What is the best management plan for a 64-year-old male patient with right shoulder pain due to mild undersurface bony spurring at the acromioclavicular joint and constant left knee pain?

Management of Right Shoulder Pain with Acromioclavicular Joint Spurring and Left Knee Pain

Physical therapy combined with topical NSAIDs and short-term muscle relaxants is the optimal first-line treatment for this 64-year-old male with mild acromioclavicular joint spurring causing right shoulder pain, while knee imaging and supportive care are appropriate for the left knee pain.

Right Shoulder Pain Management

Assessment and Diagnosis

The x-ray findings of mild undersurface bony spurring at the acromioclavicular joint indicate early osteoarthritis of the AC joint, a common cause of shoulder pain in middle-aged and older adults 1.

Treatment Plan

First-Line Interventions

1. Physical Therapy

   • Gentle stretching and mobilization techniques focusing on external rotation and abduction 2
   • Active range of motion exercises to gradually restore alignment and strengthen weak muscles in the shoulder girdle 2
   • Eccentric strengthening exercises with progressive resistance 3
   • Isometric exercises without pain to maintain muscle strength 3

2. Pain Management

   • Topical NSAIDs (diclofenac cream): Appropriate choice for localized pain with fewer systemic side effects 3
   • Muscle relaxants (methocarbamol): Short-term use (7 days) is reasonable for acute pain relief 2
   • Avoid corticosteroid injections directly into the tendon as they may inhibit healing 3

Second-Line Interventions (if first-line fails after 4-6 weeks)

• Subacromial corticosteroid injections if pain is related to inflammation in the subacromial region 2
• Diagnostic local anesthetic injection into the AC joint to confirm it as the pain source 4, 1
• AC joint corticosteroid injection if diagnostic injection provides relief 4

Monitoring and Follow-up

• Regular assessment of pain levels and functional improvement 3
• Gradual return to normal activities based on functional improvement 3
• Avoid overhead pulley exercises as they may worsen the injury 3

Left Knee Pain Management

Assessment

• Severe constant pain (10/10) for 3 weeks, yet patient maintains ability to perform ADLs and work
• X-ray is appropriate as initial imaging to rule out fracture, degenerative changes, or other pathology 2

Initial Management

1. Diagnostic workup

   • X-ray of the left knee (as planned)
   • Consider further imaging based on x-ray results

2. Supportive care

   • Knee sleeve for support and proprioception (as planned)
   • Consider adding an NSAID (oral or topical) for pain management
   • Activity modification without complete rest

Follow-up Plan

The two-month follow-up appointment is appropriate to:

• Review x-ray findings
• Assess response to physical therapy for the shoulder
• Evaluate knee pain progression and response to initial treatment
• Consider referral to orthopedics if symptoms persist or worsen

Potential Pitfalls and Considerations

• Misdiagnosis: AC joint pain can be confused with rotator cuff pathology or glenohumeral joint issues 1, 5
• Overtreatment: Radiographic AC joint degeneration is common in asymptomatic individuals and should correlate with clinical findings 6
• Returning to activities too quickly: This can delay healing and worsen symptoms 3
• Prolonged immobilization: Can lead to muscle atrophy and stiffness 3
• Overreliance on medications: Focus should be on functional restoration through physical therapy 2

The current management plan with physical therapy, topical NSAIDs, and short-term muscle relaxants for the shoulder, along with imaging and supportive care for the knee, represents an evidence-based approach that balances pain relief with functional improvement.