What is the best course of action for a patient with persistent pain and bruising in the shoulder after a full shoulder replacement surgery, exacerbated by strenuous activities?

Post-Shoulder Replacement Pain and Bruising: Evaluation and Management

Immediate Action Required

This patient requires urgent orthopedic evaluation with imaging to rule out prosthetic complications, as persistent pain with bruising 14 months post-operatively—especially when exacerbated by overhead activities—suggests potential structural pathology that may require surgical intervention. 1

Initial Diagnostic Workup

Imaging Protocol

• Obtain standard shoulder radiographs immediately (minimum 3 views: AP in internal/external rotation plus axillary or scapula-Y view) to assess prosthetic alignment, component positioning, and rule out fracture or dislocation 1
• Radiographs are the preferred initial diagnostic modality and can delineate shoulder malalignment and most complications 1
• Consider ultrasound to evaluate for soft tissue injuries including rotator cuff pathology, tendinopathy, subacromial bursa effusion, or subscapularis injury 1, 2

Critical Clinical Assessment

• Evaluate for prosthetic instability: look specifically for pain during movement, decreased velocity/precision of movement, and sensations of clunking or displacement 2
• Assess muscle tone, strength, soft tissue changes, joint alignment of the shoulder girdle, and orthopedic changes 1, 2
• Examine for signs of early dislocation or subluxation, which can occur with overhead activities and present with pain and bruising 3

Common Pitfalls to Avoid

The combination of bruising with activity-related pain is a red flag—this is NOT typical post-operative recovery at 14 months and demands investigation for:

• Prosthetic loosening or failure 4
• Rotator cuff re-tear or subscapularis deficiency 1, 3
• Instability or subluxation events 3
• Periprosthetic fracture 1

Management Algorithm Based on Findings

If Imaging Shows Structural Pathology

• Immediate orthopedic referral for consideration of revision surgery, component exchange, or other surgical intervention 4, 5
• Persistent pain affects 22% of shoulder replacement patients at 1-2 years, with higher rates in certain populations 6

If No Structural Pathology Identified

Pain Management

• Initiate analgesics: acetaminophen (up to 4g/day) or ibuprofen if no contraindications 1, 2, 7
• Consider subacromial corticosteroid injection if pain is related to subacromial inflammation (rotator cuff or bursa) 1, 7
• If spasticity is present, botulinum toxin injections into subscapularis and pectoralis muscles may be considered 1, 2, 7

Activity Modification

• Immediately cease overhead and strenuous workout activities until evaluation is complete 1, 2
• Avoid overhead pulley exercises as they may exacerbate symptoms 7
• Implement gentle range of motion exercises focusing on external rotation and abduction, gradually progressing 1, 2, 7

Rehabilitation Protocol

• Active range of motion should be increased gradually in conjunction with restoring alignment and strengthening weak muscles in the shoulder girdle 1, 2
• Gentle stretching and mobilization techniques should be employed 1, 2
• Consider functional dynamic orthoses to facilitate repetitive task-specific training 1, 2

Risk Factors Present in This Case

This patient has concerning features:

• Male gender and workout activities increase risk of complications 3
• Pain with overhead movement (8/10 severity) suggests mechanical pathology requiring investigation 1, 4
• Bruising with activity is abnormal at this post-operative timeframe and may indicate instability events or soft tissue injury 3

Follow-up Strategy

• Patients should be reassessed periodically to evaluate response to treatment 7
• If conservative management fails after appropriate trial, interventional pain management strategies or revision surgery may be necessary 4
• Persistent pain after shoulder replacement is a daily burden for 22% of patients and requires comprehensive long-term management 6

The severity of pain (8/10), presence of bruising, and timing relative to strenuous activity make structural complications the primary concern—conservative management should only proceed after structural pathology is definitively excluded. 6, 4