's about enabling patients to engage their impaired side, which directly impacts neuroplasticity and long-term recovery. Listen to the full episode to learn how a multidisciplinary, layered approach can transform the way we understand and treat post-stroke shoulder pain. In This Episode Introduction to Dr. Clay Guynn (01:00) Personal and professional background (01:52) Connecting at the AOCAPMR cryoneurolysis course (04:30) Stroke shoulder pain by the numbers (06:25) The 3 pain generator buckets: spasticity, orthopedic, neuropathic (08:42) Understanding neuropathic pain after stroke (13:47) What frozen shoulder really is (and isn't) after stroke (16:58) Frozen shoulder and subluxation prevalence data (21:45) Building a diagnostic workup: history, exam, and ultrasound (23:32) Diagnostic nerve blocks in practice (28:11) Case example: suprascapular, Sargent's patch, and lateral pectoral blocks (30:59) Blocking pain vs. fixing the underlying problem (34:08) What the evidence actually shows for PT/OT interventions (39:39) The physiatrist's role: pain, psych referrals, and CBT (41:13) Why hemiplegic shoulder patients need a neuro-trained therapist (44:48) Choosing an intervention: clinical reasoning and timing (46:05) Hydrodilation for adhesive capsulitis (48:05) Introduction to cryoneurolysis for shoulder pain (52:04) Tenotomies and fascial scraping (54:53) Treating CRPS and central post-stroke pain (56:44) Neuroplasticity, learned non-use, and why timing matters (01:00:07) Fixing the communication gap between physicians and therapists (01:01:22) Why therapists should shadow procedures (01:05:30) The future of shoulder pain rehab: shockwave, PNS, and beyond (01:07:58) Pain, motor relearning, and cortical reorganization (01:13:02) Closing thoughts and contact information (01:16:49) Our Guest Clay Guynn, DO Dr. Clay Guynn is a triple board-certified PM&R physician and osteopathic physician fellowship-trained in sports medicine, currently practicing in Atlanta, Georgia. He completed his PM&R residency at the University of Kentucky and a sports and spine fellowship in Florida. His clinical practice spans the full spectrum of physiatry, from spinal cord injury, stroke, and cerebral palsy patients to elite athletes, he serves as head team doctor for USA Blind Soccer (traveling with the team through the 2028 Games) and cares for athletes at four high schools and a college. His interventional toolbox includes diagnostic nerve blocks, joint and soft tissue injections, botulinum toxin, radiofrequency procedures, and cryoneurolysis, which he has used for spasticity management for the past four years with strong results. Resources & Links Dr. Clay Guynn on LinkedIn Henry Hoffman on LinkedIn Saebo On YouTube On Instagram On LinkedIn