What is the treatment for shoulder effusion?

Treatment of Shoulder Effusion

The treatment of shoulder effusion should begin with gentle stretching and mobilization techniques, focusing on increasing external rotation and abduction, combined with analgesics such as acetaminophen or ibuprofen for pain relief. 1

Evaluation and Diagnosis

Before initiating treatment, proper diagnosis is essential:

• Obtain standard radiographs as initial imaging:

  • Anteroposterior (AP) view in neutral position
  • Grashey view (30° posterior oblique) to profile the glenohumeral joint
  • Axillary lateral or scapular Y view to assess for instability 2

• Consider MRI without contrast (rated 7/9) for evaluating soft tissue pathology or MR arthrography (rated 9/9) if labral pathology is suspected 2

• Ultrasound can be useful for detecting joint effusions and guiding aspiration if infection is suspected 3

Treatment Algorithm

First-Line Treatment

1. Physical Therapy

   • Active range of motion exercises should be gradually increased while restoring alignment and strengthening weak shoulder girdle muscles 1
   • Focus on strengthening rotator cuff and periscapular muscles 2
   • For post-stroke shoulder effusion, use active, active-assisted, or passive range of motion exercises 1

2. Pain Management

   • NSAIDs (acetaminophen or ibuprofen) for pain relief if no contraindications 1
   • NSAIDs provide both pain control and anti-inflammatory effects 2

Second-Line Treatment

1. Injectable Therapies

   • Corticosteroid Injections:

     • Subacromial corticosteroid injections can be used when pain is related to injury or inflammation of the subacromial region (rotator cuff or bursa) 1
     • For spasticity-related shoulder pain, botulinum toxin injections into the subscapularis and pectoralis muscles may be beneficial 1
     • Note: The American Academy of Orthopaedic Surgeons states there is insufficient evidence to recommend for or against corticosteroid injections for glenohumeral osteoarthritis 1, 2

   • Viscosupplementation:

     • Injectable viscosupplementation is an option (Grade C recommendation) for glenohumeral osteoarthritis 1, 2

Special Considerations

1. For Post-Stroke Shoulder Effusion:

   • Consider functional electric stimulation (FES) as an adjuvant therapy, particularly within 6 months post-stroke 1
   • For Complex Regional Pain Syndrome (CRPS) associated with shoulder effusion:
     • Early course of oral corticosteroids (30-50 mg daily for 3-5 days, then tapering over 1-2 weeks) can reduce swelling and pain 1

2. For Frozen Shoulder (Adhesive Capsulitis):

   • Physical therapy with targeted exercises is recommended 4
   • Evidence suggests that a combination of manual therapy and exercise may not be as effective as glucocorticoid injection in the short term but may provide longer-term benefits 5

3. For Septic Shoulder Effusion:

   • Immediate joint aspiration and culture
   • Appropriate antibiotic therapy based on culture results
   • Possible surgical drainage if indicated 3

Treatment Efficacy and Monitoring

• Monitor range of motion, pain levels, and functional improvement during treatment
• If no improvement after 3-6 months of conservative treatment, consider surgical intervention 2
• For younger patients (<50 years), there is concern about performing shoulder arthroplasty due to potential risks of prosthetic loosening and decreased survivorship 1, 2

Common Pitfalls and Caveats

1. Misdiagnosis: Shoulder effusion can be a symptom of various conditions including osteoarthritis, rotator cuff tears, infection, or inflammatory arthritis. Proper diagnosis is crucial for effective treatment.

2. Inadequate Physical Therapy: Simply prescribing "physical therapy" without specific guidance on exercises targeting external rotation and abduction may lead to suboptimal outcomes.

3. Over-reliance on Corticosteroids: While effective for short-term pain relief, repeated corticosteroid injections may lead to tendon weakening and other adverse effects.

4. Delayed Recognition of Infection: Septic arthritis of the shoulder requires urgent treatment. Fever, severe pain, and systemic symptoms should prompt immediate evaluation 3.

5. Neglecting Underlying Causes: Treating only the effusion without addressing underlying causes (such as rotator cuff tears or glenohumeral instability) may result in recurrence.