Milwaukee shoulder syndrome

How does Milwaukee shoulder syndrome (apatite-associated arthropathy, rotator cuff tear arthropathy, or BCP-associated destructive arthropathy) present?

Milwaukee shoulder syndrome is a severe destructive arthritis of the glenohumeral joint with loss of the rotator cuff associated with the presence of BCP crystals. It affects mostly elderly women and is usually bilateral. Unilateral disease typically occurs in the dominant shoulder, and in bilateral disease, the dominant shoulder is usually more severely affected. Patients most often present with mild intermittent shoulder pain, worse with use and when lying on their side in bed. On exam, joint mobility can either be restricted or hypermobile, the latter due to instability seen when joint destruction is severe. Large joint effusions are common and joint aspirates often reveal blood tinged fluid with low leukocyte counts. Early x-rays may show superior subluxation of the humeral head from the glenoid, suggestive of a rotator cuff tear. As the disease progresses, x-rays may show sclerosis and cyst formation, erosions, and ultimately, complete destruction of the glenohumeral joint.

BCP arthropathy can affect other joints as well, particularly the knees and hips. A loss of joint space in the lateral compartment in the knees distinguishes this from primary OA, similar to CPPD-associated arthropathy. Rapidly destructive arthritis of the finger due to BCP has been called Philadelphia finger .

How is Milwaukee shoulder syndrome treated?

Treatment options are limited, and treatment choice is primarily dictated by severity of symptoms. Some patients with mild symptoms do well with daily NSAIDs and/or analgesics. Local heat can be beneficial. If large effusions are present, repeated arthrocentesis may relieve symptoms. Intraarticular steroids can also be helpful at 2 to 3-month intervals. Some patients benefit from percutaneous joint lavage with saline, followed by steroid injection. Patients may benefit from joint protection (decreased joint usage) early in presentation, but physical therapy will be important to maintain range of motion and strengthen the surrounding muscles. Surgical intervention may be considered for advanced degenerative changes.

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