A 58-year-old female patient with severe right shoulder pain

SECTION 1 – QUIZ Case description A 58-year-old woman presented to her primary care physician complaining of severe right shoulder pain. The pain had been ongoing for several months but had become severe over the past 2 weeks. She described the pain as “a stabbing pain,” which was mostly present on the lateral aspect of the shoulder and aggravated by lifting and overhead activities. The patient denied any history of trauma, fever, or chills. She is a homemaker and remains active but has not engaged in recent activities. She also stated that over-the-counter topical analgesics and oral nonsteroidal anti-inflammatory medications only partially relieved the pain. She had no pertinent medical or surgical history. On physical examination, there were limited abduction and internal rotation of the shoulder. There was no significant joint swelling or any discoloration of the over skin. There was no palpable mass, and the physical examination was otherwise unremarkable. The patient was referred to radiology for musculoskeletal ultrasound and radiographs of the shoulder to further evaluate. A radiograph of the right shoulder was obtained [Figure 1]. Sonographic imaging of the right shoulder demonstrated heterogeneity and enlargement of the supraspinatus tendon with an ill-defined bursal surface [Figure 2].Figure 1: Anteroposterior (Grashey) radiograph of the right shoulderFigure 2: Ultrasound images of the right shoulder. (a) Long-axis (LAX) and (b) short-axis (SAX) sonographic images of the same right shoulder, demonstrating heterogeneity and enlargement of the supraspinatus (SUPRA) tendon (open stars) with an ill-defined bursal surface (open arrows). The arrowhead points to the greater tuberosity of the proximal humerus, and MOD indicates modified (Crass position)WHAT IS THE DIAGNOSIS? Ethical statement Informed consent and protocol review were exempt per our Institutional Review Board policies for this type of study and since these examinations were clinically indicated. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.