What is the best management approach for an elderly female patient with a history of shoulder pain?

Management of Shoulder Pain in an Elderly Female Patient

For an elderly female patient with shoulder pain, begin with standard three-view radiographs (AP internal/external rotation and axillary or scapular Y views), followed by acetaminophen as first-line pain management up to 4 grams daily, and implement physical therapy focusing on external rotation and abduction while strictly avoiding overhead pulleys. 1

Initial Diagnostic Approach

Mandatory First-Line Imaging

• Standard radiography with three views is the essential first step, as it effectively identifies fractures, dislocations, arthritis, and shoulder malalignment in elderly patients 1
• The complete series must include AP views in both internal and external rotation, plus either an axillary lateral or scapular Y view 1
• In patients over 35 years, shoulder pain predominantly stems from rotator cuff disease and degenerative changes, making plain films particularly informative 1
• Critical pitfall: Never assume absence of trauma means absence of fracture—osteoporotic fractures occur with minimal or unrecognized trauma in elderly patients 1

Advanced Imaging When Needed

• MRI without contrast is the preferred advanced imaging for evaluating rotator cuff pathology, occult fractures, and soft tissue structures when radiographs are noncontributory 2, 1
• Ultrasound serves as an excellent alternative if local expertise is available, particularly for rotator cuff and biceps tendon evaluation 2, 1
• MRI, MR arthrography, and ultrasound are rated equally appropriate (score 9/9) for shoulder evaluation, with choice depending on local expertise 2

Key History Elements to Document

• Exact mechanism of injury including fall height, landing position, and whether work-related 3
• Pain location: anterior suggests rotator cuff/biceps pathology; superior indicates acromioclavicular joint disease; scapular region may indicate referred cervical spine pain 3
• Aggravating factors such as overhead activities, cross-body adduction, or specific movements 3
• Screen for neurological symptoms (numbness, tingling, weakness) suggesting cervical radiculopathy 3
• Ask about systemic symptoms (fever, chills) that may indicate septic arthritis requiring immediate intervention 3

Pain Management Algorithm

First-Line Therapy

• Start with acetaminophen at a maximum of 4 grams daily, which provides pain relief comparable to NSAIDs without gastrointestinal toxicity 1
• Add topical formulations (methyl salicylate, capsaicin cream, or menthol) for mild to moderate pain 1

Second-Line Options

• If acetaminophen fails, consider a trial of NSAIDs, but recognize elderly patients face exceptionally high risk for gastrointestinal, platelet, and nephrotoxic effects 1
• Do not prescribe NSAIDs without detailed medication history including over-the-counter use, as drug-drug and drug-disease interactions are common 1
• Avoid long-term NSAID use in elderly patients given the high frequency of adverse events 1

Interventional Pain Management

• Intra-articular glucocorticoids are beneficial for pain not adequately relieved by systemic medications, especially with evidence of inflammation and joint effusion 1
• Subacromial corticosteroid injections should be used when pain relates to injury or inflammation of the subacromial region (rotator cuff or bursa) 2
• Diagnostic injections (subacromial space, acromioclavicular joint, intra-articular, biceps tendon) help establish clear diagnosis while providing symptom relief 4
• Opioid analgesics may be preferable to NSAIDs for severe pain refractory to other therapies, given the toxicity profile of NSAIDs in elderly patients 1

Physical Therapy Protocol

Essential Interventions

• Implement range of motion exercises through stretching and mobilization techniques focusing specifically on external rotation and abduction to prevent frozen shoulder 2, 1
• Active range of motion should increase gradually in conjunction with restoring alignment and strengthening weak muscles in the shoulder girdle 2
• Consider electrical stimulation to improve shoulder lateral rotation 1
• Apply modalities including ice, heat, and soft tissue massage as adjunctive treatments 2

Critical Contraindication

• Strictly avoid overhead pulleys, which encourage uncontrolled abduction and may worsen pain 2, 1

Additional Considerations

• Positioning, passive stretching, and range-of-motion exercises should be performed several times daily if spasticity develops 1
• Shoulder strapping may be considered to prevent trauma to the shoulder 2

Conditions Requiring Specialist Referral

Immediate Referral Indications

• Clinical suspicion of septic arthritis (ultrasound or x-ray guided arthrocentesis rated 9/9 for diagnostic aspiration) 2, 1
• Presence of neurological deficits 1
• Unstable or significantly displaced fractures on imaging 1

Urgent Referral Indications

• Shoulder joint instability 1
• Suspected massive rotator cuff tears requiring expedited repair 1
• Failure of appropriate course of non-surgical treatment after 6-12 weeks 5

Age-Specific Diagnostic Considerations

Primary Pathology in Elderly Patients (>35-40 years)

• Rotator cuff disease and degenerative changes predominate as the primary causes of shoulder pain 2, 3, 1
• Rotator cuff tendinopathy/tear presents with pain during overhead activities and weakness, particularly with pushup movements that load the rotator cuff eccentrically 3
• Look for focal weakness with decreased range of motion during abduction with external or internal rotation, positive empty can test, and positive external rotation weakness 3

Contrast with Younger Patients

• In patients under 35 years, instability related to labral tears predominates, whereas older patients primarily have rotator cuff-related pathology 2
• MR arthrography is generally recommended for patients aged <35 years due to instability concerns, but is less critical in elderly patients where rotator cuff disease dominates 2