A 71-year-old woman complained of right shoulder pain that radiated
down her arm. The pain began three days earlier. It was persistent,
but had gradually improved. Her daughter was finally able to convince
her to come to the doctor.
She had had shoulder pain for the past year, which had begun
after a motor vehicle collision. The patient had been to several
orthopedists, rehabilitation physicians, and physical therapists.
Litigation was pending with regard to her injury. Her home health
aide was with her when the current episode of shoulder pain began
and noted that the patient’s arm appeared pale at that
The patient denied any recent trauma. Her past medical history
included diabetes and hypertension.
On examination, she was elderly and overweight. She appeared
fatigued but was in no acute distress. Her vital signs were normal
aside from a blood pressure of 180/100 mm Hg in both arms.
The right shoulder had mild diffuse tenderness but no swelling.
There was pain on range of motion, which became severe during passive
abduction to 70°. Sensation and strength were normal
except as limited by pain. Pulses were normal and equal in both
arms. A few small ecchymoses were present on the medial aspect of
her right upper arm.
A radiograph of the right shoulder was obtained (Figure 1).
- What are the diagnostic possibilities?
- How would you manage this patient?
The radiograph was interpreted as showing a large osteophyte extending from the acromion.
Osteophytes are outgrowths of new bone that forms at the margins of
a joint injured by degenerative osteoarthritis. Osteophyte formation
is an attempted reparative process at the edge of remaining articular
The correct interpretation is that the coracoacromial ligament
is calcified (Figure 2). This is also a response to wear-and-tear
stresses but is a “traction spur” or “bone
spur” similar to calcification of the plantar ligament
in the foot. The proper name for a bone spur is enthesophyte.
The coracoacromial ligament is partially calcified in
this patient (asterisk).
Calcification of the coracoacromial ligament may be associated
with shoulder impingement syndrome.
There is painful compression of the supraspinatus tendon between
the greater tuberosity of the humeral head and the coracoacromial
ligament when the patient abducts the shoulder. This could be the cause
of the patient’s chronic pain and limited range of motion.
Diagnosis of Shoulder Pain that Radiates Down the Arm
In a patient with shoulder pain that ...