Cerebrovascular accidents and traumatic brain injury produce most of the deformities seen in patients with spastic imbalance of the shoulder. A general awareness of the global neurologic defect is required to understand appropriate treatment alternatives. Conservative treatment techniques include early initiation of therapy exercises. Muscle or nerve block treatments may prevent severe shoulder contractures. Diagnostic blocks may help differentiate between deformity caused by spasticity and that caused by fixed soft tissue contracture. Operative release procedures are described. These operations, when combined with appropriate postoperative therapy programs, permit correction of contractures caused by unbalanced muscle forces around the shoulder in patients with severe spasticity who do not respond to conservative care.