(Kiosk 2) Shoulder Pain Due to Undiagnosed Bony Metastasis

Case Diagnosis: 75 year-old female, non-smoker, with past medical history significant for hyperlipidemia and hypothyroidism who presented for chronic left shoulder pain found to have sclerotic metastases of the left scapula secondary to adenocarcinoma of the right lung.

Case Description or Program Description: The patient presented with chronic left shoulder pain with no inciting injury. She had previously tried physical therapy, steroid injections, arthroscopic biceps tenodesis, and manipulation under anesthesia all with only temporary relief. Pain was localized to the lateral shoulder with associated numbness and tingling down to her fingers. Physical exam revealed tenderness to palpation over the anterolateral cuff with limited active and passive range of motion, as well as 4/5 abduction and external/internal rotation strength.

Setting: Outpatient musculoskeletal and sports medicine clinic.

Assessment/Results: Left shoulder x-ray revealed diffuse sclerosis of the scapula with lobulated contour, concerning for primary versus metastatic neoplasm. Of note, this was not noted on review of MRI from 1 year prior.

Subsequent CT scans revealed a spiculated 2.5 centimeter lesion in the right upper lung lobe and right pleural effusion. Further testing revealed a diagnosis of primary lung adenocarcinoma with widespread metastases including the left periscapular region.

Discussion (relevance): A fresh evaluation with appropriate imaging is always important in those with unremitting pain despite multiple previous treatments. This case serves to remind us that that isolated shoulder pain can be the first symptom related to malignancy, as bone pain is present in 25% of patients at initial presentation, and 35–60% of disease courses. Timely workup remains of great importance, as median survival from diagnosis of bone metastases has been reported as 6–7 months in patients with lung cancer.

Conclusions: A broad differential diagnosis should be maintained when presented with chronic musculoskeletal pain, as bony metastasis always remains a possibility. Early detection can lead to earlier treatment and thus improved outcomes.