Disclosures: Eric E. Twohey, MD: No financial relationships or conflicts of interest

Case Diagnosis: An 81-year-old female with a history of rheumatoid arthritis presenting with shoulder pain

Case Description or Program Description: The patient presented to an ultrasound guided procedural outpatient practice for an intra-articular glenohumeral and subacromial-subdeltoid bursa corticosteroid injection. She had developed progressive shoulder pain over the previous 2 years with significant reduction in left shoulder function recently, reduced active range of motion, and important pain with overhead movements. Her history was notable for rheumatoid arthritis, with no other known rheumatological conditions.

Setting: Outpatient PM&R Ultrasound Procedure Clinic at an Academic Institution

Assessment/Results: X-ray revealed superior subluxation of humeral head, osteoarthrosis of the glenohumeral joint, as well as periarticular calcifications. Pre-injection ultrasound scan revealed a significant effusion intra-articularly, a thickened synovium, as well as a massive complete rotator cuff tear. There was an important effusion in the region of the tear along with an important subacromial-subdeltoid bursitis, with significant uptake on Doppler ultrasound. Given findings, a diagnostic aspiration was performed at the level of the effusion within the rotator cuff tear, the bursa and intra-articularly. There was concern for an inflammatory process, especially Milwaukee shoulder, as well as a need to rule out an infectious process. The results came back as positive for calcium pyrophosphate crystals, as seen in pseudogout. The patient subsequently underwent additional investigations, referral to Rheumatology, ultrasound guided corticosteroid injection and physical therapy.

Discussion (relevance): This case highlights surprising ultrasound findings with a massive atraumatic complete rotator cuff tear, bursitis, and arthritis which was suspect for Milwaukee shoulder (hydroxyapatite crystal deposition). Aspiration diagnosed instead calcium pyrophosphate crystals as seen in pseudogout. This is an unusual presentation with a paucity of diagnostic ultrasound imaging available in the literature.

Conclusions: Undiagnosed crystal arthropathies should be suspected in association with atraumatic massive rotator cuff tears including calcium pyrophosphate and hydroxyapatite crystals.

Level of Evidence: Level V

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PM&R Meeting Abstracts - https://pmrjabstracts.org/abstract/diagnostic-ultrasound-of-a-massive-rotator-cuff-tear-with-undiagnosed-pseudogout-a-case-report/