Musculoskeletal Shoulder Pain

Painful

1

"Yes! I just saved another life!", you triumphantly think, while settling down into a more comfortable position. Ever since you downloaded this wonderful little app, you've found yourself hooked ... As you browse through the numerous case scenarios you've completed so far (across all major specialties too!), you cannot help but feel proud. After all, a primary care physician does need to be a jack of all trades...


2

A split second before you begin another case, your nurse announces the next patient of the day. Mr. McCoy, a 49 year old retail clerk, has experienced intermittent pain in his left shoulder for the last 6 weeks. The pain radiates to the left anterior chest, and is worse at night; there is a noticeable increase in intensity when he stocks the shelves in his workplace. You carefully ask if the pain worsens when he exercises or engages in strenuous activity. He replies in the negative, but mentions that aside from stocking the shelves, the most strenuous activity he engages in, is walking from the front door of his house to his car, and back! There is no history of injury to the shoulder or adjacent region. You also find out that he is right handed. On direct questioning, Mr. McCoy denies experiencing numbness or tingling in the ipsilateral arm or fingers. Nor is there a history of fever, weight loss, rashes, respiratory symptoms, or pain involving any other region of the body. His medical and surgical histories are only significant for a hiatal hernia discovered incidentally one year ago, for which he is on Omeprazole therapy. His family history is also unremarkable. He drinks around a litre of beer each Friday, but is 'stone cold sober' during the rest of the week. His smoking has been limited to a very short period of experimentation during his youth. Mr. McCoy laughs out loud when you ask him about recreational drug use.


3

Examination reveals his body mass index (BMI) to be 31.35 kg/m2. All vital signs are stable, and the general examination reveals no abnormalities. Proceeding to the left shoulder, you note that the overlying skin appears normal, with no obvious swelling or deformity. The joint is not tender, and both active and passive movements are normal. The drop arm test is negative and no focal neurological signs are present. The contralateral shoulder joint is clinically normal, as are all other joints in the body. The remainder of the examination is unremarkable.


5

Given the absence of red flags, you feel that the condition is unlikely to be limb-threatening. However, the symptoms and signs are equivocal enough that cardiac angina is still a possibility. Thus, you feel that you should refer him to a cardiologist for further assessment. At first, Mr. McCoy is highly distressed when you convey your decision. However, he leaves your office reassured, once you explain that this is just to exclude sinister causes.


6

Several days later, Mr. McCoy is back in your office. He hands over a letter from the cardiologist. Perusal reveals that a cardiac origin for the pain has been definitively excluded.


7

Now that coronary artery disease is out of the picture, you consider the next steps in his management.


8

Running over the various causes of shoulder pain in your mind, you ponder if you should image the affected shoulder.


10

Given the absence of red flags suggestive of a sinister cause, you decide against imaging studies.


11

As symptomatic management seems to be sufficient for now, you decide to prescribe an analgesic. Picking up your pen, you ponder which agent is best suited for the situation ....


12

Which analgesic agent will you prescribe?

1. Acetaminophen (Paracetamol)
2. Ibuprofen
3. Oral Morphine

13

As per current recommendations, you decide to start off with Acetaminophen, the lowest rung of the pain ladder. However, Mr. McCoy does not appear to be too happy with your decision. He asks "Doc, instead of pain pills, can't I get an injection to my shoulder? My pal Mike had the same problem a while ago, and he was completely cured afterwards"


15

You carefully explain that intra-articular corticosteroids are not a good first-line choice. Mr. McCoy looks crestfallen, and you understand that he must have been looking for a quick cure.


16

You explain that "Mike's" shoulder pain was probably far more severe, and that his doctors would almost certainly have attempted several courses of painkillers before proceeding to an injection. At the end of your speech, Mr. McCoy nods his head in understanding.


17

Suddenly he looks highly concerned. "Hey Doc! My pain becomes really bad when I move my arm like this", he demonstrates by lifting his arm. "Will I need to stop moving my arm? I won't be able to work then!", he asks.


19

You explain the importance of maintaining joint mobility, and emphasize that exercise of the affected joint often helps relieve symptoms. You also refer him to a physiotherapist. Mr. McCoy is relieved that he does not have to stop working, and leaves your office a happy man.


20

Two months later, Mr. McCoy comes back for a routine checkup. He states that his shoulder pain has gradually reduced over time, and thanks you again for managing him so well. As he stands up and leaves your office, you think that even though you may not have necessarily saved a life, you certainly did improve Mr. McCoy's quality of life .... Well done!


21

You toy with the idea of referring Mr. McCoy to the nearest emergency department - and immediately rule this out. After all, the utter absence of indications for emergency care would just result in your becoming the laughing stock of the local medical community ....


22

As Mr. McCoy's clinical picture is most suggestive of musculoskeletal pain of the shoulder joint, you decide that a course of oral analgesics should be sufficient for now. His face lights up when you convey the good news, and he happily leaves your office, prescription in hand.


23

A couple of months later, the postman delivers a letter to your clinic. It is from a lawyer representing Mr. McCoy's wife. Apparently, Mr. McCoy experienced a myocardial infarction last week, and his wife queries why you didn't refer him to a cardiologist at the time of his visit. Needless to say, a medical malpractice lawsuit will soon be filed. As you put down the letter, a low chuckle cuts through the silence. You look up to see your old friend the Grim Reaper, who flashes a malicious grin before fading away .....


24

As you prepare to order a plain radiograph of the left shoulder, you suddenly start to wonder if this is really necessary. Muttering "excuse me, please", you take hold of your tablet, and pull up a review article on the subject. It does not take long for you to realize that Mr. McCoy does not have any clinical findings which would justify imaging studies ....


25

You start Mr. McCoy on Ibuprofen, a nonsteroidal antiinflammatory drug (NSAID) with analgesic properties, which is commonly prescribed for joint pain. You also refer him to a physiotherapist for stretching and straining exercises.


26

Several weeks later, you receive a call from the head of the emergency department at your local hospital. Apparently, Mr. McCoy presented to her unit a couple of hours ago, complaining of severe epigastric pain and marked dyspeptic symptoms. "Why in the world did you prescribe NSAIDs to a patient with a hiatal hernia?!", she asks. "Well, he's on omeprazole.." you begin to say, but are cut off by the voice on the other end. "We both know that! Did you seriously think that it prevents ulcers entirely?", she says and slams the phone down. Needless to say, Mr. McCoy almost certainly won't be visiting you any more ....


27

You write the prescription and hand it over to your nurse. She glances at it and looks at you quizzically, gesturing that she would like to talk in private. "Doctor, are you sure you want to start him off with Morphine?", she asks while casting a glance at the 'pain ladder' prominently displayed on the wall of your clinic. Comprehending your mistake, you hurriedly prescribe a less potent analgesic.


28

Giving into Mr. McCoy's request, you decide to administer intra-articular corticosteroids. However, just before you ask your nurse to make the necessary arrangements, a twinge of doubt surfaces. After all, corticosteroid injections are far from benign. Shouldn't you attempt a course of analgesics beforehand?


29

You inform Mr. McCoy that you do need to immobilize his shoulder joint for a while, so as to facilitate proper healing. He looks rather depressed upon hearing this, and asks pleadingly "But Doc, is there no other option? I might be fired if I can't use my arm ..." "Hmmm.... let me see if I can come up with an alternative", you say, and quickly bring up a review article on the management of acute shoulder pain, on your tablet. What you see there gives you pause - apparently, joint immobilization is best avoided in these patients! Wiping metaphorical sweat from your brow, you tell Mr. McCoy that on second thought, he does not need to worry ....


30

Taking Mr. McCoy's pain into account, you advise him to limit movements of the affected limb for 4 weeks. He looks somewhat unhappy over this, but cordially thanks you and takes his leave. One month later, Mr. McCoy is back in your office. He informs you that the pain appears to have resolved following the course of analgesics, but that he now finds it rather difficult to move his shoulder. Horror begins to dawn as you comprehend the blunder you've made. Why in the world did you ask him to restrict his joint movements?


31

You decide that an MRI scan of the left shoulder is in order, and start to fill in the necessary forms. Halfway-through, you start to wonder if he really does require such an advanced investigation. Turning to your trusty tablet, you pull up a review article on the topic. It does not take long for you to realize that Mr. McCoy does not have any clinical findings which would justify imaging studies ....


32

Exactly two weeks later, Mr. McCoy is back in your office. He complains that 'the pills' have not reduced the pain in his shoulder, and reminds you of your promise to inject corticosteroids. The look on his face tells you that he will not be happy until he gets his injection. Thus, you acquiesce and perform the procedure.


33

Several days later, you receive a phone call from the head of the local emergency department. She informs you that Mr. McCoy presented with an infection of the left shoulder joint space a short while ago, and says that she would like to ask a few details about his management at your clinic. When she finds out that you prescribed intra-articular corticosteroids immediately after the course of acetaminophen, she attempts to conceal her surprise, but fails. After the head of the department thanks you and puts the phone down, you start to wonder. Perhaps you should have been less hasty?