How do you manage a 24-year-old patient with a history of fall, presenting with shoulder pain and restricted movement, and imaging findings showing minimal fluid in the subacromial bursa on ultrasound (US) and no significant arthritic changes on X-ray?

Management of Traumatic Shoulder Pain in a 24-Year-Old with Minimal Subacromial Bursa Fluid

Conservative management should be the first-line approach for this 24-year-old patient with post-traumatic shoulder pain showing minimal subacromial bursa fluid on ultrasound and no significant bony abnormalities on X-ray. 1

Clinical Assessment and Imaging Interpretation

The imaging findings in this case reveal:

• Minimal fluid in the subacromial bursa on ultrasound
• No acute or healing bone injury on X-ray
• Congruent glenohumeral and AC joints
• No significant arthritic changes
• No soft tissue calcification

These findings suggest a soft tissue injury following trauma, most likely involving the subacromial bursa and potentially the rotator cuff structures. The presence of fluid in the subacromial bursa indicates inflammation that may be causing the patient's pain and restricted movement 2, 3.

Management Plan

Initial Phase (0-6 weeks)

1. Pain Management:

   • Acetaminophen (up to 4g/day) as first-line analgesic 1
   • NSAIDs at the lowest effective dose for the shortest duration if acetaminophen is inadequate 1
   • Consider topical NSAIDs to minimize systemic side effects 1

2. Activity Modification and Rest:

   • Relative rest to decrease repetitive loading of injured tissues 1
   • Avoid complete immobilization to prevent muscle atrophy 1
   • Gentle active range of motion exercises after initial pain subsides 1

3. Cryotherapy:

   • Apply ice through a wet towel for 10-minute periods to reduce acute pain and inflammation 1

4. Physical Therapy:

   • Begin with gentle passive and active-assisted range of motion exercises 2, 1
   • Focus on proper positioning and posture to avoid further impingement 2
   • Avoid overhead pulley exercises as they may exacerbate symptoms 2

Intermediate Phase (6-12 weeks)

1. Progressive Rehabilitation:

   • Advance to eccentric strengthening exercises as these are most beneficial for tendon healing 1
   • Include scapular stabilization exercises to improve biomechanics 1
   • Gradually increase resistance and range of motion as tolerated 1

2. Injection Therapy (if minimal improvement):

   • Consider subacromial corticosteroid injection if pain persists despite 6 weeks of conservative management 1
   • Note that corticosteroid injections provide short-term relief but do not alter long-term outcomes 1, 4

Advanced Phase (3-6 months)

1. Functional Rehabilitation:

   • Progress to sport-specific or activity-specific exercises 1
   • Focus on return to normal activities with proper biomechanics 1

2. Additional Modalities (if symptoms persist):

   • Consider Extracorporeal Shock Wave Therapy (ESWT) for persistent symptoms 1
   • Therapeutic ultrasound may be beneficial for pain reduction and collagen synthesis 1

Special Considerations

1. Monitoring for Progression:

   • Follow up to ensure improvement in symptoms and range of motion
   • Reassess if pain worsens or fails to improve with conservative management

2. Indications for Further Imaging:

   • Consider MRI if symptoms persist beyond 6-8 weeks to evaluate for rotator cuff pathology 2
   • MRI is superior to ultrasound for evaluating partial-thickness rotator cuff tears and other intra-articular pathology 2

3. Surgical Consideration:

   • Surgical intervention should only be considered if symptoms persist despite 6 months of adequate conservative treatment 1
   • Most cases of subacromial bursitis and minor rotator cuff injuries respond well to conservative management 3

Rationale for Management Approach

The minimal fluid in the subacromial bursa seen on ultrasound is likely contributing to the patient's pain. Studies have shown that increased fluid and inflammation in the subacromial bursa correlates with shoulder pain 5, 6. The absence of bony abnormalities on X-ray supports focusing treatment on the soft tissue components.

Conservative management is strongly supported as first-line treatment for this presentation, with multiple guidelines recommending a structured approach of pain management, activity modification, and progressive rehabilitation 2, 1.