What are the treatment options for an older adult with a shoulder spur and a history of shoulder injuries or certain medical conditions?

Treatment of Shoulder Spur in Older Adults

Start with conservative management including physical therapy focused on rotator cuff and scapular stabilizer strengthening, NSAIDs or acetaminophen for pain control, and consider corticosteroid injections for persistent symptoms—surgery should be reserved only for cases that fail conservative treatment after an adequate trial. 1, 2, 3

Initial Diagnostic Evaluation

Obtain standard shoulder radiographs first with three views minimum: anteroposterior views in internal and external rotation plus an axillary or scapular-Y view to assess the spur, joint alignment, and any associated degenerative changes. 1

• Document exact pain location (anterior suggests rotator cuff pathology; superior indicates acromioclavicular joint disease) and any radiation pattern to distinguish shoulder pathology from cervical radiculopathy. 4, 5
• In patients over 35-40 years, rotator cuff disease and degenerative changes are the predominant causes of shoulder pain, often coexisting with bone spurs. 4, 6
• Screen for red flags including fever, constitutional symptoms, or neurological deficits (numbness, tingling, weakness radiating down the arm) that would require urgent evaluation. 4, 7

Conservative Treatment Protocol (First-Line)

Exercise therapy is superior to non-exercise interventions with a standardized mean difference of -0.94 for pain reduction, and specific targeted exercises outperform generic exercises. 3

Structured Rehabilitation Program

• Complete rest from aggravating activities initially, followed by progressive range of motion improvement through stretching and mobilization. 4
• Strengthen rotator cuff muscles and scapular stabilizers once pain-free motion is achieved, as scapular dyskinesis contributes significantly to rotator cuff pathology. 4
• Focus on glenohumeral protectors, scapulohumeral pivotors, and humeral positioners in the rehabilitation program. 6

Pain Management Options

• Start with acetaminophen 650-1000 mg every 6 hours (maximum 4 grams daily) as first-line therapy, particularly in elderly patients given lower risk profile. 7
• NSAIDs provide small to moderate benefit (SMD -0.29) compared to placebo but should be used cautiously in older adults due to gastrointestinal, renal, and cardiovascular risks. 3
• Corticosteroid injections are superior to no treatment (SMD -0.65) for more severe cases, with ultrasound-guided injections superior to non-guided injections (SMD -0.51). 3

Adjunctive Conservative Modalities

• Manual therapy combined with exercise is superior to exercise alone at short-term follow-up (SMD -0.32), though the benefit diminishes over time. 3
• Consider ice, heat, and soft tissue massage as supportive modalities. 4
• Extracorporeal shockwave therapy (ECSWT) shows superiority over sham (SMD -0.39) and may be considered as an adjunct. 3

When to Consider Surgical Intervention

Surgery is not more effective than active exercises for reducing pain intensity in shoulder impingement, with moderate-quality evidence supporting conservative treatment as first choice. 2

• The failure rate after surgical treatment for shoulder stiffness is higher than with conservative management. 8
• Reserve surgery for patients who fail an adequate trial of conservative management (typically 3-6 months of structured rehabilitation). 2
• Avoid surgeons who perform fewer than two shoulder arthroplasties per year to reduce risk of immediate postoperative complications if arthroplasty becomes necessary. 1

Special Considerations for Older Adults with History of Shoulder Injuries

• Older patients with shoulder dislocation history are more likely to have rotator cuff tears compared to younger patients who typically have labroligamentous injuries. 1
• If irreparable rotator cuff tear is present, total shoulder arthroplasty should not be performed based on consensus recommendation. 1
• Most rotator cuff pathology can be managed conservatively without surgical intervention initially, even in the presence of bone spurs. 5

Critical Pitfalls to Avoid

• Do not assume absence of recent trauma means absence of fracture—osteoporotic fractures can occur with minimal or unrecognized trauma in elderly patients. 4
• Do not attribute bilateral shoulder pain with systemic symptoms to musculoskeletal causes without excluding cardiac etiology, particularly in women and elderly patients. 7
• Avoid prolonged NSAID use without gastroprotection in older adults given increased risk of adverse events. 7
• Do not delay imaging if red flags are present or if symptoms suggest cervical radiculopathy rather than isolated shoulder pathology. 5