What is the best approach for managing severe arm and shoulder pain in an 88 Year Old Male (YOM) with no history of trauma?

Management of Severe Arm and Shoulder Pain in an 88-Year-Old Male Without Trauma

Begin with standard radiography including anteroposterior views in internal and external rotation plus axillary lateral or scapular Y view, followed by acetaminophen as first-line analgesia up to 4 grams daily, with physical therapy focusing on range of motion exercises. 1, 2

Initial Diagnostic Imaging

• Standard radiography is the mandatory first step for evaluating shoulder pain in this elderly patient, as it effectively demonstrates fractures, dislocations, arthritis, and shoulder malalignment even without obvious trauma history 2, 1
• The complete radiographic examination must include at least three views: AP views in internal and external rotation, and axillary lateral view or scapular Y view 1
• In patients over 35 years (and certainly at 88 years), shoulder pain predominantly relates to rotator cuff disease and degenerative changes, making plain films particularly informative 1

Advanced Imaging Considerations

If radiographs are noncontributory but pain persists:

• MRI without contrast is the preferred advanced imaging for this age group, as it evaluates rotator cuff pathology, occult fractures, and soft tissue structures 2, 1
• Ultrasound is an excellent alternative if local expertise is available, particularly for rotator cuff and biceps tendon pathology 2, 1
• MR arthrography is unnecessary in this elderly patient as it's primarily indicated for patients under 35 years with suspected labral tears or instability 1

Pain Management Algorithm

Step 1: Acetaminophen

• Start with acetaminophen as first-line therapy, which provides pain relief comparable to NSAIDs without gastrointestinal toxicity 2
• Maximum daily dose is 4 grams 2
• This is particularly important in an 88-year-old who faces high risk for NSAID complications 2

Step 2: Topical Agents

• For mild to moderate pain, add topical formulations such as methyl salicylate, capsaicin cream, or menthol 2
• These provide additional relief without systemic side effects 2

Step 3: NSAIDs (Use with Extreme Caution)

• If acetaminophen fails, consider a trial of NSAIDs, but recognize that elderly persons are at exceptionally high risk for gastrointestinal, platelet, and nephrotoxic effects 2
• NSAIDs should not be used in high doses for long periods in this age group 2
• If GI history exists or symptoms develop, COX-2 inhibitors may be considered, though rofecoxib causes fluid retention in older adults and carries increased cardiovascular risk without aspirin 2
• The choice requires careful consideration given potential renal complications 2

Step 4: Intraarticular Therapy

• For pain not adequately relieved by systemic medications or when oral NSAIDs are contraindicated, intraarticular glucocorticoids (triamcinolone hexacetonide) are beneficial, especially with evidence of inflammation and joint effusion 2
• Intraarticular hyaluronic acid preparations have shown efficacy for knee osteoarthritis and may be considered for shoulder arthritis 2

Step 5: Opioid Analgesics

• For severe pain refractory to other therapies, carefully titrated opioid analgesics may be preferable to NSAIDs or invasive interventions that pose appreciable risks in older people 2
• Opioids may be better for acute exacerbations than long-term use 2

Physical Therapy Interventions

• Avoid overhead pulleys which encourage uncontrolled abduction and may worsen pain 1
• Implement range of motion exercises through stretching and mobilization techniques focusing on external rotation and abduction 1
• Consider electrical stimulation to improve shoulder lateral rotation 1
• Positioning, passive stretching, and range-of-motion exercises should be performed several times daily if spasticity develops 2

Red Flags Requiring Specialist Referral

• Presence of neurological deficits 1
• Unstable or significantly displaced fractures on imaging 1
• Shoulder joint instability 1
• Suspected massive rotator cuff tears requiring expedited repair 1
• Clinical suspicion of septic arthritis (perform ultrasound or X-ray guided arthrocentesis immediately) 2, 1

Critical Pitfalls to Avoid

• Do not assume absence of trauma means absence of fracture in an 88-year-old—osteoporotic fractures can occur with minimal or unrecognized trauma 1
• Do not prescribe NSAIDs without detailed medication history including over-the-counter use, as drug-drug and drug-disease interactions are common 2
• Do not use NSAIDs long-term in elderly patients given the high frequency of adverse events 2
• Pain worse on movement and palpation suggests inflammatory or structural pathology requiring imaging before aggressive physical therapy 3, 4