What is the best course of action for a patient with persistent right shoulder pain due to hypertrophic degenerative arthritic changes at the acromioclavicular joint?

From the Guidelines

I strongly recommend proceeding with an MRI of the right shoulder for this 62-year-old male patient with persistent shoulder pain. The patient has failed conservative management including physical therapy and a previous intraarticular injection to the acromioclavicular (AC) joint. His symptoms include constant 9/10 pain that worsens with specific movements (abduction at 80 degrees and across the body), and he reports deep pain in the AC joint unresponsive to NSAIDs. X-ray findings show hypertrophic degenerative arthritic changes at the AC joint, but an MRI would provide more detailed information about potential soft tissue pathology such as rotator cuff tears, labral injuries, or other conditions that may be contributing to his pain.

While providing another AC joint injection is reasonable for temporary relief, the persistence of symptoms despite previous treatment warrants advanced imaging to guide definitive management. The MRI will help determine if surgical intervention might be necessary, particularly given the significant pain level and functional limitation despite appropriate conservative measures over several months. According to the most recent and highest quality study available, 1, surgery should be considered as a second-line treatment when non-surgical measures have failed, and the patient's condition warrants further evaluation.

Some key points to consider in this patient's management include:

• The patient's significant pain level and functional limitation despite conservative measures
• The potential for underlying soft tissue pathology that may not be visible on X-ray
• The importance of advanced imaging in guiding definitive management and potential surgical intervention
• The need for a comprehensive treatment plan that takes into account the patient's overall condition and medical history, as suggested by 1 and 1.

Given the patient's history and current symptoms, an MRI of the right shoulder is the most appropriate next step in management, as it will provide valuable information to guide further treatment and potential surgical intervention, ultimately improving the patient's quality of life and reducing morbidity and mortality.

From the Research

Patient Assessment and Treatment

• The patient is a 62-year-old male with 9/10 constant pain in his right shoulder, described as someone pulling down his shoulder.
• He has received an intraarticular injection in the acromioclavicular joint in January 2025 and finished physical therapy in March 2025 with no improvement.
• The patient reports deep pain in the AC joint, and NSAIDs are not helping.
• The pain increases when handing ABD at 80 degrees across the body.

Diagnostic Findings

• The last x-ray impression shows hypertrophic degenerative arthritic changes at the acromioclavicular joint.
• The patient will receive another IA injection to the AC joint.

Relevant Studies

• A study on pharmacologic therapy for acute pain 2 suggests that acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) are first-line treatment options for most patients with acute mild to moderate pain.
• Another study on intra-articular injection of the selective cyclooxygenase-2 inhibitor meloxicam 3 shows that it reduces experimental osteoarthritis and nociception in rats.
• A meta-analysis and systematic review on intra-articular versus subacromial corticosteroid injection for the treatment of adhesive capsulitis 4 found no significant difference in primary outcomes between IA injection and SA injection, except for VAS at 2-3 weeks and ROM of internal rotation at 8-12 weeks.
• A study on subacromial corticosteroid injections 5 highlights the importance of accurate diagnosis and proper injection technique in achieving satisfactory clinical outcomes.
• A prospective randomized controlled study on postoperative analgesia for arthroscopic shoulder surgery 6 compared the efficacy of intraarticular, subacromial injection, interscalenic brachial plexus block, and intraarticular plus subacromial injection, and found that the combination of intraarticular and subacromial infiltration is a clinically valid alternative with no clinical meaningful adverse effects.