What is the recommended management plan for a patient with left shoulder/back pain, suspected to be muscular strain secondary to massage injury and repetitive lifting, with associated symptoms of chest pain and shortness of breath?

Management of Musculoskeletal Chest and Shoulder Pain with Cardiopulmonary Symptoms

Immediate Assessment Priority

Given the chest pain and shortness of breath, cardiac causes must be definitively excluded before attributing symptoms solely to musculoskeletal injury, even with a normal ECG and benign examination. 1

Your patient has already had appropriate initial cardiac evaluation with a normal ECG and cardiovascular examination showing no acute changes, which significantly reduces the likelihood of acute coronary syndrome. 1 However, the combination of chest pain with shortness of breath warrants continued vigilance, particularly since physical examination contributes almost nothing to diagnosing myocardial infarction unless shock is present. 1

Diagnostic Considerations

Musculoskeletal Pain Features Present

• Chest pain reproducible with pressure (baby pressing on area) strongly argues against cardiac etiology 1
• Pain affected by position (unable to sleep on left side) and palpation are high-value negative predictors for acute coronary syndrome 1
• Tenderness on examination of the shoulder and spine supports musculoskeletal origin 1
• The temporal relationship to massage injury and repetitive lifting (caring for two young children while breastfeeding) provides a clear mechanical explanation 1

Red Flags to Monitor

• Shortness of breath when speaking requires differentiation between anxiety, dysfunctional breathing patterns, and organic cardiopulmonary disease 1, 2
• Finger numbness suggests possible cervical radiculopathy or thoracic outlet syndrome, though full range of motion and normal power make significant nerve compression less likely 1
• The patient's complex psychosocial situation (history of domestic violence, crowded living conditions, two young children, unemployed husband) increases risk for anxiety-related symptoms 2

Recommended Management Plan

Pharmacological Treatment for Musculoskeletal Pain

Start with NSAIDs as first-line therapy for musculoskeletal pain and inflammation. 3, 4

• Ibuprofen 400-600mg three times daily with food for 7-10 days 3, 5
• Avoid adding acetaminophen to ibuprofen, as combination therapy does not improve outcomes for musculoskeletal back/shoulder pain compared to NSAID monotherapy 5
• Screen for NSAID contraindications: gastrointestinal bleeding history, renal disease, cardiovascular risk factors, or current anticoagulation 3
• If NSAIDs are contraindicated or ineffective after 5-7 days, consider acetaminophen 1000mg three times daily as an alternative 3

Avoid opioids entirely for this presentation - the mechanism of injury, examination findings, and functional status do not warrant opioid therapy, and the patient has significant risk factors for misuse given her psychosocial stressors. 3

Management of Shortness of Breath

The shortness of breath when speaking suggests dysfunctional breathing patterns rather than organic cardiopulmonary disease, given normal oxygen saturation (97%), normal respiratory examination, and absence of increased work of breathing. 1, 2

• Provide education on dysfunctional breathing patterns and breathing retraining techniques 2
• Teach relaxation techniques including controlled breathing exercises 2
• Consider short-acting benzodiazepine (alprazolam 0.25mg as needed) if acute anxiety episodes with dyspnea are prominent, but use cautiously and for short duration only 2
• Alternatively, consider buspirone 5mg twice daily if ongoing anxiety management is needed, as this is safer for patients with respiratory symptoms 2

Non-Pharmacological Interventions

Implement physical therapy focused on postural correction, strengthening exercises for shoulder girdle and back, and ergonomic education for childcare activities. 1, 6

• Address repetitive lifting mechanics with two young children and breastfeeding positioning 1
• Apply heat or ice as preferred for symptomatic relief 4
• Gradual return to normal activities rather than prolonged rest 1
• Consider massage therapy once acute pain subsides, given the ironic trigger of this episode 6

Addressing Psychosocial Factors

The patient's living situation (family of 10 in one bedroom, history of domestic violence, unemployed spouse) represents significant stressors that may amplify pain perception and contribute to anxiety-related symptoms. 2

• Acknowledge the challenging circumstances of caring for two young children while breastfeeding in a crowded environment 2
• Provide resources for housing assistance (note that housing has been arranged per history) 2
• Screen for ongoing domestic violence and provide appropriate referrals if needed 2

Follow-Up Plan

Schedule follow-up in 7-10 days to reassess pain, functional status, and respiratory symptoms. 2, 6

• If pain persists beyond 2-3 weeks despite appropriate treatment, consider cervical spine imaging to evaluate for radiculopathy given finger numbness 1
• If shortness of breath worsens or occurs at rest without exertion, reassess cardiac status with repeat ECG and consider cardiology referral 1, 2
• Monitor for development of new symptoms suggesting pulmonary embolism (sudden worsening dyspnea, pleuritic pain, tachycardia), though risk is low in this young patient without prolonged immobility 1

Critical Pitfalls to Avoid

Do not attribute all symptoms to anxiety without thoroughly excluding organic causes, particularly in patients with chest pain and dyspnea. 1, 2

• The normal ECG is reassuring but does not completely exclude cardiac disease; maintain clinical vigilance 1
• Avoid long-term benzodiazepines due to dependence risk and potential respiratory depression 2
• Do not prescribe opioids for this presentation - the injury mechanism, examination findings, and psychosocial risk factors make this inappropriate 3
• Recognize that musculoskeletal chest pain can coexist with anxiety, and both may require treatment 2

Ensure contraceptive counseling given recent return of menses and current breastfeeding status with two young children. This patient received her last contraceptive injection in July 2025 and has had one period since, indicating return of fertility.