Photo Quiz

Shoulder Pain and Stiffness with Abnormal Imaging Findings

 

Am Fam Physician. 2020 Dec 1;102(11):695-696.

A 51-year-old patient presented with several years of diffuse pain in the right shoulder. The pain, which the patient rated as 10 out of 10 on a pain scale, was exacerbated by any activity. The patient reported shoulder stiffness and subjective weakness in the arm. The patient had no history of injury or surgery to the shoulder but had undergone bilateral hip replacements and right ankle fusion. The patient had a history of type 2 diabetes mellitus and hypertension.

On physical examination, the patient's right shoulder was diffusely tender and mildly warm. The range of motion was significantly decreased in all planes. Rotator cuff strength could not be evaluated because of pain. Results of the Hawkins and Neer impingement tests, empty can test, lift off test, and drop arm test were grossly positive. The patient could not tolerate further testing because of pain. Shoulder radiography (anteroposterior view; Figure 1) and magnetic resonance imaging (T2 frontal view; Figure 2) were performed.

FIGURE 1


FIGURE 1

FIGURE 2


FIGURE 2

Question

Based on the patient's history, physical examination, and imaging findings, which one of the following is the most likely diagnosis?

  • A. Adhesive capsulitis.

  • B. Inflammatory arthritis.

  • C. Rotator cuff tear.

  • D. Synovial chondromatosis.

Discussion

The answer is B: inflammatory arthritis. Inflammatory arthritis encompasses multiple conditions that are categorized as autoimmune connective tissue disease (e.g., rheumatoid arthritis, systemic lupus erythematosus, vasculitis), spondyloarthritis (e.g., ankylosing spondylitis, psoriatic arthritis, reactive arthritis, inflammatory bowel disease–related arthritis), infectious arthritis (e.g., bacterial, viral), and crystal arthritis (e.g., gout, calcium pyrophosphate deposition disease).1

Large erosions on radiography and magnetic resonance imaging (MRI) can be typical findings in patients with rheumatoid arthritis, psoriatic arthritis, and gout. This patient's MRI demonstrates a large glenohumeral joint effusion that contains multiple

Address correspondence to Justin Lee, MD, CAQSM, at Justin_Lee@med.unc.edu. Reprints are not available from the author.

Author disclosure: No relevant financial affiliations.

References

show all references

1. Pujalte GGA, Albano-Aluquin SA. Differential diagnosis of polyarticular arthritis. Am Fam Physician. 2015;92(1):35–41. Accessed October 16, 2020. https://www.aafp.org/afp/2015/0701/p35.html...

2. Mishra BN, Poudel RR, Jha A, et al. Rheumatoid subacromial-subdeltoid bursitis with rice bodies: a case report [correction published online September 26, 2020]. J Clin Clin Orthop Trauma. Accessed October 16, 2020. https://www.journal-cot.com/article/S0976-5662(20)30466-5/fulltext. J Clin Orthop Trauma. 2019;10(3):514–517.

3. Ramirez J. Adhesive capsulitis: diagnosis and management. Am Fam Physician. 2019;99(5):297–300. Accessed October 16, 2020. https://www.aafp.org/afp/2019/0301/p297.html

4. Sambandam SN, Khanna V, Gul A, et al. Rotator cuff tears: an evidence based approach. World J Orthop. 2015;6(11):902–918.

5. Monica J, Vredenburgh Z, Korsh J, et al. Acute shoulder injuries in adults. Am Fam Physician. 2016;94(2):119–127. Accessed October 16, 2020. https://www.aafp.org/afp/2016/0715/p119.html

6. Neumann JA, Garrigues GE, Brigman BE, et al. Synovial chondromatosis. JBJS Rev. 2016;4(5):01874474-201605000-00005.

This series is coordinated by John E. Delzell Jr., MD, MSPH, associate medical editor.

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