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Shouldering the burden: a case of pain in the middle-aged female athlete
  1. Kathryn Darras,
  2. Gordon Andrews,
  3. 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}

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Part 1: Question

A 56-year-old previously well left-handed woman presents to her family physician with a 2-year history of pain and stiffness in her left shoulder. She describes a constant ‘ache’ that became ‘sharp’ when playing tennis or golf. Over the last 2 months, the pain has become increasingly worse and she has had to reduce her tennis matches from four times per week to only once.

On examination, there was a soft tissue swelling over the left shoulder with no bruising or muscle wasting. Her pain reproduced with active abduction of the left shoulder while the passive range of motion was full. There was reduced power with abduction and flexion of the shoulder. Sensation was intact in the upper extremity.

Plain films and an ultrasound examination were performed (figures 1 and 2).

Figure 1

Anteroposterior radiograph of the patient's left shoulder demonstrating a focus of calcification within a tendon of the rotator cuff, superior to the humeral head (arrow). Calcium deposition can be localised to the rotator cuff by anteroposterior radiographs in internal and external rotation as well as the axillary lateral radiograph.

Figure 2

Sonographic image of the shoulder demonstrating a supraspinatus calcium deposit appearing as a well-circumscribed, anechoic focus with posterior acoustic shadowing (arrow).

What is the most likely diagnosis?

For answer see page 1135

For question see page 1079

Part 2: Answer

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 …

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  • Contributors All authors contributed to the conception, writing, and revising of this article.

  • Competing interests None.

  • Provenance and peer review Not commissioned; internally peer reviewed.