What are the best options for pain management and muscle relaxation in a 61-year-old patient with a history of Gastroesophageal Reflux Disease (GERD), Irritable Bowel Syndrome (IBS), atrophic pancreas, asymptomatic Human Immunodeficiency Virus (HIV), and Chronic Obstructive Pulmonary Disease (COPD), who has tendinosis of the right shoulder and has not responded to previous treatments with Norco (hydrocodone), diclofenac gel, and patches, and is awaiting X-ray results to rule out new injuries?

Pain Management for Shoulder Tendinosis in a Complex Patient

For this 61-year-old patient with shoulder tendinosis who has failed initial conservative therapy, I recommend a structured physical therapy program emphasizing eccentric strengthening exercises as the primary next step, while avoiding NSAIDs given his GERD/IBS history and explicitly avoiding corticosteroid injections due to lack of long-term efficacy and potential tendon weakening. 1

Why Avoid the Options You Mentioned

Toradol (Ketorolac) - Do Not Use

• Ketorolac is absolutely contraindicated in this patient due to his GERD and IBS history 2
• The FDA label explicitly warns that ketorolac "is contraindicated in patients with previously documented peptic ulcers and/or GI bleeding" and can cause "serious gastrointestinal adverse events including bleeding, ulceration and perforation" 2
• Maximum duration is only 5 days, making it inappropriate for chronic tendinosis management 2
• His COPD further increases risk, as ketorolac can cause bronchospasm in susceptible patients 2

Oral NSAIDs (including additional diclofenac) - Avoid

• NSAIDs provide only short-term pain relief with no effect on long-term outcomes in tendinopathy 1
• His GERD, IBS, and atrophic pancreas make him extremely high-risk for serious GI complications 3
• The FDA label warns that NSAIDs "can cause ulcers and bleeding in the stomach and intestines at any time during treatment" with increased risk in older patients and those with poor general health 3
• Concurrent COPD increases risk of cardiovascular events with NSAID use 3

Corticosteroid Injections (Decadron) - Not Recommended

• While corticosteroid injections may provide short-term pain relief (weeks), they do not alter long-term outcomes and should be avoided 1
• Evidence shows corticosteroids may be "more effective than oral NSAIDs in acute-phase pain relief but do not alter long-term outcomes" 1
• Animal studies suggest potential for tendon weakening, though human data is limited 4
• Given that he's awaiting X-ray for possible new injury, injecting before ruling out structural damage would be premature 1

Muscle Relaxers - Not Indicated

• Muscle relaxers have no role in tendinosis treatment, as this is a degenerative tendon condition, not a muscle spasm disorder 1, 5
• They would add sedation risk in a COPD patient without addressing the underlying pathology 1

What You Should Do Instead

Primary Recommendation: Eccentric Strengthening Physical Therapy

• Eccentric strengthening is the most evidence-based treatment for tendinopathy and may actually reverse degenerative changes 1
• This involves controlled lengthening exercises of the rotator cuff muscles under load 1, 6
• Refer to physical therapy specifically requesting an eccentric strengthening protocol for rotator cuff tendinosis 1
• Expected timeline: 6-12 weeks for meaningful improvement 1

Adjunctive Measures You Can Prescribe Now

Relative Rest and Activity Modification:

• Reduce repetitive overhead activities and heavy lifting while maintaining some movement 1
• "Relative rest and reduced activity prevent further damage and promote healing" 1

Cryotherapy:

• Apply melting ice water through a wet towel for 10-minute periods, multiple times daily 1
• This provides acute pain relief and is widely accepted as safe 1

Consider Topical Analgesics:

• Since oral NSAIDs are contraindicated, topical preparations might be safer, though he's already tried diclofenac gel 1
• Topical NSAIDs have fewer systemic side effects but still carry some GI risk 1

Special Considerations for This Patient's Comorbidities

HIV-Specific Pain Management Principles

• This patient requires a holistic, multimodal approach given his HIV status and multiple comorbidities 1
• The HIV guidelines emphasize that "chronic pain management requires repeated evaluations over time" with an interdisciplinary team approach 1
• His asymptomatic HIV status is favorable, but monitor for any new pain that could represent opportunistic infection or medication adverse effects 1

Critical Opioid Warning

• Never escalate to chronic opioid therapy for this condition 7, 8
• Opioids are "absolutely contraindicated for chronic pain management" in patients with GI conditions due to risk of narcotic bowel syndrome, gut dysmotility, serious infection risk, and increased mortality 7
• His IBS and atrophic pancreas make him particularly vulnerable to opioid-induced GI complications 7, 8

When Conservative Therapy Fails

Timeline for Surgical Consideration

• Surgery should be reserved only after 3-6 months of failed conservative therapy 1
• "Surgery is an effective treatment that should be reserved for patients who have failed conservative therapy" 1
• Given he's only been treated for one month since MRI, he has not yet exhausted conservative options 1

Alternative Interventions to Consider at 3+ Months

• Extracorporeal shock wave therapy appears safe and effective for chronic tendinopathies, though expensive 1
• Sclerotherapy and nitric oxide patches have shown promise in some studies 6
• PRP injections have shown short-term efficacy but lack long-term data 5

Immediate Next Steps

1. Await X-ray results to rule out new structural injury (fracture, calcific tendinitis, etc.) 1
2. Refer to physical therapy with specific request for eccentric strengthening protocol 1
3. Prescribe ice therapy as described above for immediate symptom relief 1
4. Avoid all systemic NSAIDs and corticosteroid injections given his GI comorbidities and lack of long-term benefit 1, 3
5. Schedule follow-up in 6-8 weeks to assess response to physical therapy 1
6. Screen for depression and pain catastrophizing given his chronic pain and HIV status, as these predict worse outcomes 1

Common Pitfalls to Avoid

• Do not pursue corticosteroid injection for quick fix - it won't help long-term and may harm the tendon 1, 4
• Do not prescribe NSAIDs despite patient request - his GI history makes this dangerous 3
• Do not assume failed topical/oral NSAIDs means opioids are next - they are contraindicated 7, 8
• Do not skip physical therapy referral - this is the only treatment proven to reverse tendon degeneration 1, 6