What is the recommended management for a patient with lower back pain, right shoulder pain, and cough, considering their history of injury and previous tendon/muscle rupture?

Management Approach for Acute Lower Back and Shoulder Pain Following Gardening Injury

Immediate Management Priority

This patient requires conservative multimodal therapy with NSAIDs, structured physical therapy, and reassurance about staying active, while avoiding routine imaging at this stage. 1

Lower Back Pain Management

Initial Assessment and Red Flag Screening

• No red flags are present in this case—specifically no saddle anesthesia, urinary retention/incontinence, progressive neurologic deficits, or bilateral leg weakness, which would mandate urgent imaging. 1
• The mechanism (prolonged sitting followed by sudden movement) and 7/10 pain severity without neurologic compromise indicates nonspecific mechanical low back pain. 1

Imaging Decision

• Do not obtain imaging at this stage. Routine imaging for nonspecific low back pain does not improve outcomes, increases costs, and fails to identify a precise cause in most cases. 1
• Imaging is only indicated if severe/progressive neurologic deficits develop or if symptoms persist beyond 4-6 weeks without improvement. 1

Pharmacologic Management

• Start with acetaminophen up to 4 grams daily as first-line therapy given its favorable safety profile and low cost, though it provides slightly less pain relief than NSAIDs (approximately 10 points less on a 100-point scale). 1
• If acetaminophen is insufficient, escalate to NSAIDs (ibuprofen or naproxen), which are more effective for pain relief but carry gastrointestinal and renovascular risks. 1
• Consider a short course (5-7 days) of skeletal muscle relaxants if muscle spasm is prominent, as they show similar efficacy to NSAIDs for short-term relief. 1
• Avoid systemic corticosteroids—they are not more effective than placebo for low back pain with or without sciatica. 1

Activity and Self-Care

• Advise the patient to remain active and avoid bed rest. Staying active is more effective than bed rest for acute low back pain. 1
• If severe symptoms require brief rest periods, encourage return to normal activities as soon as tolerable. 1
• Apply heat therapy (heating pads or heated blankets) for short-term relief. 1

Physical Therapy Referral

• Initiate physical therapy immediately focusing on range of motion restoration and core strengthening, as the patient demonstrates severely limited spinal flexion, extension, and right lateral flexion. 1, 2
• Exercise programs should be individualized, supervised, and incorporate both stretching and strengthening components. 1

Right Shoulder Pain Management

Initial Imaging

• Obtain standard shoulder radiographs immediately with three views: AP in internal and external rotation, plus axillary or scapular-Y view. 1, 3, 4
• Radiography is mandatory to assess for fracture, dislocation, or significant malalignment, which are primary concerns in acute traumatic shoulder pain. 1, 4
• The axillary view is vital because glenohumeral and acromioclavicular dislocations can be missed on AP views alone. 1

Clinical Findings Interpretation

• Tenderness over the acromioclavicular joint and humeral head with limited abduction to 90 degrees bilaterally suggests rotator cuff pathology, possibly acute-on-chronic tendinopathy or impingement syndrome. 3, 5
• The history of previous tendon/muscle rupture increases risk for recurrent rotator cuff injury. 3
• Pain with internal rotation against resistance localizing to the AC joint and humeral head is consistent with rotator cuff tendinopathy and possible AC joint involvement. 3, 5

Conservative Management Strategy

• Start structured exercise therapy combined with NSAIDs, which shows large effect sizes in reducing pain and improving function in shoulder pathology. 3
• Avoid corticosteroid injections initially—evidence is conflicting and they may compromise tendon biology. 3
• Physical therapy should focus on range of motion exercises through stretching and mobilization, particularly external rotation and abduction, while avoiding overhead pulleys that encourage uncontrolled abduction. 4

Advanced Imaging Decision

• Reserve MRI without contrast for 8-12 weeks if conservative management fails, as most patients show significant improvement after 8 weeks of exercise therapy. 3
• Do not assume the prior MRI findings are current—acute exacerbation may represent progression or new rotator cuff involvement. 3

Cough Management

• For symptomatic relief, consider dextromethorphan (cough suppressant) if the cough is dry and interfering with sleep or daily activities. 6
• If cough persists beyond 3 weeks or is associated with fever, hemoptysis, or systemic symptoms, further evaluation is warranted.

Reassessment Timeline

• Reassess at 2 weeks for medication tolerance and early response to therapy. 1
• Formal reassessment at 8-12 weeks for both back and shoulder pain to determine if advanced imaging or specialist referral is needed. 1, 3
• Surgery for shoulder pathology should only be considered after an adequate 3-6 month trial of conservative management fails, or if imaging reveals significant full-thickness rotator cuff tear. 3

Critical Pitfalls to Avoid

• Do not order MRI or CT for the lower back at this stage—it will not change management and may lead to unnecessary interventions. 1
• Do not prescribe opioids as first-line therapy—they should be reserved for severe pain refractory to other therapies given risks of dependence. 1
• Do not overlook scapular dyskinesis in shoulder rehabilitation, as it contributes significantly to both rotator cuff and labral injuries. 3
• Do not assume absence of fracture based solely on mechanism—radiographs are mandatory to exclude occult fracture, especially given the patient's age. 1, 4