Management of Severe Arm and Shoulder Pain in the Elderly

Initial Diagnostic Imaging

Standard radiography is the mandatory first step for evaluating shoulder pain in elderly patients, as it effectively demonstrates fractures, dislocations, arthritis, and shoulder malalignment, according to the American College of Radiology 3, 1
The complete radiographic examination must include at least three views: AP views in internal and external rotation, and axillary lateral view or scapular Y view, as recommended by the American College of Radiology and Praxis Medical Insights 1
In patients over 35 years, shoulder pain predominantly relates to rotator cuff disease and degenerative changes, making plain films particularly informative, as noted by Praxis Medical Insights 1

MRI without contrast is the preferred advanced imaging for elderly patients, as it evaluates rotator cuff pathology, occult fractures, and soft tissue structures, according to the American College of Radiology and Praxis Medical Insights 3, 1
Ultrasound is an excellent alternative if local expertise is available, particularly for rotator cuff and biceps tendon pathology, as recommended by the American College of Radiology and Praxis Medical Insights 3, 1

The American Geriatrics Society recommends starting with acetaminophen as first-line therapy, which provides pain relief comparable to NSAIDs without gastrointestinal toxicity, with a maximum daily dose of 4 grams 2
For mild to moderate pain, add topical formulations such as methyl salicylate, capsaicin cream, or menthol, as suggested by the American Geriatrics Society 2
If acetaminophen fails, consider a trial of NSAIDs, but recognize that elderly persons are at exceptionally high risk for gastrointestinal, platelet, and nephrotoxic effects, as noted by the American Geriatrics Society 2
Intraarticular glucocorticoids are beneficial for pain not adequately relieved by systemic medications, especially with evidence of inflammation and joint effusion, according to the American Geriatrics Society 2
Opioid analgesics may be preferable to NSAIDs or invasive interventions for severe pain refractory to other therapies, as recommended by the American Geriatrics Society 2

Avoid overhead pulleys, which encourage uncontrolled abduction and may worsen pain, as recommended by Praxis Medical Insights 1
Implement range of motion exercises through stretching and mobilization techniques focusing on external rotation and abduction, as suggested by Praxis Medical Insights 1
Consider electrical stimulation to improve shoulder lateral rotation, as recommended by Praxis Medical Insights 1
Positioning, passive stretching, and range-of-motion exercises should be performed several times daily if spasticity develops, according to the Stroke journal 4

Presence of neurological deficits requires specialist referral, as recommended by Praxis Medical Insights 1
Unstable or significantly displaced fractures on imaging require specialist referral, as noted by Praxis Medical Insights 1
Shoulder joint instability requires specialist referral, according to Praxis Medical Insights 1
Suspected massive rotator cuff tears requiring expedited repair require specialist referral, as recommended by Praxis Medical Insights 1
Clinical suspicion of septic arthritis requires immediate specialist referral, as noted by the American College of Radiology and Praxis Medical Insights 3, 1

Do not assume absence of trauma means absence of fracture in elderly patients, as osteoporotic fractures can occur with minimal or unrecognized trauma, as recommended by Praxis Medical Insights 1
Do not prescribe NSAIDs without detailed medication history, including over-the-counter use, as drug-drug and drug-disease interactions are common, according to the American Geriatrics Society 2
Do not use NSAIDs long-term in elderly patients given the high frequency of adverse events, as noted by the American Geriatrics Society 2