What is the appropriate workup for a patient presenting with right shoulder pain and limited range of motion (ROM), which started yesterday after lifting grandchildren, with a history of myocardial infarction (heart attack) in September and who took a muscle relaxer (e.g. cyclobenzaprine)?

From the Guidelines

For a patient with right shoulder pain and limited range of motion that began after holding grandchildren, with a recent history of heart attack, I recommend a comprehensive evaluation including physical examination focusing on shoulder range of motion, strength testing, and special tests for rotator cuff pathology and impingement. Initial imaging should include plain radiographs of the shoulder to rule out fracture or arthritis, as suggested by the American College of Radiology 1. Given the cardiac history, NSAIDs should be avoided; instead, acetaminophen 500-1000mg every 6 hours as needed for pain is appropriate, considering the patient's cardiac history and the potential risks associated with NSAIDs 1. The patient should apply ice for 15-20 minutes several times daily to reduce inflammation. Physical therapy referral is warranted for gentle range of motion exercises and strengthening, which can help improve shoulder function and reduce pain, as supported by guidelines for adult stroke rehabilitation and recovery 1. The patient should temporarily avoid activities that aggravate the pain, particularly overhead movements. This approach addresses what appears to be an acute muscle strain or possible rotator cuff tendinopathy while considering the patient's cardiac history. If symptoms persist beyond 2-3 weeks or worsen, further imaging such as ultrasound or MRI may be necessary to evaluate for rotator cuff tear or other structural abnormalities, as recommended by the American College of Radiology 1.

Some key points to consider in the evaluation and management of this patient include:

• The importance of a comprehensive physical examination to assess shoulder range of motion, strength, and special tests for rotator cuff pathology and impingement.
• The use of plain radiographs as the initial imaging modality to rule out fracture or arthritis.
• The avoidance of NSAIDs due to the patient's cardiac history and the potential risks associated with their use.
• The use of acetaminophen as a safe alternative for pain management.
• The role of physical therapy in improving shoulder function and reducing pain.
• The potential need for further imaging, such as ultrasound or MRI, if symptoms persist or worsen.

Overall, a comprehensive and multidisciplinary approach is necessary to evaluate and manage this patient's shoulder pain, taking into account their cardiac history and the potential risks and benefits of different treatment options.

From the Research

Initial Assessment

The patient presents with right shoulder pain, limited range of motion (ROM), and no specific injury, but was holding grandkids all day. The patient has a history of heart attack in September and took a muscle relaxer.

• The first step is to conduct a thorough history and physical examination to determine the cause of the shoulder pain, as outlined in 2.
• The examination should include items related to pain, alignment, movement, muscle length, muscle strength, and function, as described in 3.

Diagnostic Considerations

The patient's symptoms could be related to various shoulder pathologies, including:

• Subdeltoid subacromial bursitis
• Glenohumeral joint capsulitis
• Calcific tendinosis
• Acromioclavicular joint osteoarthritis
• Long head of biceps tendinosis, as discussed in 4
• Adhesive capsulitis or glenohumeral joint arthritis, as mentioned in 5

Treatment Options

Treatment for shoulder pain can include:

• Physiotherapy, as described in 3 and 6
• Anti-inflammatory medication
• Local corticosteroid injections, as discussed in 4 and 2
• Ultrasound-guided injection and other techniques, such as hydrodilatation, barbotage, and extracorporeal shockwave treatment, as outlined in 4

Importance of Accurate Diagnosis

Accurate diagnosis is crucial in determining the appropriate treatment for the patient, as emphasized in 4, 2, and 5. The physician should consider the patient's problem, age, medical condition, and prior level of function when recommending treatment, as stated in 2.

Role of Exercise in Management

Exercise can play a key role in reducing pain and improving mobility and function in patients with shoulder pain, as highlighted in 6. A simplified approach to evaluating and managing atraumatic shoulder pain can be based on triaging symptoms on presence or loss of range of motion, as described in 5.