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Br J Sports Med doi:10.1136/bjsports-2013-092320a
  • I-Test

Shouldering the burden: a case of pain in the middle-aged female athlete

  1. Bruce B Forster
  1. Department of Radiology, University of British Columbia, Vancouver, British Columbia, Canada
  1. Correspondence to Dr Bruce B Forster, Department of Radiology, Vancouver General and University of British Columbia Hospitals, Vancouver, British Columbia V6T 1Z3, Canada; bruce.forster{at}vch.ca
  • Accepted 17 March 2013
  • Published Online First 19 April 2013

Part 2: Answer

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Shoulder pain is a frequent complaint among patients and diagnosing the cause can be challenging, often requiring imaging studies. As the first-line modality, plain radiography should be ordered for all patients with pain persisting beyond 6 weeks.1 The differential diagnosis for this middle-aged female patient with atraumatic shoulder pain includes arthritis and rotator cuff pathology. However, before considering these more common causes, it is important to exclude infection and malignancy.

Septic arthritis is always a consideration when there is pain at a single joint. Depending on the organism, septic arthritis can either be aggressive causing rapid joint destruction or indolent. The diagnosis is typically made on clinical assessment and laboratory values since radiographs may be normal or demonstrate non-specific findings, especially early in the course.

Musculoskeletal malignancies often present with atraumatic pain. The more common primary bone tumours include multiple myeloma, sarcoma, leukaemia and lymphoma. However, in this age group, metastases are more likely. Radiologically, osseous metastatic lesions can be broadly grouped into osteolytic (eg, renal, lung and thyroid cancer) and osteoblastic (eg, breast and prostate cancer) lesions.

Glenohumeral joint arthritis is classified as degenerative (eg, osteoarthritis) or inflammatory (eg, rheumatoid arthritis) and can generally be diagnosed on a plain film. Radiographic features of osteoarthritis (OA) include focal joint space loss, subchondral cysts, sclerosis and osteophyte formation. Features of inflammatory arthritis include diffuse joint space loss, periarticular osteopenia and erosions.2 OA may be primary, when there …