Management of Chronic Shoulder Tendinitis and Aortic Knob Plaquing in an Elderly Patient
For this elderly patient with chronic shoulder tendinitis causing severe pain (8/10), start with acetaminophen up to 4 grams daily as first-line therapy, combined with a structured exercise program emphasizing gentle range-of-motion and isometric strengthening exercises, while monitoring the aortic knob plaquing with periodic imaging but no immediate intervention. 1
Pain Management Strategy
First-Line Pharmacologic Treatment
Initiate acetaminophen as the primary analgesic, with a maximum daily dose of 4 grams, as it is as effective as NSAIDs for mild-to-moderate pain and has a superior safety profile in elderly patients. 1, 2, 3
Exercise caution with NSAIDs in this elderly patient due to significant risks of gastrointestinal bleeding, cardiovascular complications, renal toxicity, and drug-drug interactions that are more frequent in older adults. 1, 4
If acetaminophen provides inadequate relief after an appropriate trial, consider a short-term course of NSAIDs at the lowest effective dose for the shortest duration possible, recognizing that elderly patients are at high risk for adverse effects. 1, 5
Topical NSAIDs or counterirritants (capsaicin cream, methyl salicylate, menthol) are preferred alternatives for localized shoulder pain, as they provide similar pain relief with fewer systemic side effects compared to oral NSAIDs. 1, 6, 7
Advanced Pain Management Options
For severe refractory pain, carefully titrated opioid analgesics may be preferable to NSAIDs in elderly patients, as they pose fewer risks than the gastrointestinal, cardiovascular, and renal complications associated with NSAIDs. 1
Intraarticular corticosteroid injections can be considered for acute pain exacerbations, particularly when there is evidence of inflammation and joint effusion, though this is more commonly used for knee osteoarthritis than shoulder tendinitis. 1
Use corticosteroid injections with significant caution, as they may provide acute pain relief but do not alter long-term outcomes and may inhibit healing and reduce tensile strength of tendons. 6, 7
Exercise and Rehabilitation Protocol
Initial Phase: Gentle Range-of-Motion
Begin with static stretching exercises performed daily when pain and stiffness are minimal, ideally before bedtime. 1
Precede exercises with a warm shower or application of superficial moist heat to the shoulder. 1
Apply ice through a wet towel for 10-minute periods for short-term pain relief after activities. 6, 7
Perform movements slowly, extending range of motion to a comfortable level that produces slight resistance, holding terminal stretch positions for 10-30 seconds. 1
Strengthening Phase: Isometric Then Isotonic
Start with isometric strengthening exercises, as these produce low articular pressures and are well tolerated by patients with painful, inflamed joints. 1
Inflamed joints should be isometrically strengthened with only a few repetitions; movements should not be resisted. 1
Progress to isotonic strengthening exercises as tolerated, as these closely correspond to everyday activities and are the recommended form of dynamic strength training. 1
Initiate eccentric strengthening exercises, as they have proven beneficial in reversing degenerative changes, reducing symptoms, and increasing strength in chronic tendinosis. 6, 7, 8
Exercise Session Structure
Each session should include three phases: 5-10 minute warm-up with low-intensity range-of-motion exercises, training period for strengthening, and 5-minute cool-down with static stretching. 1
Muscles should not be exercised to fatigue, and exercise resistance must be submaximal. 1
Joint pain lasting more than 1 hour after exercise or joint swelling indicates excessive activity and requires modification of the program. 1
Critical Exercise Principles
Avoid complete immobilization, as this accelerates muscular atrophy and deconditioning in elderly patients. 6, 7, 8
Modify stretching exercises to avoid pain or when the joint is inflamed by decreasing the extent of joint range of motion or duration of holding static positions. 1
Specific exercises should be selected based on joint stability and degree of pain and inflammation. 1
Management of Aortic Knob Plaquing
Surveillance Strategy
The aortic knob plaquing requires monitoring but no immediate intervention, as it represents calcium buildup that should be watched for changes including possible aneurysm development. 1
Periodic imaging surveillance is indicated, though the specific interval should be determined by the patient's cardiovascular risk factors and the extent of calcification. 1
No outside referral is needed at this time unless there is evidence of aneurysm formation or rapid progression. 1
Risk Factor Modification
Strongly encourage smoking cessation if applicable, as tobacco use is associated with growth of thoracic aortic aneurysms and increased mortality. 1
Blood pressure control is essential, as hypertension accelerates aortic disease progression. 1
Counsel the patient to seek immediate medical care for any unexpected chest discomfort, as this could indicate acute aortic complications. 1
Expected Timeline and Outcomes
Approximately 80% of patients with overuse tendinopathies fully recover within 3-6 months with appropriate conservative treatment including exercise and pain management. 6, 7
If symptoms persist after 3-6 months of appropriate conservative management, surgical consultation may be warranted. 6, 7
Regular moderate-level exercise does not exacerbate chronic tendon pain or accelerate the pathological process; rather, increasing physical activity reduces pain and morbidity. 1
Common Pitfalls to Avoid
Never use overhead pulley exercises for shoulder rehabilitation, as these are not recommended and may worsen symptoms. 1
Do not prescribe NSAIDs in high doses for long periods in elderly patients due to cumulative toxicity risks. 1
Avoid the misconception that rest alone will resolve chronic tendinitis; structured exercise is essential for recovery. 1
Do not ignore the cardiovascular implications of the aortic plaquing; ensure appropriate monitoring is in place even though immediate intervention is not required. 1