From the Guidelines
For a 65-year-old female with left shoulder and thoracic spine pain due to AC joint arthritis and thoracic degenerative changes, a conservative management approach is recommended, focusing on pain relief and functional improvement without immediate resort to advanced imaging or invasive procedures, as suggested by the American College of Radiology Appropriateness Criteria 1.
Initial Management
The initial approach should include oral NSAIDs such as ibuprofen (400-600mg three times daily with food) or naproxen (250-500mg twice daily) for 2-3 weeks, combined with acetaminophen (500-1000mg every 6 hours, not exceeding 3000mg daily) for pain relief.
- Physical therapy is crucial, focusing on gentle range of motion exercises, posture correction, and strengthening of the rotator cuff and periscapular muscles, which should be pursued for 6-8 weeks.
- Application of moist heat for 15-20 minutes several times daily can help relieve stiffness.
- Activity modification to avoid overhead movements and heavy lifting is important to reduce strain on the affected joints.
Considerations for Imaging and Further Intervention
Given the guidelines from the American College of Radiology Appropriateness Criteria 1, imaging may be considered in those patients who have persistent pain despite 6 weeks of conservative treatment, or in the presence of "red flag" symptoms such as a history of cancer, infection, immunosuppression, or trauma.
- For patients without these indicators, the focus should remain on conservative management strategies to alleviate symptoms and improve quality of life.
Additional Interventions
If conservative measures fail, corticosteroid injections into the AC joint (typically methylprednisolone 40mg with lidocaine) may provide temporary relief.
- For persistent thoracic pain, thoracic facet joint injections might be considered as part of a multimodal approach to manage pain and improve function. These recommendations prioritize a patient-centered approach, targeting inflammation reduction, pain management, and functional improvement while addressing the underlying degenerative processes in both the shoulder and thoracic spine, in line with the most recent guidelines 1.
From the Research
Management Approach
The recommended management approach for a 65-year-old female with left shoulder pain and thoracic spine pain, diagnosed with mild to moderate arthritic changes at the acromioclavicular (AC) joint and multilevel mild to moderate thoracic degenerative changes, involves conservative management as the mainstay of treatment 2.
Conservative Management
Conservative management options include:
- Use of analgesics and NSAIDs to control pain
- Epidural steroid injections
- Physical methods such as bracing and flexion strengthening exercises 3
- Radiotherapy for refractory osteoarthritis, which has been shown to be an effective treatment option for pain reduction compared to other conventional methods 4
Surgical Intervention
Surgical intervention can be considered an appropriate and viable option when conservative measures have failed 2. However, the decision to proceed with surgery should be based on the specific nature and location of the patient's individual pathology.
Treatment Options
Treatment options should always be directed toward the specific nature and location of the patient's individual pathology 2. In some cases, epidural steroid injection with triamcinolone acetate may be effective in providing pain relief, as seen in a patient with transient neurologic syndrome resistant to treatment with NSAIDs, amitriptyline, and gabapentin 5.
Complications and Considerations
It is essential to be aware of the potential complications associated with various treatment options, including total disk replacement, which may be considered for symptomatic lumbar degenerative disk disease when conservative management has failed 6.