Milwaukee shoulder syndrome (MSS) is a rare destructive, calcium phosphate crystalline arthropathy. It encompasses an effusion that is noninflammatory with numerous aggregates of calcium hydroxyapatite crystals in the synovial fluid, associated with rotator cuff defects. We describe a patient that presented with recurrent shoulder pain and swelling with characteristic radiographic changes and MSS was confirmed on aspiration of the synovial fluid. 1. Case An 89-year-old lady presented to the medical assessment unit with a four-day history of melaena associated with shortness of breath on exertion, postural dizziness, and lethargy. This was secondary to esophagitis and gastric erosions. During her hospital stay she developed a rapid onset, painful swelling of her right shoulder with a limited range of movement. There was no history of recent trauma to the right shoulder. This was her third presentation; previous ones had been followed up by her general practitioner. Past medical history included well-controlled asthma, hypertension, and atrial fibrillation. There was no history of diabetes, hyperparathyroidism, or syphilis. She was an ex-smoker with a 10-pack-year history and consumed minimal amounts of alcohol only. On examination, she was pale, with no rashes or bruises. There was a large right shoulder effusion. Both active and passive movements were limited. Figure 1 shows the patient’s large right shoulder swelling which was warm to touch and tender with no erythema. Figure 1: Submission remains copyrighted by the Ipswich Hospital NHS trust as per trust policy—we have permission from the patient and also from the trust to publish. Plain radiograph of the affected shoulder showed joint space narrowing, subchondral sclerosis, destruction of subchondral bone, soft-tissue swelling, capsular calcifications, and intra-articular loose bodies (Figure 2). Figure 2: Submission remains copyrighted by the Ipswich Hospital NHS trust as per trust policy—we have permission from the patient and also from the trust to publish. Arthrocentesis was performed and 250？mLs of haemorrhagic fluid was aspirated. Analysis of the synovial fluid showed a noninflammatory cell count with leukocytes 721/mm3 which were predominantly neutrophils. Gram stain was negative; no organisms were cultured and cytology analysis was negative, as was VDRL on the synovial fluid. The aspirate stained bright orange-red with alizarin red S, indicating the presence of calcium hydroxyapatite crystals. The diagnosis of Milwaukee shoulder syndrome was made and she was treated conservatively with
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