Atypical Shoulder Pain

ATYPICAL SHOULDER PAIN HISTORY: A 59-year old female presented to the clinic with new onset right shoulder pain. She was moving boxes from her attic two days ago when she began to develop some pain. She does not recall any acute traumatic injury. She has been experiencing progressively worsening shoulder pain and is unable to move her arm. The pain is severe and fleeting with motion, and is localized over the lateral shoulder. She also states she has some pain more medially. She denies any previous significant injuries to this shoulder. She is quite physically active and works out regularly in the gym. Physical ExamPhysical exam revealed tenderness to palpation over distal insertion of supraspinatus, as well as over the subscapularis and medial shoulder. She had full strength but globally limited range of motion secondary to pain. She had weakness and pain with Jobe’s, lift off test, Hawkins/Kennedy, and O’Brien’s. Differential diagnosis1. Rotator cuff calcific tendonitis2. Glenohumeral joint osteoarthritis3. Acromioclavicular joint osteoarthritisTests/resultsShoulder radiographs: Possible intra-articular loose body/less likely calcific tendinitis Shoulder MRI w/o contrast: Thickening and low signal along the expected course of the coracoacromial ligament with surrounding edema in the rotator cuff interval. Findings are highly suggestive of hydroxyapatite deposition disease.Final/working diagnosis Calcification of coracoacromial ligament Treatment/outcomes Using ultrasound guidance, needle tenotomy of the calcification within the coracoacromial ligament was performed followed by a corticosteroid injection partially to the ligament and the subacromial bursa. The patient tolerated the procedure well. She was seen for follow-up 12 days following the procedure and reported complete resolution of pain and able to complete activities of daily living with no restrictions. On exam, she had full painless ROM and full strength. Repeat point-of-care ultrasound showed minimal calcification to the ligament. She was cleared to resume working out with no restrictions.