What is the best course of treatment for a 62-year-old woman with a history of hypertension (high blood pressure) and hypothyroidism, presenting with pain and swelling at the right sternoclavicular joint, limited range of motion, and subluxation, with a 5-year history of clavicle deformity and a previous episode of similar pain that resolved with over-the-counter (OTC) painkillers?

Sternoclavicular Joint Arthropathy with Recurrent Pain and Subluxation

Initial Management Approach

This patient requires conservative management with NSAIDs, physical therapy, and close monitoring of her hypertension and hypothyroidism, as the recurrent inflammatory arthropathy at the sternoclavicular joint with subluxation typically responds well to anti-inflammatory treatment and supportive care. 1

Diagnostic Considerations

The clinical presentation suggests sternoclavicular joint arthropathy with the following key features:

• Recurrent episodes of pain and swelling at the SC joint 1
• Limited range of motion due to pain 1
• Subluxation with chronic deformity (5-year history) 1
• Previous episode resolved with OTC analgesics 1

This pattern is consistent with either osteoarthritis of the SC joint or inflammatory arthropathy, both of which are managed conservatively in the absence of infection or severe structural damage. 1

Treatment Algorithm

First-Line Pharmacologic Management

NSAIDs are the cornerstone of treatment for inflammatory joint pain and swelling, but require careful consideration given her hypertension: 1, 2

• Before initiating NSAID therapy, blood pressure must be measured and monitored closely, as NSAIDs can lead to new-onset hypertension or worsening of pre-existing hypertension 2, 3
• Naproxen or celecoxib are preferred in patients with cardiovascular risk factors (hypertension qualifies) 3
• Avoid NSAIDs if possible in treatment-resistant hypertension 3
• If NSAIDs are used with her existing antihypertensive regimen, consider empirical addition or dose increase of an antihypertensive agent of a different class 3
• Monitor blood pressure during NSAID initiation and throughout therapy 2, 3

Thyroid Optimization

Ensure adequate thyroid hormone replacement before attributing persistent symptoms solely to joint pathology:

• Hypothyroidism itself can contribute to hypertension and joint symptoms 4, 5, 6
• Verify TSH and free T4 levels are optimized, as inadequate thyroid replacement may perpetuate both hypertension and musculoskeletal complaints 7, 8
• Thyroid hormone replacement therapy can lead to normalization of blood pressure in some hypertensive patients with hypothyroidism 4, 5

Physical Interventions

Comprehensive physical therapy and supportive measures are recommended: 1

• Range of motion exercises (avoiding overhead pulley exercises which are contraindicated in shoulder pathology) 1
• Positioning and supportive devices to reduce stress on the SC joint 1
• Patient education on joint protection and activity modification 1

Monitoring Strategy

Close follow-up is essential given her comorbidities:

• Blood pressure monitoring every 1-2 weeks after NSAID initiation 2, 3
• Reassess joint symptoms in 1-2 weeks 1
• If no improvement with conservative management over 1 week, consider short course of oral corticosteroids (prednisone 0.5-1 mg/kg) 1

Critical Pitfalls to Avoid

Do not overlook infection: While the recurrent nature and previous resolution with OTC medications suggest non-infectious etiology, any fever, systemic symptoms, or failure to respond to initial therapy warrants evaluation for septic arthritis. 1

NSAID-related complications in this patient:

• Her hypertension increases risk of NSAID-induced blood pressure elevation 2, 3
• Use the lowest effective dose for the shortest duration 2, 3
• Avoid in setting of treatment-resistant hypertension 3
• Consider adding gastroprotection (PPI) if she has any GI risk factors 3

Hypothyroidism management: Inadequately treated hypothyroidism can contribute to both her hypertension and potentially to joint symptoms, so optimization of thyroid replacement is not merely supportive but potentially therapeutic. 4, 5, 6

When to Escalate Care

Consider intra-articular corticosteroid injection if conservative management fails after 2-4 weeks. 1

Surgical consultation (tenotomy or joint stabilization) should be reserved for severe cases with persistent pain and functional limitation despite maximal conservative therapy. 1