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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.

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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 time.

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The patient denied any recent trauma. Her past medical history included diabetes and hypertension.

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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.

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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.

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A radiograph of the right shoulder was obtained (Figure 1).

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  • What are the diagnostic possibilities?
  • How would you manage this patient?

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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 cartilage.

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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.

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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.

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Differential Diagnosis of Shoulder Pain that Radiates Down the Arm

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In a patient with shoulder pain that ...

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