Whom to refer a patient with left shoulder pain, radiographic evidence of orthopedic anchors, arthritic changes, and post-operative changes?

From the Guidelines

For a patient with left shoulder pain and X-ray findings showing orthopedic anchors, arthritic changes, and post-operative changes, referral to an orthopedic surgeon is most appropriate, preferably one who specializes in shoulder surgery. This recommendation is based on the patient's complex presentation, which includes surgical history and hardware, making an orthopedic surgeon the best specialist to evaluate and manage the condition 1.

Given the presence of orthopedic anchors and post-operative changes, it is crucial to assess the integrity of the previous repair and determine if the current pain is related to hardware issues, incomplete rehabilitation, or advancing arthritis. The orthopedic surgeon can review the surgical history, evaluate the patient's condition, and develop a comprehensive management plan.

While other specialists, such as sports medicine physicians or rheumatologists, may also have expertise in shoulder conditions, the presence of surgical hardware and post-operative changes makes an orthopedic surgeon the most suitable initial specialist for evaluation and management planning. According to the American College of Radiology 1, MRI, MR arthrography, and ultrasound are equivalent in evaluating suspected retear after prior rotator cuff repair, but the initial referral should still be to an orthopedic surgeon for a thorough assessment.

Key considerations in this referral include:

• The patient's surgical history and presence of orthopedic anchors
• The need for a comprehensive evaluation of the previous repair and current condition
• The potential for hardware-related complications or advancing arthritis
• The importance of a specialist with expertise in shoulder surgery for optimal management and treatment planning.

From the Research

Patient Referral for Left Shoulder Pain

The patient presents with left shoulder pain, and an X-ray shows orthopedic anchors noted, arthritic, and post-op changes. To determine the best course of action, consider the following:

• The patient's symptoms and medical history should be thoroughly evaluated to determine the cause of the shoulder pain.
• The presence of orthopedic anchors, arthritic changes, and post-op changes suggests a complex condition that may require specialist care.

Treatment Options

For patients with acute mild to moderate pain, the following treatment options may be considered:

• Acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) are first-line treatment options, as stated in 2 and 3.
• Topical NSAIDs may be recommended for non-low back, musculoskeletal injuries, as mentioned in 2.
• Combination therapy using a small amount of opioid together with a nonopioid pain reliever may be effective, as discussed in 4.

Specialist Referral

Given the complexity of the patient's condition, referral to a specialist may be necessary. Consider referring the patient to:

• An orthopedic specialist to evaluate the orthopedic anchors and post-op changes.
• A rheumatologist to assess the arthritic changes and develop a treatment plan.
• A pain management specialist to address the patient's pain and develop a comprehensive treatment plan, as suggested in 2, 3, and 4.

Additional Considerations

When developing a treatment plan, consider the following:

• The patient's medical history, including any history of gastrointestinal bleeding, cardiovascular disease, or chronic renal disease, as mentioned in 2.
• The potential risks and benefits of each treatment option, including the use of opioids, as discussed in 2, 3, and 4.
• The importance of minimizing opioid use and risks, as emphasized in 2 and 4.