What is the next course of treatment for an elderly woman with shoulder pain after a fall, no fracture or dislocation on X-ray, with small marginal osteophytes and mild joint space narrowing?

Conservative Management with Physical Therapy and Analgesics

For this elderly woman with post-fall shoulder pain showing radiographic evidence of mild glenohumeral osteoarthritis (marginal osteophytes and joint space narrowing) but no acute fracture, initiate conservative treatment with pain control, physical therapy focusing on range of motion and strengthening, and consider intra-articular corticosteroid injection if symptoms persist beyond initial management. 1, 2

Initial Pain Management Strategy

• Start with acetaminophen 650-1000 mg every 6 hours (maximum 4 grams daily) as first-line therapy, particularly appropriate for elderly patients given the lower risk profile compared to NSAIDs 3
• Consider short-term NSAIDs for acute pain if no contraindications exist, though use caution given gastrointestinal, renal, and cardiovascular risks in elderly populations 3
• Intra-articular corticosteroid injection (triamcinolone) is an evidence-based option for glenohumeral osteoarthritis when conservative measures provide insufficient relief, with demonstrated efficacy for pain reduction 1

Physical Therapy Protocol

The cornerstone of treatment involves structured physical therapy with specific components:

• Improve range of motion through stretching and mobilization techniques, focusing especially on external rotation and abduction to prevent progression to adhesive capsulitis (frozen shoulder) 1, 2
• Initiate rotator cuff and scapular stabilizer strengthening exercises once pain-free motion is achieved 2
• Apply modalities including ice, heat, and soft tissue massage as adjunctive treatments 1, 2
• Avoid overhead pulleys, which encourage uncontrolled abduction and may worsen symptoms 1

Clinical Reasoning for This Approach

The radiographic findings of marginal osteophytes and mild joint space narrowing indicate early-stage glenohumeral osteoarthritis 1. While the fall prompted evaluation, these degenerative changes suggest underlying chronic pathology rather than acute traumatic injury 2. The absence of fracture or dislocation on X-ray confirms that surgical intervention is not immediately indicated 1.

For elderly patients over 35-40 years, rotator cuff disease and degenerative changes are the predominant causes of shoulder pain, making conservative management the appropriate initial strategy 2. The American Academy of Orthopaedic Surgeons guidelines support non-operative treatment as first-line therapy for glenohumeral osteoarthritis 1.

Monitoring and Escalation Criteria

• Reassess at 4-6 weeks to evaluate response to conservative treatment 1
• If symptoms persist despite 3-6 months of appropriate conservative management, consider viscosupplementation (hyaluronate injections) as a next-step option for glenohumeral osteoarthritis 1
• Shoulder arthroplasty (total shoulder arthroplasty or hemiarthroplasty) becomes an option only when conservative treatments fail and symptoms significantly impair quality of life, though this is typically reserved for more advanced disease 1

Critical Pitfalls to Avoid

• Do not assume the fall caused the osteoarthritis—the radiographic changes represent chronic degenerative disease that predated the trauma 2
• Avoid premature surgical referral, as the evidence supports exhausting conservative options first for mild-to-moderate glenohumeral osteoarthritis 1
• Do not overlook the possibility of rotator cuff pathology coexisting with osteoarthritis, particularly given the patient's age; if weakness or specific rotator cuff signs emerge, consider MRI without contrast for further evaluation 1, 2
• Ensure proper shoulder positioning and protection from trauma during recovery, as staff education to prevent trauma to the affected shoulder reduces complications 1