What is the appropriate evaluation and treatment for shoulder pain in a patient with glucose‑6‑phosphate dehydrogenase deficiency?

Evaluation and Treatment of Shoulder Pain in G6PD Deficiency

Evaluate and treat shoulder pain in G6PD-deficient patients using the same standard orthopedic approach as the general population, but strictly avoid NSAIDs and other oxidant medications that can trigger hemolysis.

Key Principle: G6PD Status Does Not Alter Shoulder Pathology

The presence of G6PD deficiency does not change the underlying causes, diagnostic workup, or non-pharmacologic treatment of shoulder pain. The critical difference lies entirely in medication selection for analgesia and inflammation control. 1

Initial Evaluation

History and Physical Examination

• Assess for rotator cuff pathology, glenohumeral osteoarthritis, adhesive capsulitis, or impingement syndrome using standard orthopedic examination techniques 1
• Evaluate range of motion (active and passive), strength, alignment of the shoulder girdle, and pain patterns 1
• Document any recent trauma, overuse, or systemic inflammatory conditions 1

Imaging

• Plain radiographs are the initial imaging modality for suspected glenohumeral osteoarthritis or fracture 1
• MRI or ultrasound may be indicated for soft tissue pathology (rotator cuff tears, labral injuries) based on clinical findings 1

Critical Medication Contraindications in G6PD Deficiency

Absolutely Avoid

• NSAIDs (including ibuprofen, diclofenac, aspirin) are contraindicated as they can precipitate hemolysis in G6PD-deficient patients 1, 2, 3
• Aspirin is specifically contraindicated in all individuals with G6PD deficiency 3

Safe Analgesic Options

• Acetaminophen can be used safely for pain relief if there are no other contraindications 1
• Opioids (codeine, fentanyl) have not been shown to cause hemolytic crises and are safe alternatives for moderate to severe pain 4, 5
• Regional anesthesia with bupivacaine is safe and effective for procedural pain control 5

Treatment Algorithm by Etiology

For Rotator Cuff Pathology or Impingement

• Physical therapy with gentle stretching and mobilization techniques, focusing on external rotation and abduction 1
• Active range of motion exercises should be increased gradually while restoring alignment and strengthening weak shoulder girdle muscles 1
• Acetaminophen for analgesia rather than NSAIDs 1

For Glenohumeral Osteoarthritis

• Injectable viscosupplementation (sodium hyaluronate) is an option for pain relief (Grade C recommendation) 1
• Corticosteroid injections (subacromial or intra-articular) can be used when pain is related to inflammation of the rotator cuff or bursa, though evidence is limited (Grade I recommendation) 1
• Total shoulder arthroplasty or hemiarthroplasty for advanced disease with functional impairment (Grade C recommendation, with TSA preferred over hemiarthroplasty when feasible) 1

For Hemiplegic Shoulder Pain (Post-Stroke)

• Gentle stretching and mobilization with gradual increase in active range of motion 1
• Botulinum toxin injections into subscapularis and pectoralis muscles if spasticity is contributing 1
• Subacromial corticosteroid injections for rotator cuff or bursal inflammation 1

Monitoring for Hemolysis

Patient Education

Educate patients to recognize early signs of hemolysis: 2, 3

• Dark urine (hemoglobinuria)
• Sudden fatigue or pallor
• Jaundice (most common presentation)
• Abdominal or back pain

If Hemolysis Occurs

• Immediately discontinue any potentially oxidant medication 3
• Aggressive IV hydration to maintain renal perfusion and prevent hemoglobin-induced acute kidney injury 2, 3
• Folic acid 1 mg daily to support compensatory erythropoiesis 1, 3
• Monitor hemoglobin, reticulocyte count, LDH, haptoglobin, and indirect bilirubin 1, 3
• Transfuse only if hemoglobin falls below 7–8 g/dL with symptoms 1, 3

Common Pitfalls to Avoid

• Never prescribe NSAIDs for musculoskeletal pain in G6PD-deficient patients, even for short courses 1, 2, 3
• Do not assume all analgesics are contraindicated—acetaminophen and opioids are safe alternatives 1, 4
• Avoid G6PD testing during acute hemolysis or within 50–120 days of transfusion, as results may be falsely normal 6, 3
• Regional anesthesia and corticosteroid injections are not contraindicated and should be considered when appropriate 1, 5