What is the best management plan for a patient with limited neck and shoulder mobility, shoulder pain, and cardiovascular comorbidities including irregular heart rate and pedal edema?

Management of Rotator Cuff Pathology with Cardiovascular Comorbidities

This patient has rotator cuff tendinopathy/impingement (positive empty can test, pain with external rotation resistance, limited forward flexion to 110°) that requires structured physical therapy as first-line treatment, with careful consideration of NSAIDs given the cardiovascular comorbidities of irregular heart rate and pedal edema. 1, 2

Immediate Clinical Priorities

Cardiovascular Risk Assessment

• The irregular heart rate and bilateral pedal edema require urgent cardiology evaluation before initiating any NSAID therapy, as ibuprofen can worsen heart failure, cause fluid retention, and increase risk of myocardial infarction in patients with cardiovascular disease 3
• NSAIDs should be avoided entirely in patients with severe heart failure unless benefits clearly outweigh risks, and if used, patients must be monitored for worsening heart failure 3
• The concurrent cardiovascular findings suggest this patient may have underlying heart failure or arrhythmia that contraindicates standard NSAID use 3

Pain Management Strategy

• Acetaminophen is the safer initial analgesic choice given the cardiovascular comorbidities, though it is less effective than ibuprofen for rotator cuff pain 4
• If NSAIDs are deemed necessary after cardiology clearance, use the lowest effective dose for the shortest duration possible, with close monitoring for worsening edema, heart failure symptoms, or arrhythmia 3
• Subacromial corticosteroid injection is a reasonable alternative when pain is clearly related to rotator cuff or bursa inflammation, avoiding systemic cardiovascular risks of oral NSAIDs 4, 2

Structured Physical Therapy Protocol (Primary Treatment)

Weeks 1-3: Initial Phase

• Begin with gentle passive and active-assisted range of motion exercises, specifically targeting external rotation and abduction to address the impingement mechanism and prevent frozen shoulder 1, 2
• Active ROM should be increased gradually while simultaneously restoring proper shoulder alignment and strengthening weak shoulder girdle muscles 4, 1
• Apply ice before each exercise session for symptomatic relief 2
• Critical: Avoid overhead pulley exercises entirely, as they encourage uncontrolled abduction and have the highest incidence of developing hemiplegic shoulder pain 1

Weeks 4-8: Progression Phase

• Advance to intensive strengthening exercises targeting rotator cuff and scapular stabilizers (addressing the mild scapular winging noted on examination) 2
• Emphasize posterior shoulder musculature strengthening and correction of scapular dyskinesis 2
• Implement graduated return to overhead activities with proper mechanics 2

Adjunctive Modalities

• Local heat application before exercise is beneficial 1
• Soft tissue massage can reduce pain/swelling and improve tissue elasticity 1
• Neuromuscular electrical stimulation (NMES) may be considered as an adjunct, though efficacy data remain limited 1

Diagnostic Imaging Considerations

• Obtain three-view radiographs (AP in internal rotation, AP in external rotation, and axillary or scapula-Y view) if symptoms persist beyond 6 weeks to rule out structural pathology 5
• Ultrasound evaluation can assess for rotator cuff tears or significant bursal inflammation if not improving with conservative management 2

Reassessment Timeline

• If no improvement after 3-4 weeks of conservative management, consider imaging and orthopedic referral 5, 2
• Ensure complete resolution of symptoms before returning to full overhead activities 2
• Monitor for development of adhesive capsulitis, which can occur in up to 72% of cases with prolonged immobilization 5

Critical Pitfalls to Avoid

• Never prescribe NSAIDs without cardiology clearance in this patient with irregular heart rate and pedal edema, as NSAIDs increase risk of MI, heart failure hospitalization, and death in patients with cardiovascular disease 3
• Never allow prolonged immobilization of the shoulder, as this causes adhesive capsulitis 5
• Never rely on AP radiographs alone if imaging is obtained, as dislocations are frequently missed without axillary views 5
• Avoid aggressive passive range-of-motion exercises performed improperly, as they can cause more harm than good 1

Addressing the Neck Findings

The 50-degree bilateral neck ROM limitation is relatively minor and likely unrelated to the primary shoulder pathology. However, cervical spine impairments can contribute to shoulder symptoms in some cases 6. If shoulder symptoms fail to improve with targeted shoulder therapy, consider cervical spine evaluation and treatment as a contributing factor 6.