What is the appropriate workup and management for a patient presenting with bilateral shoulder and left knee pain?

Workup and Management for Bilateral Shoulder and Left Knee Pain

The appropriate workup for bilateral shoulder and left knee pain should begin with plain radiography of both shoulders and the left knee, followed by MRI or ultrasound if radiographs are normal or indeterminate, with laboratory tests including ESR and CRP to evaluate for inflammatory conditions. 1

Initial Imaging Evaluation

Shoulder Pain Workup

1. Plain Radiography (First-line)

   • Standard views should include:
     • Anteroposterior (AP) views in internal and external rotation
     • Axillary or scapula-Y view 1
   • Radiographs should be performed upright as malalignment can be underrepresented on supine imaging 1

2. Advanced Imaging (If radiographs are normal/indeterminate)

   • MRI without contrast is usually appropriate for:
     • Suspected rotator cuff tears
     • Labral tears
     • Soft tissue pathologies 1
   • Ultrasound is an equivalent alternative to MRI for:
     • Rotator cuff evaluation
     • Detection of bursitis
     • Effusions 1

Knee Pain Workup

1. Plain Radiography (First-line)

   • Weight-bearing views are preferred 1

2. Advanced Imaging (If radiographs are normal/indeterminate)

   • MRI without contrast for:
     • Meniscal injuries
     • Ligament injuries
     • Cartilage damage 1
   • CT may be considered if:
     • Loose bodies are suspected
     • Osteochondritis dissecans is present 1

Laboratory Evaluation

1. Inflammatory Markers

   • Erythrocyte Sedimentation Rate (ESR):
     • Better for monitoring chronic inflammatory conditions due to longer half-life 2
     • Can be elevated in osteoarthritis with correlation to radiographic severity 3
   • C-Reactive Protein (CRP):
     • More useful for acute inflammatory conditions 2
     • More sensitive for early detection of inflammation 4
     • May increase in early-stage knee osteoarthritis (KL-II) 3

2. Additional Testing (based on clinical suspicion):

   • Rheumatoid factor and anti-CCP antibodies if rheumatoid arthritis is suspected
   • Uric acid if gout is suspected
   • Consider polymyalgia rheumatica in elderly patients, even with normal ESR 5, 6

Management Approach

Non-Pharmacological Interventions

1. Physical Therapy

   • Gentle stretching and mobilization techniques focusing on external rotation and abduction 7
   • Gradually increase active range of motion exercises 7
   • Avoid overhead pulley exercises for shoulder pain 7
   • Early intervention is crucial - consider intensive physical therapy if full function not achieved by 6-8 weeks 7

2. Activity Modification

   • Rest but avoid complete immobilization to prevent muscular atrophy 7
   • Allow activities that don't worsen pain 7
   • Apply ice through a wet towel for 10-minute periods for acute pain 7

Pharmacological Management

1. NSAIDs (e.g., Naproxen)

   • For pain relief and anti-inflammatory effects 7, 8
   • Consider topical NSAIDs for fewer systemic side effects 7
   • Monitor for gastrointestinal side effects including ulcers and bleeding 8
   • Contraindicated in patients with history of asthma attack, hives, or allergic reaction to NSAIDs 8

2. Intra-articular Injections

   • Corticosteroid injections for significant pain 7
   • Target intra-articular or subacromial injections rather than intramuscular 7
   • Consider methylprednisolone acetate 40mg with lidocaine 1% for rapid pain relief 7

Special Considerations

When to Consider Inflammatory Conditions

• If bilateral shoulder pain with morning stiffness is present, especially in older patients, consider polymyalgia rheumatica even if ESR is normal 5, 6
• Ultrasound or MRI can detect inflammatory shoulder lesions (bursitis, synovitis) even in patients with normal ESR 5

When to Refer for Surgical Evaluation

• Consider surgical referral if conservative management fails after 3-6 months 7
• Surgical options depend on specific diagnosis:
  • Arthroscopic subacromial decompression for impingement
  • Rotator cuff repair
  • Knee arthroscopy for meniscal tears or loose bodies 7

Prognosis

• Approximately 80% of patients recover completely within 3-6 months with appropriate conservative treatment 7
• Workers' compensation status may correlate with less favorable outcomes 7
• Age-related factors (patients over 50 having higher rates of full-thickness rotator cuff tears) can impact outcomes 7

Common Pitfalls to Avoid

• Delaying physical therapy intervention 7
• Using advanced imaging (MRI/CT) before plain radiographs 1
• Relying solely on ESR for diagnosis of inflammatory conditions, as it can be normal in some cases of polymyalgia rheumatica 5, 6
• Complete immobilization of the affected joints, which can lead to stiffness and muscle atrophy 7
• Overlooking the possibility of referred pain from cervical spine pathology