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Anterior-posterior x-ray of the patient’s shoulder
A 33-year-old man presents with pain in his left shoulder of 3 weeks’ duration. He denies injuring the shoulder and admits that the pain worsens with physical activity. He is employed as a security guard and works out daily at the gym. The patient says that the pain is particularly noticeable when he performs bench presses. On physical examination, he has full passive and active range of motion of the left shoulder. He has a negative Neer’s sign and O’Brien’s test. The patient has increased pain with horizontal adduction of the left arm. X-rays were taken.
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Distal clavicle osteolysis is strongly associated with male weight trainers. Osteolysis is thought to be caused by the effects of repetitive use, leading to microfracture of the subchondral bone. If weight lifters work out frequently without resting their shoulders, which would heal the microfractures, the bone of the acromioclavicular (AC) joint will begin to break down, causing pain. The patient’s anterior-posterior shoulder x-ray shows classic findings of subchondral bone loss, slight enlargement of the distal clavicle, and widening of the AC joint.
Patients with distal clavicle osteolysis present with pain over the AC joint that is made worse with horizontal adduction. Common x-ray findings may also include osteopenia and cyst formation of the distal clavicle. The acromial region typically shows no changes on x-ray, which helps differentiate osteolysis from AC joint arthritis.
First-line treatment for distal clavicle osteolysis includes ice, nonsteroidal anti-inflammatory drugs, and modification of the patient’s workout routine. Patients should be instructed to keep their arms further apart while doing push-ups or bench presses and to avoid dips, flies, and other lifts that elicit pain. Many patients who are unwilling to modify their workout routine will have continued pain. A corticosteroid injection to the AC joint is the next-line treatment. A steroid injection also helps confirm the diagnosis, provided the patient experiences pain relief afterwards.
An arthroscopic distal clavicle excision, also known as a Mumford procedure, is indicated in patients with persistent symptoms despite conservative treatment. During the procedure, approximately 0.5 cm to 1 cm of the distal clavicle is removed. Weight lifters can expect a return to full activities without pain approximately 6 to 8 weeks after the procedure.
The patient in this case has a negative Neer’s sign, which likely rules out subacromial impingement, a negative O’Brien’s test, which likely rules out a labral tear, and full passive range of motion, which rules out adhesive capsulitis.
Dagan Cloutier, MPAS, PA-C, practices in a multispecialty orthopedic group in the southern New Hampshire region and is editor in chief of the Journal of Orthopedics for Physician Assistants (JOPA).
References
- Schwarzkopf R, Ishak C, Elman M, Gelber J, Strauss DN, Jazrawi LM. Distal clavicular osteolysis: a review of the literature. Bull NYU Hosp Jt Dis. 2008;66(2):94-101.
- Cadet E, Ahmad CS, Levine WN. The management of acromioclavicular joint osteoarthrosis: debride, resect, or leave it alone. Instr Course Lect. 2006;55:75-83.
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