October 31, 2016

Septic Arthritis of the Untouched Shoulder

What we typically see in these atypical cases


By Sumit Kanwar, MD, Manisha R. Chand, MD, and Gregory Gilot, MD


Cleveland Clinic is a non-profit academic medical center. Advertising on our site helps support our mission. We do not endorse non-Cleveland Clinic products or services. Policy

The medical literature contains no mention of septic arthritis of the untouched shoulder, yet we’ve seen several cases in our practice and believe it’s frequently missed.

Overall, the literature on septic shoulder arthritis is mostly limited to case reports or small series, and no reports have specifically focused on cases developing without any manipulation, injury, injections, arthroscopy or surgical procedures within the prior year.

Regardless of etiology, early identification of glenohumeral septic arthritis is vital to preventing morbidity and improving functional outcomes.

A typical atypical case

While the presenting symptoms of “virgin” shoulder infections may be vague and variable, in our experience a typical case is a middle-aged (average 57-61 years) male, presenting with either acute or vague anterior or posterior shoulder pain and limited range of motion, typically in the dominant arm. Elevated erythrocyte sedimentation rate (ESR) and inflammatory markers, low-grade fever and x-ray displaying degenerative joint disease are also common.

For all such cases, we recommend further workup with advanced imaging, such as ultrasound, CT or MRI. If there is anterior space joint effusion with soft tissue involvement, septic arthritis of the glenohumeral joint should be suspected.

Septic arthritis management traditionally has involved incision and drainage or needle aspiration of synovial fluid, supplemented with three to six weeks of intravenous antibiotics. However, arthroscopy may be preferred for infections in the shoulder, due to better irrigation and joint visualization. If these methods fail, open surgical drainage is necessary.

Case 1: 59-year-old male

One of our recent cases was a 59-year old disabled male who presented with a chief complaint of left shoulder pain of two weeks’ duration in the anterior, posterior and superior aspects. Although he had not had any shoulder interventions within the previous year, his past history was notable for rotator cuff repair of his other (right) shoulder.


MRI of the right shoulder. Anterior space effusion is visible.

On examination, he had swelling, global tenderness and painful range of motion. Laboratory findings included elevated ESR and C-reactive protein levels. His MRI was highly suspicious for abscesses and osteomyelitis of the humeral head.

After we diagnosed him with septic arthritis, we performed a left incision and drainage of the abscess with an arthrotomy of the glenohumeral joint with exploration and drainage. Culture was positive for Staphylococcus aureus, which was resistant to penicillin G.

We inserted a central catheter for long-term antibiotic (ciprofloxacin and gentamicin) treatment, and he completely recovered in six weeks.

Case 2: 55-year-old male

Another case, a 55-year-old male, presented with intense, sharp, right shoulder pain of about two months’ duration, swelling and limited ROM. He reported that he felt a “pop” in his shoulder two months’ prior, following a motor vehicle accident. He had a past medical history of morbid obesity and peripheral vascular disease, and had previously undergone bilateral knee arthroscopy.


Ultrasound of the right shoulder. Anterior space effusion is visible.

On examination, his right upper extremity had pitting edema down to the fingers.


His preoperative laboratory results included elevated white blood cell count, ESR and CRP, and postoperative culture detected E. coli. He was treated with surgical arthrotomy and extended spectrum beta lactam antibiotics and has been stable to date.

These and other cases continue to remind us to keep an open mind for the possibility of infection in the glenohumeral joint, even when it seems to have arisen de novo.

Drs. Kanwar and Chand are research fellows in the Department of Orthopaedic Surgery at Cleveland Clinic Florida.

Dr. Gilot is Chair of the Department of Orthopaedic Surgery at Cleveland Clinic Florida.

Related Articles

Multiple MRI scans of knees
February 12, 2024
Arthritis Foundation and Cleveland Clinic to Build National Osteoarthritis Imaging Center

Center will coordinate, interpret and archive imaging data for all multicenter trials conducted by the foundation’s Osteoarthritis Clinical Trial Network

November 7, 2018
Early Detection of Osteoarthritis with Quantitative MRI

Leading-edge technology will improve diagnosis and prognosis

October 28, 2016
Walch Classification: Adding Two New Glenoid Types

Current definitions insufficient for interpreting clinical outcomes

April 14, 2016
Preserving Functional Motion in the Arthritic Wrist

Pioneering techniques eliminate pain, restore mobility

Blue illustration of knee with torn ACL in red
February 29, 2024
Aspiration and Corticosteroid Injection Are Safe After ACL Injury

Study reports zero infections in nearly 300 patients

Swollen knee with scar
February 26, 2024
Is Joint Inflammation and Pain After Total Knee Arthroplasty an Infection or Gout?

How to diagnose and treat crystalline arthropathy after knee replacement

Dissected knee with robotic pins inside the incision
February 19, 2024
Intraincisional Pin Placement Is Safe Alternative in Robot-Assisted Total Knee Arthroplasty

Study finds that fracture and infection are rare

Close up of the one round white pill in female hand.
January 4, 2024
Patients Use Less Pain Medication After Robot-Assisted Hip Replacement Compared With Conventional Surgery

Reduced narcotic use is the latest on the list of robotic surgery advantages