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Musculoskeletal System ORGAN SYSTEMS

Milwaukee shoulder syndrome (MSS)

Introduction

Rare destructive shoulder arthropathy characterised by pain, large joint or bursa effusion associated with the deposition of calcium hydroxyapatite crystals

  • Typically occurs in elderly patients aged 60–90 years
  • Female preponderance of 4 : 1

History

The term Milwaukee shoulder syndrome (MSS) was first used in 1981 to describe four elderly women in Milwaukee in the state of Wisconsin, USA, with recurrent bilateral shoulder effusions, radiographic evidence of severe destructive changes of the glenohumeral joints, and massive tears of the rotator cuff. The term rapid destructive arthritis of the shoulder was introduced in 1982 to describe six elderly females with spontaneous large glenohumeral effusions, mild pain, and tears of the rotator cuff. Apatite-associated destructive arthritis and idiopathic destructive arthritis were introduced to illustrate rotator cuff tear arthropathy of the shoulder in 1983.

Aetiology

Risk factors:

  • Trauma/overuse  
  • Calcium pyrophosphate dehydrate crystal deposition  
  • Neuroarthropathy  
  • Dialysis arthropathy  
  • Denervation  
  • Female gender  
  • Advanced age

Pathophysiology

Characterised by intra-articular or periarticular hydroxyapatite crystals and rapid destruction of the rotator cuff and the glenohumeral joint.

  • Intraarticular/periarticular hydroxyapatite crystals
  • Rapid destruction of the rotator cuff and the glenohumeral joint

Intra-articular calcium hydroxyapatite deposition
↓
Release of lysosomal enzymes
↓
Damage to periarticular tissues, including rotator cuff

Clinical features

crim.rheumatology2014-458708.001
Large right shoulder swelling which was warm to touch and tender with no erythema | Nadarajah, C. V., & Weichert, I. (2014). Milwaukee shoulder syndrome. Case Reports in Rheumatology, 2014, 458708. https://doi.org/10.1155/2014/458708

Diagnosis

Radiograph:

crim.rheumatology2014-458708.002
Plain radiograph of tan MSS shoulder showing joint space narrowing, subchondral sclerosis, destruction of subchondral bone, soft-tissue swelling, capsular calcifications, and intra-articular loose bodies | Nadarajah, C. V., & Weichert, I. (2014). Milwaukee shoulder syndrome. Case Reports in Rheumatology, 2014, 458708. https://doi.org/10.1155/2014/458708

USG:

  • Exuberant subacromial bursitis
  • Rotator cuff tear
f3.medium
Shoulder ultrasonography (GE Logiq 5 ultrasound machine; 7–12 MHz linear probe; transversal scan): exuberant distension of the subacromial bursa revealed by a hypoechoic image which represents synovial fluid effusion, without power Doppler signal in the synovial membrane. (A) Right shoulder and (B) left shoulder. | Santiago, T., Coutinho, M., Malcata, A., & da Silva, J. A. P. (2014). Milwaukee shoulder (and knee) syndrome. BMJ Case Reports, 2014, bcr2013202183. https://doi.org/10.1136/bcr-2013-202183

Bursa aspiration:

  • Haemorrhagic non-inflammatory fluid and hydroxyapatite crystals were identified with alizarin red staining
  • Serohematic synovial fluid with low cellularity (<2000 leucocytes/mL) cells.
f4.medium
Subacromial bursa aspiration yielded over 200 mL of a haemorrhagic synovial fluid, which exhibited a non-inflammatory cell count (leucocytes 800/mm3). | Santiago, T., Coutinho, M., Malcata, A., & da Silva, J. A. P. (2014). Milwaukee shoulder (and knee) syndrome. BMJ Case Reports, 2014, bcr2013202183. https://doi.org/10.1136/bcr-2013-202183

Differential diagnosis

  • Rapidly destructive or progressive arthropathy
  • Septic arthritis
  • Neuropathic arthropathy
  • Osteonecrosis
  • Inflammatory arthritis
  • Crystal-associated arthropathy
  • Arthropathy of late syphilis

Management

Supportive management:

  • Physiotherapy: provides the required exercise to maintain the range of motion and strengthen the surrounding muscles

Medical management:

  • NSAIDs
  • Colchicine
  • Arthrocentesis

Surgical management (severe/advanced degenerative changes):

  • Partial/complete arthroplasty

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