Clinical Case 008

Shoulder Pain in a 57-Year-Old Man

(courtesy of Medscape)

Background

Figure 1 below.

A 57-year-old man presents to the emergency department (ED) complaining of vague left shoulder pain for the past 3 months following an incident in which a garage door fell on him. The pain is slightly worse with movement, but he denies any limitation in the range of motion. The pain is dull and has recently become increasingly severe. He denies experiencing any prior trauma to the area, as well as any history of arthralgia, myalgia, other associated symptoms, or any prior surgeries or medical problems. He denies any weight loss, chills, night sweats, or recent illnesses. He previously smoked about 1 pack of cigarettes per day for about 30 years, but he quit 8 years ago. He admits to drinking 1 or 2 beers every night. He does not use any illicit drugs and does not take any medications other than an occasional nonsteroidal anti-inflammatory drug (NSAID), which seems to relieve the pain. He has no allergies.

On physical examination, the patient's oral temperature is 99.5°F (37.5°C), his pulse has a regular rhythm measured at 87 bpm, and his blood pressure is 136/88 mm Hg. He is noted to be in mild distress as a result of his left shoulder pain. The examination of his head, including inspection of the ears, eyes, and throat, is normal. His lungs are clear to auscultation. His heart sounds are normal and no murmurs are detected. His abdomen is soft, nontender, and no distention is noted. He has full range of motion of the left shoulder and neck. Mild tenderness to palpation over the posterolateral aspect of the left scapula is found, but no lumps or nodules are palpated. He does not have any skin lesions. He is neurovascularly intact throughout both of his upper extremities, with symmetric reflexes. No pain is elicited with provocative maneuvers of the shoulder, including with Neer, Hawkins-Kennedy, or O'Brien tests.

Laboratory studies, including a complete blood cell count (CBC) and a serum electrolyte panel that includes calcium levels, are obtained in the ED and are found to be normal. Plain radiographic films of the left shoulder are obtained, which reveal multiple well-circumscribed lytic lesions of the neck and glenoid regions of the scapula (Figures 1-3). The patient is discharged from the ED with pain medication and a shoulder sling for comfort. He is asked to follow-up with the orthopedic clinic within the following week. Serum immunoglobulin levels and serum and urine protein electrophoresis are all normal when obtained in the outpatient clinic. A biopsy is performed, which reveals a clear margin and a narrow zone of transition to normal surrounding bone.

shoulderfilm.jpg

What is your diagnosis?

Hint: Note the lytic characteristics of the lesions.

  1. Fibrous dysplasia
  2. Aneurysmal bone cyst
  3. Isolated bone plasmacytoma
  4. Chondrosarcoma
Unless otherwise stated, the content of this page is licensed under Creative Commons Attribution-NonCommercial-NoDerivs 3.0 License