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Case Spotlight

Orthopedic Surgery

Shoulder/Elbow

Summary

  • 70 y/o F with with persistent R shoulder pain with restricted ROM.
  • PCP asked for management modality recommendations for this patient given her limited resources.
  • Specialist suggested that the patient likely has a chronic tear of the rotator cuff or long head of the biceps tendon and recommended either physical therapy, focusing on scapular stabilization and strengthening, plus oral NSAIDs to reduce inflammation, subacromial cortisone injections, or arthroscopic surgical debridement.

eConsult transcript

PCP submission:

70-year-old female with pain in R shoulder radiating to R elbow following straining it pulling a shopping cart 1 year ago. In the last month pain has worsened, now painful to lift her arm or lift any objects. She is able to fully abduct her arm with some pain in shoulder but is unable to complete Apley’s scratch test due to restricted ROM. Pain from GHJ to elbow, along biceps. X-ray shoulder is normal other than minor degenerative changes. Taking ibuprofen 600mg with no relief. She is not able to access physical therapy due to minimal financial and time-related resources.

PCP wants to know management modalities for this patient given limited resources?

Specialist response:

Hi, thank you for your question! Given the patient’s age, the patient likely has a chronic tear of the rotator cuff or long head of the biceps tendon that was acutely aggregated by the pulling of the cart. Regardless of whether the rotator cuff tendon is inflamed or torn, there are 3 options in treatment: 1) Physical therapy, focusing on scapular stabilization and strengthening, and oral NSAIDs to reduce inflammation 2) Subacromial cortisone injections 3) Arthroscopic surgical debridement, possible repair I would start with physical therapy focusing on scapular stabilization to help strengthen the shoulder and improve range of motion.

Specialist response:

If the patient is unable to undergo PT, then I would consider a subacromial or bicoastal groove cortisone injection and a referral to ortho. If these conservative modalities fail to improve the patient’s pain, then an MRI would be warranted. This would be done in preparation for surgery; either arthroscopic subacromial decompression or arthroscopic rotator cuff tendon repair depending on the MRI findings. I hope this helps guide your treatment. Thank you for your consult!

Tags: insurance, noncompliance, limited resources, management modalities