Milwaukee shoulder refers to a destructive shoulder arthropathy due to deposition of hydroxyapatite crystals, and identification of these crystals in synovial fluid is the cornerstone of diagnosis.
Milwaukee shoulder frequently affects older women, often with a history of trauma to the region.
Symptoms are usually comparatively mild, despite rapid and marked progression of radiographic features.
Radiographic findings are striking and almost resembles a neuropathic joint, with advanced articular surface destruction with intra-articular loose bodies, subchondral sclerosis, soft tissue swelling and rotator cuff disruption. Cases often demonstrate superior subluxation of the humeral head in relation to the glenoid fossa 4. The superior subluxation can also result in a pseudoarthrosis with the distal clavicle and/or acromion 7.
MRI findings mirror those of the plain radiographs and include:
- large shoulder joint effusion
- complete rotator cuff tear
- narrowing of the glenohumeral joint
- thinning of cartilage
- destruction of subchondral bone
Treatment and prognosis
No specific treatment is available, only supportive treatment for symptom relief 3.
History and etymology
Regius Professor of Surgery, Dr Robert Adams (1791 -1875) was an Irish surgeon who first described this pathology in his own textbook published in 1857 5.
In 1981, a group of Milwaukee based researchers encountered four cases of rotator cuff loss, shoulder arthropathy and joint effusions containing calcium phosphate crystals and hence coined the term 'Milwaukee shoulder' 6.
General imaging differential considerations include
- 1. Dondelinger RF, Marcelis S, Daenen B et-al. Peripheral Musculoskeletal Ultrasound Atlas. Thieme. (1996) ISBN:0865775923. Read it at Google Books - Find it at Amazon
- 2. Llauger J, Palmer J, Rosón N et-al. Nonseptic monoarthritis: imaging features with clinical and histopathologic correlation. Radiographics. 2000;20 Spec No : S263-78. Radiographics (full text) - Pubmed citation
- 3. Santiago T, Coutinho M, Malcata A et-al. Milwaukee shoulder (and knee) syndrome. BMJ Case Rep. 2014;2014 (may14 4): . doi:10.1136/bcr-2013-202183 - Pubmed citation
- 4. McCarty DJ. Milwaukee shoulder syndrome. Transactions of the American Clinical and Climatological Association. 102: 271-83; discussion 283-4. Pubmed
- 5. Adams R. Treatise on Rheumatic Gout. 2nd ed. London, England: John Churchill & Sons; 1873: 91.
- 6.Daniel J. Mccarty, Paul B. Halverson, Guillermo F. Carrera, Bruce J. Brewer, Franklin Kozin. “Milwaukee shoulder”—association of microspheroids containing hydroxyapatite crystals, active collagenase, and neutral protease with rotator cuff defects. i. clinical aspects. (1981) Arthritis & Rheumatism. 24 (3): 464. doi:10.1002/art.1780240303 - Pubmed
- 7. Soares, Ines, Mewar, Devesh. 30. Milwaukee Shoulder Syndrome - an incidental finding but important cause of acute shoulder arthropathy. (2017) Rheumatology Advances in Practice. doi:10.1093/rap/rkx011.005
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