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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: - targets both articular cartilage & periarticular tendons & ligaments - inflammatory state causing progressive destruction of the rotator cuff & glenohumeral joint. - glenohumeral joint degeneration - erosion of the humeral head - rotator cuff calcific tendonitis & rotator cuff tears - soft tissue calcification - 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 - intermittent bilateral shoulder pain, mainly on abduction 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 - case [3] of 15,000 leukocytes/uL b) few to many RBC - case [3] of 120,000 RBC/uL, many dysmorphic RBC c) gram stain negative d) no crystals seen - individual crystals cannot be seen on routine polarization microscopy - positive identification requires electron microscopy or elemental analysis - Alizarin red staining for Ca+2 with crystals visualized as large globular clumps - small, round bodies 0.5-100 um seen as lumps of crystals Radiology: - destruction of subchondral bone - soft tissue swelling - intra-articular effusion is usually present - a large effusion may be present (shoulder) [3] - X-ray may show articular & periarticular dystrophic calcification - calcific deposits in rotator cuff tendons - erosion of the humeral head - glenohumeral joint degradation - 'high-riding' humeral head [3] 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; basic calcium phosphate-associated arthritis 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 - Medical Knowledge Self Assessment Program (MKSAP) 20 American College of Physicians, Philadelphia 2025
  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