From the Guidelines
I strongly recommend proceeding with the ordered right shoulder X-ray to evaluate the patient's chronic shoulder pain, as it is a safe, fast, and low-cost imaging modality that can effectively demonstrate many forms of shoulder pathology, as suggested by the American College of Radiology 1. The patient's occupation as a janitor may involve repetitive overhead movements or heavy lifting that could contribute to rotator cuff pathology, osteoarthritis, or other shoulder conditions. Given the patient's description of sharp pain in the muscle and the chronic nature of the condition, it is essential to investigate potential structural abnormalities that may be contributing to his symptoms. Some key points to consider when evaluating the patient's condition include:
- The patient's decline of pain medication and physical therapy, which makes imaging an appropriate next step to determine the cause of his pain
- The potential for rotator cuff pathology, osteoarthritis, or other shoulder conditions given the patient's occupation and symptoms
- The importance of reviewing the X-ray results with the patient to discuss appropriate treatment options based on the findings After reviewing the X-ray results with the patient, we can discuss appropriate treatment options based on the findings. If the X-ray is inconclusive but symptoms persist, further imaging such as an MRI might be warranted to evaluate soft tissue structures, as suggested by the multimodal approach for assessing shoulder pathology 1. While the patient has declined initial treatment options, having objective findings may help him better understand his condition and potentially reconsider conservative management approaches like modified activity, targeted exercises, or anti-inflammatory medications.
From the Research
Patient Complaints and History
- The patient is a 64-year-old male who works as a janitor and has been experiencing sharp pain in the muscle of his right shoulder for years.
- The patient declined any pain medications offered and also declined physical therapy.
Diagnostic Approach
- An x-ray of the right shoulder has been ordered to help diagnose the cause of the patient's pain 2.
- The x-ray will be reviewed with the patient to discuss the findings and determine the next steps in management.
- Other diagnostic tools, such as ultrasound 3 or magnetic resonance imaging (MRI) 4, may also be considered if the x-ray is inconclusive or if further evaluation is needed.
Potential Causes of Shoulder Pain
- The patient's symptoms could be related to a variety of conditions, including rotator cuff injury, shoulder instability, or impingement 5.
- Other potential causes of shoulder pain include subdeltoid subacromial bursitis, glenohumeral joint capsulitis, calcific tendinosis, acromioclavicular joint osteoarthritis, and long head of biceps tendinosis 3.
Treatment Options
- If the patient's pain is found to be related to a condition such as subdeltoid subacromial bursitis or calcific tendinosis, treatment options may include ultrasound-guided injection or other techniques such as steroid injections, hydrodilatation, or extracorporeal shockwave treatment 3.
- However, the patient has already declined pain medications and physical therapy, so other treatment options may need to be considered.
- It is also important to note that the patient's occupation as a janitor may be contributing to their shoulder pain, and modifications to their work activities or ergonomic changes may be necessary to help manage their symptoms.
Pharmacologic Management
- If the patient's pain is severe or refractory, pharmacologic management may be considered, including the use of acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), or other medications 6.
- However, the patient has already declined pain medications, so this option may not be viable.