A 65-year-old man returns to the office for follow-up 10 days after receiving a subacromial corticosteroid injection for right-sided rotator cuff tendinopathy. The tendinopathy was confirmed on musculoskeletal ultrasound of the shoulder prior to the injection. The patient initially experienced mild improvement of the shoulder pain, but starting 2 days ago, the pain significantly worsened and is now accompanied by generalized body ache and fatigue. He does not report trauma or excessive shoulder use since the injection. Medical history includes type 2 diabetes mellitus and gout. Temperature is 37.9 C (100.2 F), blood pressure is 130/85 mm Hg, and pulse is 109/min. On examination, there is mild swelling in the lateral right shoulder. Range of motion is limited in multiple axes due to significant pain, which is worse compared to examination prior to the injection. Which of the following is the most appropriate next step in management of this patient?

Question

A 65-year-old man returns to the office for follow-up 10 days after receiving a subacromial corticosteroid injection for right-sided rotator cuff tendinopathy.  The tendinopathy was confirmed on musculoskeletal ultrasound of the shoulder prior to the injection.  The patient initially experienced mild improvement of the shoulder pain, but starting 2 days ago, the pain significantly worsened and is now accompanied by generalized body ache and fatigue.  He does not report trauma or excessive shoulder use since the injection.  Medical history includes type 2 diabetes mellitus and gout.  Temperature is 37.9 C (100.2 F), blood pressure is 130/85 mm Hg, and pulse is 109/min.  On examination, there is mild swelling in the lateral right shoulder.  Range of motion is limited in multiple axes due to significant pain, which is worse compared to examination prior to the injection.  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d86a_3a26_bc81_7d742bfe6073_MD0003_00 This patient's clinical features are worrisome for iatrogenic septic bursitis, presenting with acute pain following an initial positive response to corticosteroid injection. Subacromial injections are used to treat subacromial bursitis, rotator cuff tendinopathy, and adhesive capsulitis. During the procedure, the needle penetrates the subacromial bursa, depositing corticosteroids into the bursa and near the supraspinatus tendon. However, injection can introduce skin flora (eg, Staphylococcus aureus, Streptococcus pyogenes) into the deep structures. subacromial bursa Infection typically manifests as worsening pain, redness, swelling, and systemic symptoms (eg, fever, myalgias) several days after the procedure. In contrast, postcorticosteroid injection flare (ie, steroid-induced chemical synovitis) typically occurs rapidly and resolves within 48 hours. In some cases, the bursa communicates with the glenohumeral joint capsule, and septic bursitis may progress to septic arthritis. When infection is suspected, an image-guided (eg, ultrasound) aspiration of the bursa and/or joint is necessary to assess for infection. (Choice B) Range-of-motion exercises and analgesics are appropriate for adhesive capsulitis, which presents with pain and reduced shoulder motion in multiple axes. However, adhesive capsulitis is a chronic condition that presents insidiously; this patient's acute pain, swelling, and myalgias are more consistent with septic bursitis. (Choice C) Intraarticular and soft tissue corticosteroid injections are contraindicated when infection is suspected because they can worsen the infection. In the absence of infection, repeat injections are typically separated by at least several months to reduce the risk of tendon rupture and cartilage damage. (Choice D) Gout can cause acute inflammatory bursitis resembling septic bursitis but likely would have responded completely to the initial corticosteroid injection. Furthermore, the serum uric acid level, even when elevated, does not rule out infection and cannot replace a diagnostic aspiration. (Choice E) Shoulder x-ray is useful to assess for fracture (which is unlikely in the absence of trauma) but is not sufficient to rule out infection. Educational objective: During a joint or bursal aspiration or injection, introduction of skin flora may result in septic bursitis or septic arthritis, presenting as worsening pain several days following the procedure. Diagnostic aspiration of the joint or bursa is necessary to assess for infection. References: Diagnostic and therapeutic injection of the shoulder region. (http://www.ncbi.nlm.nih.gov/pubmed/12674455)

A 65-Year-Old Man Returns to the Office for Follow-Up 10