Shoulder Pain from a UTI?

Introduction: Our case highlights the importance of proper antibiotic selection and taking the whole patient into context when prescribing any medication. We hope to showcase how unwanted medication side effects can lead to morbidity, especially in our geriatric patients.

Case Study: The patient is a 70 year old female who presented to the family medicine clinic with right arm pain. Two weeks prior, she was pulling up her jeans when she heard a pop and felt an acute stabbing pain in the region of her distal right biceps tendon. Since the event, her pain has not resolved and she has a limited range of motion. The patient’s history is significant for Ciprofloxacin use for the treatment of a urinary tract infection a few weeks prior. Physical exam was significant for limited range of motion of the right upper extremity at the shoulder, elbow, and wrist secondary to pain. She was tender to palpation at the insertion site of the distal biceps tendon. Ecchymosis was noted. She had reduced strength in the right upper extremity.

No further imaging was performed and she was clinically diagnosed with a distal biceps tendon rupture. She was prescribed Naproxen and a lidocaine patch for pain, with close follow-up to monitor for GI side effects due to her history of stomach polyps. Also, she was referred to orthopedic surgery and physical therapy for evaluation. She had already completed her course of Ciprofloxacin, otherwise, the medication would have been discontinued. She was advised to avoid Fluoroquinolone use in the future due to the adverse reaction she developed.

Discussion: The diagnosis of this case required holistic thinking. We had to take the whole patient into account which is one of the osteopathic tenants. We had to look back at their history. We did a comprehensive review of all the medicines that she was on that may have been contributing to the vulnerable injury that she suffered. We are writing this case to urge other family medicine physicians to take into account the negative side effects that certain medications can have and to practice proper antibiotic stewardship. Additionally, we are trying to show them that musculoskeletal complaints can come from the result of medications that were prescribed earlier prior to the acute injury.