RFS – CLINICAL VIGNETTE
Differential Diagnosis of Sudden-Onset Shoulder Pain in a
58-Yr-Old Male Patient With an Elevated C-Reactive Protein
A Clinical Vignette
Kyu Hwan Choi, MD, Sam-Guk Park, MD, Wonho Lee, MD,
Mathieu Boudier-Revéret, MD, and Min Cheol Chang, MD
Downloaded from http://journals.lww.com/ajpmr by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8K2+Ya6H515kE= on 12/08/2021
Key Words: Shoulder Pain, Calcific Tendinitis,
C-Reactive Protein, Diagnosis
(Am J Phys Med Rehabil 2021;100:e126–e128)
PATIENT INFORMATION
A 58-yr-old man with no significant medical history visited
the orthopedic surgery department of a university hospital because
of sharp, sudden-onset right shoulder pain for 5 days. He re-
ported nonradiating pain in the lateral shoulder area around the
greater tubercle. The pain had a severity score of 8/10 on a Nu-
meric Rating Scale that significantly affected his sleep. The pain
was sharp and aggravated when the patient abducted his right
arm. The pain was not exacerbated by neck motion. Moreover,
there were no precipitating factors, such as trauma, heavy work,
or previous injections to the right shoulder area. One year prior,
the patient had intermittent right shoulder pain (pain degree: Nu-
meric Rating Scale 1–2); however, it was well managed with oral
pain medications (acetaminophen 650 mg/d). Before visiting our
hospital, the patient visited the local hospital 4 days after the onset
of the sharp pain. Laboratory tests at the local hospital performed
4 days after pain onset revealed elevated C-reactive protein (CRP)
levels (4.4 mg/dl; reference range = 0.3–1 mg/dl). The physician
at the local hospital suspected septic arthritis of the right shoulder
joint. The following day (5 days after pain onset), the patient was
referred to this hospital for further evaluation and management.
From the Department of Rehabilitation Medicine, College of Medicine, Yeungnam
University, Daegu, Republic of Korea (KHC, MCC); Department of Orthopaedic
Surgery, College of Medicine, Yeungnam University, Daegu, Republic of Korea
(S-GP); Department of Radiology, Topspine Hospital, Daegu, Republic of Korea
(WL); and Department of Physical Medicine and Rehabilitation, Centre
hospitalier de l’Université de Montréal, Montreal, Québec, Canada (MB-R).
All correspondence should be addressed to: Min Cheol Chang, MD, Department of
Physical Medicine and Rehabilitation, College of Medicine, Yeungnam
University 317-1, Daemyungdong, Namku, Taegu, 705-717, Republic of Korea.
Supported by a National Research Foundation of Korea grant funded by the Korean
Government (Grant No. NRF-2021R1A2C1013073).
The patient provided informed consent for participation in the study.
Kyu Hwan Choi is in training.
Financial disclosure statements have been obtained, and no conflicts of interest have
been reported by the authors or by any individuals in control of the content of
this article.
Supplemental digital content is available for this article. Direct URL citations appear
in the printed text and are provided in the HTML and PDF versions of this article
on the journal’s Web site (www.ajpmr.com).
Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.
ISSN: 0894-9115
DOI: 10.1097/PHM.0000000000001746
e126 www.ajpmr.com American Journal of Physical Medicine & Rehabilitation • Volume 100, Number 9, September 2021
Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.
CLINICAL FINDINGS
The patient’s body temperature at presentation in our hos-
pital was 36.7°C. Tenderness over the right greater tubercle and
warmth around the greater tubercle were noted; however, no
swelling or erythema was observed. During active and passive
range of motion of the right shoulder joint, pain increased.
When the patient abducted his right shoulder over 60 degrees,
the patient’s pain was most severely aggravated as compared
with that during internal and external rotation, adduction, flex-
ion, and extension. In addition, the patient had right shoulder
pain even in the resting state. During passive internal and external
rotation and adduction, no limitation of motion was observed.
However, passive abduction range of motion could not be
assessed because of severe pain. No sulcus sign was observed.
No weakness was observed in right elbow flexion, elbow exten-
sion, wrist extension, and finger flexion. Motor examination of
his right shoulder could not be performed against resistance be-
cause of pain. There were no sensory deficits in his right upper ex-
tremity. The biceps and triceps muscle stretch reflexes were normal
on both sides. Spurling sign was negative. This study conforms to
all AJPMR RFS CARE guidelines and reports the required in-
formation accordingly (see Supplemental Checklist, Supple-
mental Digital Content 1, http://links.lww.com/PHM/B266).
What is your differential diagnosis for the patient’s shoulder
pain? What diagnoses do you need to rule out? What is the most
likely diagnosis?
DIAGNOSTIC ASSESSMENT
Blood tests revealed an elevated CRP level (6.159 mg/dl;
reference range = 0.3–1 mg/dl) and erythrocyte sedimentation
rate (92 mm/H; reference range = 0–25 mm/H). The white
blood cell count (8190 cells/μl, neutrophils = 64.4%; reference
range = 4000–10,000 cells) and procalcitonin level (0.037 ng/
ml; reference range = 0–5 ng/mL) were within the reference
ranges. The uric acid level was also normal (4.3 mg/dl; refer-
ence range = 2.2–7.8 mg/dl).
We considered the following disorders as possible causes
of sudden unilateral shoulder pain:
1. Septic arthritis: This was considered, given the elevated CRP
level and the development of sudden, severe pain. In addition,
warmth around the shoulder joint supports this diagnosis. Al-
though our patient was afebrile and had a normal white blood
cell count range, septic arthritis could not be ruled out be-
cause septic arthritis can occur without fever or leukocytosis.1
2. Gouty arthritis: In the case of acute monoarthritis, gouty ar-
thritis should be considered along with septic arthritis. A
Volume 100, Number 9, September 2021 Shoulder Pain With Elevated CRP

FIGURE 1. Plain radiographs of the right shoulder in the anterior-posterior (A) and axial (B) views showing the largest calcific deposit, measuring
1.0  1.7 cm (arrows), above the greater tubercle of the right humerus.

significantly elevated CRP level supports this diagnosis.2
Although the serum uric acid level was normal in our pa-
tient, gouty arthritis could not be ruled out. Approximately
60% of patients with acute gout attacks have normal serum
uric acid levels.2 However, gouty arthritis rarely develops
in the shoulder joint.
3. Calcific tendinitis: Sudden onset of severe pain with wors-
ening of pain with shoulder movements, resting pain, and
tenderness over the greater tubercle support the possibility
of this disorder. In addition, the CRP level can be increased
in severe cases.3,4
4. Adhesive capsulitis: This diagnosis is possible, however, it
usually develops more gradually.5 In addition, patients with
this disorder have limitations of motion in abduction and
external rotation.
5. Rotator cuff tear: This disorder can induce weakness in abduc-
tion and external rotation of shoulder muscles.6 In our patient,
the presence of weakness could not be exactly checked because
of severe pain. However, this disorder usually causes pain dur-
ing shoulder movement in a specific direction, but not at rest.
In addition, the CRP level is usually not elevated. Therefore,
in our patient, the possibility of this diagnosis is low.
6. Fracture or dislocation: The absence of a trauma history
makes this diagnosis significantly less likely.
7. Polymyalgia rheumatica: This disorder causes sudden onset
of severe shoulder pain and increased CRP level.7 However,
in most cases, bilateral shoulder joints are involved. There-
fore, it is highly unlikely that our patient had this disorder.
Overall, the most likely disorders are septic arthritis, gouty ar-
thritis, and calcific tendinitis, so imaging studies were performed.
Plain radiographs of the right shoulder in the anterior-posterior
view showed the largest calcific deposit, measuring 1.0  1.7 cm
above the greater tubercle of the right humerus (Fig. 1). On the axial
view of the plain radiograph, calcific deposits were located near the
superior and middle facets of the greater tubercle. Based on plain
radiography findings, we suspected calcific tendinitis of the
supraspinatus tendon.
For precise localization and identification of the extent of
the lesion, magnetic resonance imaging was obtained (Fig. 2).
All pulse sequences presented low-signal lobulated lesions
near the greater tubercle of the right humerus, which demon-
strated calcification. Magnetic resonance images revealed a
lobulated calcification in the supraspinatus tendon near the
greater tubercle (insertion area; Fig. 2). Lobulated tendon cal-
cifications that migrated into the subdeltoid bursa and in-
creased bursa effusion with surrounding soft tissue edema
were also observed. All these magnetic resonance imaging

FIGURE 2. Magnetic resonance imaging of the right shoulder. A, Axial gradient echo, (B) oblique coronal T1-weighted, and (C) oblique sagittal proton
density fat-saturated images showing calcification (arrows) in the supraspinatus tendon near the greater tubercle of the right humerus. Lobulated tendon
calcifications migrating into the subdeltoid bursa and increased bursal effusion with surrounding soft tissue edema can also be observed.

© 2021 Wolters Kluwer Health, Inc. All rights reserved. www.ajpmr.com e127

Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.

Choi et al.
findings demonstrated calcific tendinitis in the supraspinatus
tendon and migration of calcification into the bursa, inducing
calcific bursitis.
The primary diagnosis was calcific tendinitis at the right
supraspinatus tendon with calcific bursitis.
How would you manage calcific tendinitis with calcific
bursitis?
THERAPEUTIC INTERVENTION
Nonsteroidal anti-inflammatory drug (Melodex, Meloxicam
7.5 mg twice daily) was administered.
FOLLOW-UP AND OUTCOMES
The patient’s shoulder pain completely disappeared 2 days
after the initial oral medication. The oral medication was ad-
ministered for another 1 wk. At 1- and 2-mo follow-up after
the onset of severe shoulder pain, the patient reported that his
pain did not recur.
DISCUSSION
In clinical practice, when a patient presents with sudden
onset of unilateral shoulder pain with elevated CRP levels,
clinicians usually suspect septic arthritis. Septic arthritis is an
important differential diagnosis requiring urgent treatment be-
cause it can cause devastating complications in patients. Some
clinicians consider the possibility of gouty arthritis; however,
because of its rare development in the shoulder joint, it is con-
sidered less often than septic arthritis.8 Likewise, in our case,
the physician at the local hospital referred the patient to our
university hospital given the suspicion of septic arthritis.
C-reactive protein level is a widely used marker of inflam-
matory conditions, such as infection, rheumatoid arthritis, gout
attack, chronic inflammatory musculoskeletal diseases, and some
cardiovascular diseases.9 Especially in bacterial infection, the
CRP level is markedly elevated. In calcific tendinitis, although
the exact percentage of patients who show elevated CRP levels
has not been evaluated, some previous studies reported cases of
calcific tendinitis with highly elevated CRP levels.3,4
Calcific tendinitis results from calcium hydroxyapatite
crystal deposition in any tendon of the body. However, it most
e128 www.ajpmr.com
Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.
Volume 100, Number 9, September 2021
commonly occurs in rotator cuff tendons, and the incidence of
shoulder pain from calcific tendinitis is reported to be approx-
imately 7%.3 It becomes acutely symptomatic when calcium
hydroxyapatite crystals pass through the tendon into an adja-
cent bursa,4 producing an inflammatory response. Inflamma-
tion increases the CRP level and causes severe and disabling
pain, which mimics septic arthritis.3,4 Calcific tendinitis is usu-
ally a self-limiting condition and, in most cases, can be treated
with oral pain medications. If the pain is not well controlled
with oral medications, extracorporeal shock wave therapy,
subacromial steroid injection, ultrasound-guided percutaneous
lavage, and iontophoresis can be applied.10
CONCLUSIONS
When a patient develops acute atraumatic shoulder pain
that is present at rest and during movement, clinicians should con-
sider the possibility of calcific tendinitis. The elevation of CRP
levels can be a supportive finding for the diagnosis of calcific ten-
dinitis. In addition, before confirming the diagnosis, differential
diagnosis should be conducted; septic arthritis and gouty arthritis
should be ruled out with imaging studies including radiography,
magnetic resonance imaging, or ultrasonography.
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