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Rheumatology 2006 45(12):1533; doi:10.1093/rheumatology/kel188
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© The Author 2006. Published by Oxford University Press on behalf of the British Society for Rheumatology. All rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.org

Chronic shoulder pain and diaphragmatic endometriosis

J. E. Freeston1, M. J. Green2, D. G. King3 and J. M. I. Iveson2

1Specialist Registrar, Academic Unit of Musculoskeletal Disease, Chapel Allesten Hospital, Leeds L57 4SA, 2Consultant Rheumatologist, and 3Consultant Muscoloskeletal Radiologist, York District Hospital, Wigginton Road, York Y031 8HE, UK

Correspondence to: J. E. Freeston. E-mail: medjef{at}leeds.ac.uk

A 25-yr-old Caucasian woman was referred by her GP with a 3 yr history of right shoulder pain. The shoulder pain frequently occurred at the start of menses and was responsive to ibuprofen. Clinical examination, shoulder radiographs and blood tests (CRP, rheumatoid factor) were all normal.

The MRI of the shoulder and right hemi-diaphragm showed small areas of high signal on T1, T2 and STIR sequences at the lateral right hemi-diaphragm, consistent with areas of recent haemorrhage, suggestive of ectopic endometrial tissue (Fig. 1). Positive identification and ablation of the endometrial tissue by laparoscopy was thought to be a low-yield procedure so the patient commenced the continuous progestogen—only pill which caused amenorrhoea and resolution of her symptoms.


Figure 1
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  		FIG. 1. A Coronal T1 SE MR image showing a small area of high signal at the right hemi-diaphragm, consistent with endometriosis (see arrow).

 
Endometriosis affects women predominantly aged 25–35 yrs, most commonly causing pelvic disease (ovaries, peritoneum) whilst extra-pelvic endometrial deposits (diaphragm, umbilicus) are rare. When present, diaphragmatic endometriosis can be associated with chest pain, right upper quadrant pain and chronic shoulder tip pain [1, 2]. The pain is referred from the hormonally influenced endometrial tissue located on the diaphragm, due to the common innervation of C5 and is an important differential in young women with shoulder tip pain but without clinical findings.

The patient provided written consent according to the Declaration of Helsinki.

The authors have declared no conflicts of interest.

References

  1. Cooper MJ, Russell P, Gallagher PJ. (1999) Diaphragmatic endometriosis Med J Aust 171:142–3.
  2. Basama FM. (2004) Widespread intraperitoneal and diaphragmatic endometriosis presenting with frequent bowel motions and chronic shoulder tip pain. J Obstet Gynaecol 24:931–2.[Medline]

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This Article
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