Working Diagnosis:
Right shoulder rotator cuff and proximal biceps tendon tear secondary to rheumatoid arthritis

Treatment:
Given complete disruption of the long head of the biceps tendon and partial thickness tear of supraspinatus at the critical zone noted on right shoulder MRI, this patient was referred to orthopedic surgery for surgical evaluation. Ultimately, she underwent synovectomy, subacromial decompression, and rotator cuff repair. Additionally, the rheumatologic workup confirmed
inflammatory markers concerning for rheumatoid arthritis and she was recommended to establish
care with rheumatology for further work-up and treatment.

Outcome:
The patient completed right shoulder physical therapy post-operatively and reported improved strength and mobility. She was followed by a rheumatologist. She subsequently developed morning stiffness in bilateral knees and polyarthralgias including her left elbow and left shoulder.
She was started on immunosuppressive therapy with continued rheumatology follow-up.

Author's Comments:
Rheumatoid arthritis is an autoimmune inflammatory disease afflicting approximately 5 in 1000
people around the world.(1) In fact, women are affected 2-3 times more often than men. Generally,
rheumatoid arthritis is a polyarticular disease that initially presents as pain and swelling of the
metacarpophalangeal, metatarsophalangeal, and proximal interphalangeal, joints. People may
develop tenosynovitis prior to the classic rheumatoid arthritic joint symptoms. Rheumatoid arthritis
can be detrimental to activities of daily life and quality of life - similar or worse quality of life than
those suffering from cardiovascular disease or diabetes mellitus.(2)(3) In 2021, Ishida et al.
emphasized the rarity and difficulty of diagnosing rheumatoid arthritis with onset of shoulder
monoarthritis (only 2 of 113 subjects).(4) This study also showed that people presenting with a large
joint monoarthritis may not necessarily meet the criteria for rheumatoid arthritis diagnosis using the
2010 American College of Rheumatology/European League Against Rheumatism (2010
ACR/EULAR) criteria. This uncommon presentation of RA, with most cases causing polyarthralgias
of small joints earlier in the disease process, highlights the importance of creating a broad differential
diagnosis for younger patients presenting with insidious onset of monoarticular large joint pain.

Editor's Comments:
This patient is an example of unusual presentation of a young patient presenting with rheumatoid arthritis in a single large joint with atypical symptoms in conjunction with very common mixed mechanical shoulder pain.

Given that the workup for RA likely took place after MRI interpretation, it raises that question regarding timing of surgery vs treatment of RA. It is difficult to determine how much of the patient's symptoms were from synovitis vs the tear. Consideration could have been given to treating the patients RA to see how much clinical improvement occurred prior to proceeding with surgery.

References:
1, . Aletaha D and Smolen J. Diagnosis and management of rheumatoid arthritis: a review.
JAMA. 2018;320(13): 1360-1372. Web.
2. Radner H, Smolen JS, Aletaha D. Comorbidity affects all domains of physical function and
quality of life in patients with rheumatoid arthritis. Rheumatology (Oxford). 2011;50(2):
381-388. Web.
3. Matcham F, Scott IC, Rayner L, et al. The impact of rheumatoid arthritis on quality-of-life
assessed using the SF-36: a systematic review and meta-analysis. Semin Arthritis Rheum.
2014;44(2): 123-130. Web.
4. Ishida K, Nagira K, et al. Rheumatoid arthritis onset from shoulder monoarthritis. Open
Access Rheumatology: Research and Reviews. 2021;13: 103-109. Web.

Return To The Case Studies List.