Author: Kana Maeji, DO
Co Author #1: Justin Mark J Young, MD
Senior Editor: Mandeep Ghuman, MD, FAMSSM
Editor: Elizabeth Rothe, MD

Patient Presentation:
21-year-old right-handed female college tennis player with medical history significant for lumbosacral (L5-S1) spondylolisthesis presented with acute right shoulder pain and loss of range of motion.

History:
The pain began during a tennis tournament but she denied trauma or injury. She recalled a mild upper respiratory infection at that time. She subsequently developed slow-onset pain, swelling, and stiffness of her right index finger and right ankle. She failed conservative management with oral NSAIDs, topical NSAIDs, icing, physical therapy, and cupping. She was evaluated by an orthopedic hand surgeon and received a cortisone injection in her right index finger for presumed trigger finger, but this provided only mild relief. One month later she presented to the emergency room due to worsening joint pain and swelling and was prescribed antibiotics for presumed cellulitis of her right index finger. The symptoms persisted and she was no longer able to participate in tennis.

Physical Exam:
Physical exam revealed normal vital signs. Lungs were clear to auscultation bilaterally. Cardiac exam demonstrated regular rate and rhythm. Skin examination was significant for erythema of the right index finger and right ankle, but there were no other lesions or rashes.

Musculoskeletal exam: Patient had tenderness to palpation of right anterior shoulder, biceps insertion, and acromioclavicular joint. Range of motion of the right shoulder joint was limited. Special Tests of Right shoulder included a positive Painful Arc test, positive O'Briens test, positive Hawkins test, and positive Neer test.
Examination of the right index finger Case Photo #1 revealed edema, erythema, and tenderness to palpation of right second distal interphalangeal joint, proximal interphalangeal joint and metacarpophalangeal joint with slight contracture. Range of motion of the right index finger was limited.

Examination of the right ankle revealed swelling of her medial malleolus with tenderness over the distribution of the posterior tibialis tendon, as well as non-tender swelling over the lateral malleolus that tracked posteriorly to Achilles tendon with slight tenderness to palpation. ROM of the ankle was normal and symmetrical.

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