Management of Bilateral Shoulder and Spine Pain in a Patient with Bone-on-Bone Knee Arthritis

This patient requires a comprehensive multimodal approach prioritizing exercise therapy, weight reduction if overweight/obese, acetaminophen as first-line analgesia, and topical NSAIDs before systemic medications, while avoiding opioids for chronic management. 1

Initial Assessment Priorities

Determine if this represents inflammatory arthritis versus osteoarthritis by assessing for morning stiffness lasting >1 hour, symmetric small joint involvement, and systemic symptoms (fever, weight loss, fatigue), which would suggest rheumatoid arthritis rather than OA. 2 The presence of bone-on-bone knee arthritis suggests advanced OA, making polyarticular OA the most likely diagnosis for shoulder and spine pain unless red flags are present.

Rule out serious pathology ("red flags") including:

Acute trauma or fracture
Infection (fever, acute monoarticular swelling)
Malignancy (unexplained weight loss, night pain)
Neurological compromise in spine pain 1

Non-Pharmacological Management (First-Line)

Exercise Therapy - Strongly Recommended

Exercise is the cornerstone of treatment for all affected joints and should be initiated immediately. 1

For shoulder pain:

Exercise-based physical therapy focusing on rotator cuff strengthening, range of motion, and pain reduction 3
No specific exercise prescription (duration, intensity, frequency) has proven superior, so tailor to patient preference including walking, cycling, resistance training, or neuromuscular training 3

For spine pain:

Regular moderate-level exercise does not exacerbate OA pain or accelerate pathological progression 1
Low-impact aerobic fitness exercises (walking, cycling) with effect sizes of 0.52 for pain relief and 0.46 for disability reduction 1

For knee arthritis:

Quadriceps strengthening exercises with statistically significant and possibly clinically important effects on pain and function 1
Range-of-motion/flexibility exercises to address joint stiffness 1

Weight Management - Strongly Recommended if Applicable

If the patient is overweight or obese, weight loss ≥5% of body weight should be a primary goal. 1 Clinically important benefits continue to increase with weight loss of 5-10%, 10-20%, and >20% of body weight, with efficacy enhanced by concomitant exercise programs. 1

Self-Management and Education - Strongly Recommended

Enroll the patient in self-efficacy and self-management programs combining skill-building (goal-setting, problem-solving), disease education, joint protection measures, and fitness goals. 1 These programs show consistent benefits across studies with minimal risks. 1

Consider Tai Chi for knee and hip symptoms, which combines meditation with slow, gentle movements, breathing, and relaxation, showing efficacy through holistic impact on strength, balance, and self-efficacy. 1

Assistive Devices

For knee arthritis: Use a cane if disease is causing sufficient impact on ambulation, joint stability, or pain. 1 Consider tibiofemoral knee braces if the patient can tolerate the associated burden. 1

Pharmacological Management (Stepwise Approach)

First-Line: Acetaminophen (Paracetamol)

Acetaminophen is the oral analgesic to try first and, if successful, the preferred long-term oral analgesic for OA. 1 This recommendation applies to knee, hip, and hand OA based on EULAR guidelines. 1

Second-Line: Topical NSAIDs

Topical NSAIDs are strongly recommended for knee OA and should be considered before oral NSAIDs due to less systemic exposure. 1 They are conditionally recommended for hand OA but unlikely to benefit shoulder or spine due to joint depth. 1

Topical capsaicin is conditionally recommended as an alternative topical agent. 1

Third-Line: Oral NSAIDs (Use with Caution)

If acetaminophen and topical agents fail, oral NSAIDs should be considered, but NOT used in high doses for long periods. 1

Critical safety considerations:

Elderly patients are at high risk for GI, platelet, and nephrotoxic effects 1
If history of gastroduodenal ulcers or GI bleeding, use COX-2 selective inhibitors with caution due to potential renal complications and cardiovascular risk 1
Take detailed medication histories including OTC use, as adverse events with nonselective NSAIDs are more frequent than any other drug class 1

Injectable Therapies

For knee arthritis with acute flare and effusion:

Intra-articular corticosteroid injection (e.g., triamcinolone hexacetonide) is indicated 1
Hyaluronic acid preparations may provide efficacy for pain not adequately relieved with non-invasive therapies 1

For shoulder arthritis:

Injectable corticosteroids have insufficient evidence (Grade I recommendation) but are widely used in practice 3, 4
Viscosupplementation (hyaluronic acid) is an option (Grade C recommendation), typically three weekly injections with improvements at 1,3, and 6 months 3, 4

Opioids - Use Only as Last Resort

Opioids should be avoided for chronic management but may be considered for severe refractory pain when carefully titrated. 1 They may be better for acute exacerbations than long-term use. 1 Almost all guidelines urge caution and/or discourage opioid use. 1

Treatments to AVOID

Do NOT use:

Glucosamine or chondroitin for disease modification in knee OA 1
Massage therapy (conditionally recommended against for knee/hip OA) 1
TENS (strongly recommended against for knee/hip OA) 1
Knee arthroscopic lavage and debridement unless mechanical locking present 1

When to Consider Surgical Referral