What is the differential diagnosis (ddx) and management of a 67-year-old male with bilateral hip, shoulder, and wrist pain exacerbated by movement and exercise?

Bilateral Hip, Shoulder, and Wrist Pain in a 67-Year-Old Male

The most likely diagnosis is polymyalgia rheumatica (PMR), and you should immediately check ESR and CRP to confirm inflammatory activity, then initiate corticosteroid therapy if elevated; however, if inflammatory markers are normal, osteoarthritis affecting multiple joints is the primary consideration and exercise therapy should be strongly recommended as first-line treatment.

Differential Diagnosis

Primary Considerations

Polymyalgia Rheumatica (PMR)

• Classic presentation: bilateral shoulder and hip pain in patients >50 years, exacerbated by movement, often with morning stiffness >45 minutes
• Wrist involvement occurs in a subset of PMR patients
• Dramatically elevated ESR (typically >40 mm/hr) and CRP are hallmark features
• Requires urgent evaluation as untreated PMR significantly impacts quality of life and may be associated with giant cell arteritis

Osteoarthritis (OA)

• Bilateral involvement of hips, shoulders, and wrists is common in generalized OA 1
• Pain worsened by movement and exercise is characteristic of mechanical joint pain 1
• Age 67 is typical for symptomatic OA 1

Rheumatoid Arthritis (RA)

• Bilateral symmetric joint involvement affecting wrists, shoulders, and hips
• Morning stiffness typically >30 minutes
• Check rheumatoid factor, anti-CCP antibodies, ESR, CRP

Red Flags to Exclude

• Malignancy: Night pain, unexplained weight loss, history of cancer 2
• Infection: Fever, acute onset, systemic symptoms 1
• Fractures: Recent trauma, osteoporosis risk factors 1

Diagnostic Workup

Initial Laboratory Tests

• ESR and CRP (essential for PMR diagnosis) 2
• Complete blood count (anemia common in PMR)
• Rheumatoid factor and anti-CCP antibodies if RA suspected 2
• ANA if systemic inflammatory condition suspected 2

Imaging Protocol

Hip Evaluation

• Start with AP pelvis and lateral femoral head-neck radiographs to assess for OA, fractures, or dysplasia 3, 2
• Plain radiographs are excellent screening tools for common hip disorders 2
• MRI without contrast if radiographs negative but symptoms persist, particularly for occult fractures or osteonecrosis 2

Shoulder Evaluation

• Radiographs are the preferred initial diagnostic modality for acute shoulder pain 1
• AP and lateral views to evaluate for OA, fractures, or calcific tendinitis 1

Wrist Evaluation

• PA and lateral wrist radiographs to evaluate bony architecture, joint spaces, and alignment 4
• Specialized views if scaphoid pathology suspected 5

Clinical Examination Pearls

Hip Assessment

• FADIR test (flexion-adduction-internal rotation): negative test helps rule out hip-related pain, though sensitivity is limited 1, 2
• Trendelenburg gait suggests abductor tendon pathology 6
• Exclude lumbar spine and sacroiliac joint as pain sources 2

Shoulder Assessment

• Painful arc and restricted passive range of motion suggest adhesive capsulitis or OA 7
• Empty can test and external rotation weakness suggest rotator cuff pathology 7
• Cross-body adduction pain suggests acromioclavicular joint involvement 7

Wrist Assessment

• Localize tenderness to specific anatomic structures through palpation 4
• Finkelstein test for de Quervain tenosynovitis 5
• Grind test for first carpometacarpal OA 4

Management Algorithm

If Inflammatory Markers Elevated (PMR Suspected)

1. Initiate prednisone 15-20 mg daily
2. Expect dramatic improvement within 48-72 hours (diagnostic and therapeutic)
3. Refer to rheumatology for confirmation and long-term management
4. Monitor for giant cell arteritis symptoms (headache, jaw claudication, vision changes)

If Inflammatory Markers Normal (OA Most Likely)

First-Line Treatment: Exercise Therapy

• Exercise is strongly recommended for patients with knee, hip, and/or hand OA 1
• Walking, stationary cycling, resistance training, or aquatic exercise all demonstrate benefit 1
• Focus on patient preferences and access to improve adherence 1
• Strengthening exercises address muscle weakness and improve function 1
• Pain during exercise is not a contraindication; shared decision-making regarding exercise initiation is advisable 1

Physical and Occupational Therapy Referral

• Delivery of instruction by therapists is helpful and often essential for appropriate initiation and maintenance of exercise 1
• Therapists incorporate self-efficacy training, thermal therapies, and instruction in use of splints/braces 1
• Most OA patients benefit from referral at various times during disease course 1

Adjunctive Measures

• NSAIDs for pain control (consider cardiovascular and GI risk)
• Intra-articular corticosteroid injections for severe flares
• Weight loss if BMI elevated
• Assistive devices as needed

If Conservative Management Fails After 6-12 Weeks

• Reassess diagnosis with advanced imaging (MRI) 2
• Consider referral to orthopedics for surgical evaluation if structural pathology identified 1
• For hip: evaluate for labral tears, FAI syndrome, or advanced OA requiring arthroplasty 1
• For shoulder: evaluate for rotator cuff tears or severe glenohumeral OA 7

Critical Pitfalls to Avoid

• Do not dismiss bilateral symptoms as "just arthritis" without checking inflammatory markers - PMR is highly treatable and dramatically impacts quality of life if untreated
• Do not delay corticosteroid therapy if PMR is confirmed - patients experience rapid, dramatic improvement
• Do not tell OA patients to avoid exercise due to pain - exercise improves pain and function despite initial discomfort 1
• Do not rely on imaging alone for diagnosis - symptoms and clinical signs must be integrated with imaging findings 1, 2
• Do not order MRI as first-line imaging - plain radiographs are essential initial studies for all three joint regions 1, 3, 2