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Milwaukee shoulder/knee syndrome

Etiology: - basic calcium phosphate deposition arthritis - often occurs in the setting of overuse or trauma Epidemiology: 1) 80% are women 2) average age is 72 years, range 50-90 years Pathology: 1) glenohumeral joint degeneration 2) soft tissue calcification 3) rotator cuff tears 4) electron microscopy (EM) shows crystals of hydroxyapatite History: - history of overuse or trauma Clinical manifestations: 1) generally dominant shoulder is involved 2) pain, stiffness & is swelling tend to occur gradually 3) symptoms may be bilateral 4) symptoms range from asymptomatic to severe pain at rest & at night 5) active range of motion is limited 6) passive range of motion may be preserved 7) large non-inflammatory effusion [3] Laboratory: - synovial fluid from joint aspiration a) few WBC (case [2] of 8300 leukocytes/uL) b) few to many RBC c) no crystals seen - individual crystals cannot be seen on routine polarization microscopy - small, round bodies 0.5-100 um seen as lumps of crystals - positive identification requires electron microscopy or elemental analysis - Alizarin red staining for Ca+2 with crystals visualized as large globular clumps Radiology: - destruction of subchondral bone - soft tissue swelling - intra-articular effusion is usually present - X-ray may show articular & periarticular dystrophic calcification Differential diagnosis: - CPPD - gout - septic arthritis - adhesive capsulitis - both active & passive range of motion limited * non-inflammatory synovial fluid in Milwaukee shoulder syndrome Management: 1) non-steroidal anti-inflammatory drugs (NSAIDS) 2) steroid joint injection 3) aspiration of shoulder joint if indicated 4) tidal irrigation 5) surgical: complete arthroplasty

Related

hydroxyapatite

General

hydroxyapatite deposition disease; calcium hydroxyapatite deposition disease; basic calcium phosphate deposition disease syndrome

References

  1. Weiner, S in: Intensive Course in Geriatric Medicine & Board Review, Santa Monica, CA, Sept 20-23, 2000
  2. Weiner, S in: Intensive Course in Geriatric Medicine & Board Review, Marina Del Ray, CA, Sept 12-15, 2001
  3. Medical Knowledge Self Assessment Program (MKSAP) 15, 16, 17. American College of Physicians, Philadelphia 2009, 2012, 2015
  4. Forster CJ, Oglesby RJ, Szkutnik AJ, Roberts JR. Positive alizarin red clumps in Milwaukee shoulder syndrome. J Rheumatol. 2009 Dec;36(12):2853 PMID: 19966203
  5. Genta MS and Gabay C. Images in clinical medicine. Milwaukee shoulder. N Engl J Med 2006 Jan 13; 354:e2 PMID: 16407503
  6. Halverson PB Crystal deposition disease of the shoulder (including calcific tendonitis and milwaukee shoulder syndrome). Curr Rheumatol Rep. 2003 Jun;5(3):244-7 PMID: 12744818