A case of shoulder pain

57 yo female with a history of hypertension, osteoarthritis, and asthma with chronic steroid use, presenting with multiple complaints, including chronic right shoulder pain that has been worsening the past week. The pain is constant and worse with any ROM of the right shoulder. Physical exam, including Spurling's Test, is otherwise unremarkable. On further discussion, the patient has had a remote hip replacement for avascular necrosis, and no recent traumas.

Stage 3 Avascular Necrosis of the Humerus

Avascular necrosis is caused by an interruption of the blood supply to the humeral head, leading to death of cells in the bony matrix of the bone. The bone is reabsorbed, leading to remodeling and collapse of the bone.

Patients at risk for AVN include those on chronic steroids, sickle cell, AIDs, and autoimmune diseases. Post-traumatic AVN may also occur. Symptoms are usually slowly progressive pain and loss of range of motion, with weakness of the rotator cuff and deltoid muscle on examination. Early disease will show no radiographic findings, however overtime as AVN progresses you will see the osteolytic lesion, reabsorption of the bone, and finally a crescent sign (as seen in this case) as the bone collapses.
Treatment is operative; core decompression can treat early Stage 1-2, while more severe cases may require arthroplasty. Disposition should be discharge with outpatient orthopedic follow-up for MRI and further management.