“I feel this kind of stiffness across my shoulder and back with a weird pain running down from my shoulders to my waist.”

M.K., a 52-year-old Caucasian male, presents to the clinic accompanied by his 21-year-old son with a complaint of feeling stiff in his shoulders and back. He also notes that he has a pain that runs down from his shoulders to his waist area, especially his lower back. He reports that both the stiffness and pain have been there for the last 4 months, but have been getting worse over the last 2 weeks.

He notes that the stiffness and pain are making it hard for him to take care of himself, and he fears that he is getting too dependent on others. He rates the pain at a 4 out of 10. He denies any other pains, including muscle pain, fever, weakness, or numbness.

·         Metformin 500 mg BID

·         Lisinopril 20 mg daily

·         Advil 200mg PRN

·         HTN

·         T2DM (Managed)

·         Overweight

Maternal HTN and T2DM

Older brother obese, with T2DM, HTN

·         Quit smoking at 46 years (6 years ago)

·         Takes alcohol (Beer 8 bottles over weekends, no drinking during weekdays)

·         Veteran

·         Majorly sedentary lifestyle in his later age

·         Lives with wife and 2 sons

·         Daughter married

Reports shoulder and back stiffness and pain between the shoulders, and upper and lower back, no reported joint swelling

Denies numbness, tingling, or dizziness

Slight cough, No wheezing or SOB reported, No reported history of COPD or other respiratory infections.

No reported bleeding or ease of bruising

Denies chest pain, reports palpitations, and slight throbbing with physical exertion

Reports of polyuria (T2DM-associated) (Managed)

Reports regular bowel movements, denies constipation, abdominal pain, no N/V/D

Denies episodes of depressive symptoms, anxiety, or mood swings

Alert, oriented to time, space, and person, appears mildly uncomfortable when moving.

Warm, dry, intact

Normocephalic, atraumatic, pupils appear round, normoreactive to light, one eye slightly closed, no redness in throat. No visible or palpable masses on face or neck

RRR, no murmurs, normal peripheral pulses. Palpitations with physical exertion

Clear to auscultation bilaterally, No crackles or wheezes

Soft, non-tender, normoactive bowel sounds, distended

Mild paraspinal muscle tenderness along the thoracic and lumbar spine. Decreased ROM in the shoulders and lumbar spine. Pain on the back to the touch and minor exertion at the third lumbar spine vertebra (L3) noted. No joint warmth, deformity, or swelling noted

CN II–XII intact, strength 5/5 in upper and lower extremities, normal reflexes, strong for age.

Cooperative during examination, appropriate mood and affect.

Older adults, due to physical changes, are likely to develop musculoskeletal issues due to reduced flexibility and loss of muscle function. Such musculoskeletal issues can lead to physical disability and impairments, which contribute to social isolation, depression, and anxiety (Welsh et al., 2020). Early and targeted diagnosis, treatment, and follow-up care is recommended to reduce comorbidity-associated risks (Tengesdal et al., 2024).