A woman in her late 50s with no significant comorbidities presented with constant dull aching pain in her right arm for over a few years without any shoulder pain or restrictions in arm movement. She had mild symptomatic improvement in pain with non-steroidal anti-inflammatory medications. Clinically, she was found to have tenderness along the right deltoid region. Plain radiograph of the right shoulder and humerus (figure 1) showed cortical thickening, and trabecular coarsening throughout the right humerus and proximal shaft, suspicious of metastatic/metabolic disease. Blood biochemistry showed elevated alkaline phosphatase 280 U/L (45–117 U/L) with bone-specific alkaline phosphatase being 76% (14%–68%). Rest of the laboratory work-up was unremarkable with complete blood count, liver function tests and renal function tests within normal range. A radionuclide whole-body scan with 21.8 mCi technetium 99m hydroxydiphosphonate (figure 2) showed increased radiotracer activity in the right humerus consistent with Paget's disease. Patient was treated with a single dose of 5 mg intravenous zoledronic acid. At the 6-month follow-up, she continued to have dull ache in her arm. However, bone-specific alkaline phosphatase levels and whole-body scan remained stable.