M71.01 Abscess of bursa, shoulder

Name of the Condition

• Abscess of bursa, shoulder

Summary

An abscess of the bursa, shoulder is a localized collection of pus within the bursa of the shoulder, a small fluid-filled sac that reduces friction between tissues. This condition typically causes pain, swelling, and warmth at the affected site. The shoulder-specific designation indicates the abscess is localized to the bursa in the shoulder region.

Causes

Abscesses of the shoulder bursa usually result from bacterial infection, often introduced through direct trauma, skin breakdown, or spread from adjacent tissues. Staphylococcus aureus is a common causative organism. Non-infectious causes, such as foreign body reaction or sterile inflammation, are less frequent.

Risk Factors

• Recent injury or surgery near the shoulder bursa
• Skin infections or open wounds in the shoulder area
• Immunocompromised states (e.g., diabetes, HIV)
• Chronic inflammatory conditions (e.g., rheumatoid arthritis)
• Repetitive motion or pressure on the shoulder bursa

Symptoms

• Localized pain, tenderness, or throbbing in the shoulder
• Swelling, redness, or warmth over the bursa
• Limited range of motion in the shoulder joint
• Possible fever or systemic signs if infection spreads
• Pus drainage if the abscess ruptures

Diagnosis

Diagnosis involves a physical examination to assess bursal swelling, warmth, and tenderness. Imaging (e.g., ultrasound) may confirm fluid collection. Aspiration of the bursa may be performed to identify the causative organism and guide treatment.

Treatment Options

• Antibiotic therapy to address bacterial infection
• Incision and drainage of the abscess to remove pus
• Pain management with analgesics
• Rest and immobilization of the shoulder to reduce inflammation
• Follow-up care to monitor healing and prevent recurrence

Prognosis and Follow-Up

With appropriate treatment, most shoulder bursa abscesses resolve without long-term complications. Follow-up may include monitoring for recurrence, assessing range of motion, and ensuring complete resolution of infection. Delayed or inadequate treatment can lead to chronic bursal issues or spread of infection.

Complications

• Chronic bursitis or persistent pain
• Spread of infection to surrounding tissues or joints
• Limited shoulder mobility or stiffness
• Systemic infection (sepsis) if left untreated
• Recurrence of the abscess

Lifestyle & Prevention

• Avoid repetitive overhead motions or excessive pressure on the shoulder
• Maintain good skin hygiene to prevent infection
• Promptly treat shoulder injuries or skin wounds
• Manage underlying conditions like diabetes or arthritis
• Use protective gear during activities that strain the shoulder

When to Seek Professional Help

Seek medical attention if you experience persistent shoulder pain, swelling, or warmth, especially with fever or difficulty moving the joint. Immediate care is needed if the abscess ruptures or symptoms worsen rapidly.

Tips for Medical Coders

Document the shoulder-specific location and confirm the presence of an abscess (not just inflammation) to justify the M71.01 code. Include details on infection source, diagnostic methods (e.g., aspiration), and treatment to support medical necessity. Ensure no other bursal site is specified to avoid miscoding.