What is the next best step for a female patient with type 2 diabetes (T2D), chronic kidney disease (CKD), and hypertension, who is on insulin, lisinopril (Angiotensin-Converting Enzyme Inhibitor), and glycine, and has recently received an intra-articular injection into the right shoulder for shoulder pain, considering her impaired renal function?

Physical Therapy is the Next Best Step

After administering an intra-articular corticosteroid injection for shoulder pain in this patient with diabetes, CKD, and hypertension, the next step is to refer for physical therapy to restore shoulder mobility and function. 1

Rationale for Physical Therapy

Physical therapy is the appropriate next step because:

• Intra-articular corticosteroid injections require complementary rehabilitation to maximize functional recovery and prevent recurrence of adhesive capsulitis, which is common in diabetic patients 1
• Moderate-intensity physical activity for at least 150 minutes per week is specifically recommended for patients with diabetes and CKD to provide cardiometabolic, kidney, and cognitive benefits 2
• Physical therapy addresses the underlying mechanical dysfunction that caused the shoulder pain, while the injection provides temporary pain relief 1

Why Other Options Are Inappropriate

Avoid NSAIDs (Ibuprofen)

NSAIDs like ibuprofen are contraindicated in this patient for multiple critical reasons:

• In patients with CKD on ACE inhibitors (lisinopril), NSAIDs cause deterioration of renal function including possible acute renal failure 3
• The combination of NSAIDs with ACE inhibitors in patients with compromised renal function is particularly dangerous and these effects, while usually reversible, can precipitate acute kidney injury 3
• NSAIDs attenuate the antihypertensive effect of lisinopril, potentially worsening blood pressure control 3
• Renal function must be monitored periodically if NSAIDs are used with ACE inhibitors, but avoidance is preferable 3

Immobilization is Harmful

• Immobilization contradicts the fundamental management principle of encouraging physical activity in patients with diabetes and CKD 2
• Patients with diabetes and CKD should be counseled to avoid sedentary behavior, not encouraged toward it through immobilization 2
• Shoulder immobilization would worsen adhesive capsulitis and lead to further loss of range of motion 1

Surgery is Premature

• Surgical referral is not indicated as first-line management after a single corticosteroid injection, particularly when conservative therapy (physical therapy) has not yet been attempted 1

Critical Monitoring Considerations Post-Injection

This patient requires careful glucose monitoring following the corticosteroid injection:

• Steroid injections cause significant and prolonged elevation of blood glucose levels in diabetic patients, with increased insulin requirements lasting up to 4 weeks 4
• Patients should monitor glucose levels more carefully after steroid injections to avoid ketoacidosis 4
• The patient's insulin regimen may need adjustment during this period 4

Comprehensive Management Context

While physical therapy is the immediate next step, this patient's overall management requires attention to multiple systems:

• Continue lisinopril as RAS inhibitors are recommended for patients with diabetes, hypertension, and albuminuria (which is likely given her CKD) 2
• Monitor serum potassium and creatinine within 2-4 weeks given the ACE inhibitor use 2
• Consider adding SGLT2 inhibitor if GFR ≥20 mL/min/1.73 m² for cardio-renal protection 2
• Optimize glycemic control while avoiding hypoglycemia risk, particularly important given the recent steroid injection 2

Common Pitfall to Avoid

The most dangerous error would be prescribing ibuprofen in this patient with CKD on an ACE inhibitor, as this triple combination (NSAID + ACE inhibitor + CKD) significantly increases acute kidney injury risk 3.