Bilateral Shoulder Pain in a Young Patient: A Case-Based Approach to Diagnosis

First rule out diabetes and thyroid disease, which account for around 30% of bilateral shoulder presentations in practice, then check for manual/overhead work. If negative, get a plain X-ray to rule out joint space narrowing and calcific tendinopathy, then trial physiotherapy (ultrasonic therapy, TENS, shoulder exercises) with a 3-week NSAID course. In this case, rheumatoid factor came back positive with MRI showing bilateral partial-thickness supraspinatus tears and subacromial bursitis — so the approach became NSAIDs, DMARDs for the underlying rheumatoid disease, a triamcinolone injection into the subacromial bursa, and physiotherapy. A repeat steroid injection should not be given before 3 months. If there is still no response, proceed to shoulder arthroscopy to debride the bursa, assess the AC joint and address the tendon tears directly.

Yes. Chronicity is labelled at 3 months, with 6 to 12 weeks as the clinical boundary. A patient should start with NSAIDs, not regenerative therapy. Only if steroid injection has also failed to control the inflammation between 6 and 12 weeks should regenerative therapy be considered, and 3 months is the ideal timing.

Around 10 to 14 ml of blood is drawn from the patient into a kit-supplied vial containing heparin, then centrifuged to separate the platelet-rich plasma from the rest of the blood. This typically yields about 5 ml of PRP solution, which is injected as multiple pricks around the tendon or ligament rather than as a single injection, to achieve the best results.

Platelets contain multiple growth factors, including PDGF and TGF-beta, that promote healing through two mechanisms: increasing vascularisation of the target tissue and stimulating cellular regeneration. One group of factors increases local blood supply, while another increases cellular activity — together they drive ligament, tendon and articular cartilage repair.

For articular cartilage involvement, collagen type 2, often combined with Boswellia, promotes cartilage cell multiplication and needs to be taken long-term. For partial tears of ligaments and tendons — which are rich in collagen type 1 and 3 — separate collagen 1 and 3 formulations are more appropriate, since they support healing of that specific tissue.

Diabetes and thyroid disease should be checked first, since together they explain around 30% of bilateral shoulder presentations.

A plain X-ray to exclude joint space narrowing and calcific tendinopathy, followed by a three-week trial of physiotherapy and NSAIDs, with an ultrasound reserved for patients who do not respond, to check for subacromial bursitis or partial supraspinatus and infraspinatus tears.

It shifts the diagnosis from a mechanical shoulder problem to an inflammatory one, changing the plan to NSAIDs for acute pain, DMARDs for the underlying rheumatoid disease, a triamcinolone injection into the subacromial bursa, and continued physiotherapy.

It is held in reserve if the patient does not respond to the combined NSAID, DMARD, steroid injection and physiotherapy plan.