Presenting Problem
Eleanor, 82-year-old female, living independently; reliant on wheeled walker indoors and out.
Presenting with bilateral shoulder pain, left worse than the right going down the arm to the elbow. The pain started insidiously and seemed to be worsening over the last few weeks.
Eleanor was concerned about how her shoulder symptoms were affecting her, and whether there was anything specific she could do to help herself as exercises had not stalled the onset or produced any benefit in pain relief on use of her arms. This was affecting her independence and social ability as the pain in her shoulders pushing on her wheeled walker meant she wasn’t going out as much and this was getting her down.
Basic history gathered from previous consults, investigations, problems and medication; checked back with the patient to clarify details.
The patient had a history of bilateral cataracts and myopia, however, I advised if she had any sudden change in vision to seek urgent medical attention, similarly if she had any change in strength or use of her hands.
Red flags cleared were related to Giant Cell Arteritis and PMR (no loss of appetite, no headaches or scalp tenderness, no jaw/tongue pain, no recent change in vision – is awaiting surgery for cataracts, no hip/pelvic girdle pain, no pins and needles or numbness, peripheral swelling in foot – unchanged for years – no other joint swelling (RA)). Also to clear for infection and cancer – feeling well in herself, no weight loss, no constant unremitting night pain. Mixed questioning style of open and closed questions, based on the ICE principles to ascertain the patient’s ideas, concerns, and expectations.
Inflammatory element: diurnal pattern worse in the morning, stiffness variable can be more than 30 minutes; there was also a mechanical patterning element including pain when lifting the arms or pushing on her 4-wheeled walker. Easing factors were tramadol – not positional or movement related.
Objective testing active range of movement of the cervical spine reproduced her shoulder pain; left shoulder movements limited due to pain, right unlimited.
Differential Diagnoses & Clinical Reasoning
- Cervical spondylosis – with upper nerve irritation referring to the shoulders.
- Rotator cuff deficiency.
- OA shoulder.
Other conditions:
- Multiple myeloma – symptoms can include joint/bone pain – but no unintended weight loss or night sweats, not complaining of malaise.
- Thyroid disease but no weakness, weight gain or paraesthesias (TSH normal 0.79 (0.27-4.2); parathyroid also possible (but not complaining of bone pain, muscular weakness, or gastrointestinal symptoms but did not specifically ask re this).
- Statin-induced myalgia (patient was on simvastatin but this had not been recently prescribed so the timeline wouldn’t really fit).
- Other drug-related adverse effects – patient on quinine bisulphate – but no recent change to fit the timeline.
- Infection – osteomyelitis – but no soft tissue swelling, not generally unwell.
Other inflammatory disorder:
- PMR due to bilateral presentation described.
- RA (but no joint swelling or peripheral joint involvement), polymyositis (creatine kinase normal).
- Fibromyalgia (but not multiple sites of pain or fatigue).
Summary
- Moving forwards from the patient’s perspective, the desire was to reduce pain to enable her to use her 4-wheeled walker to mobilise.
- Clinically, it was to clear red flags and enable restoration of function.
- Action plan: Due to bilateral shoulder pain and prolonged stiffness in the morning for over 2 weeks, blood tests were deemed appropriate. Liaised with the GP regarding this, who agreed and ran the appropriate blood tests.
- Encouraged gentle supported ROM exercises for the neck and shoulders, and reassured and arranged follow-up for the results and future management plan. Safety-netted regarding worsening symptoms or new ones.
Feedback
“I felt put at ease and understood by the FCP. He listened and took my pain seriously, and I was reassured by the advice and further tests to help me get back to walking and living independently as I need to.”
