High Yield Topics

Distal Clavicular Osteolysis

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Ovid: 5-Minute Sports Medicine Consult, The


Distal Clavicular Osteolysis
Ryan C. Fowler
Keith A. Stuessi
Basics
Description
  • A loss of subchondral bone detail with osteoporosis, cystic changes, osteolysis, and osteophyte formation of the distal clavicle while sparing the acromion
  • Most commonly associated with atraumatic mechanism but can be trauma-related
Epidemiology
Incidence
  • True incidence of distal clavicular osteolysis (DCO) is unknown.
  • Associated with repetitive heavy lifting and occasionally as a result of trauma
  • Rare reports of idiopathic cases (1)
Risk Factors
  • Any activity putting excessive repetitive force on the acromioclavicular (AC) joint may increase risk.
  • Weight lifting appears to be a significant risk factor in nontraumatic cases (2,3).
  • Occasionally will result from blunt trauma to the shoulder
  • Traumatic injuries include AC joint dislocation and separation, as well as clavicle fractures.
General Prevention
  • Atraumatic causes are potentially prevented by limiting repetitive lifting, but no studies address this issue.
  • Athletes generally are reluctant to decrease training.
Etiology
  • Although the specific pathophysiologic cause has not been determined, atraumatic osteolysis is thought to start as a stress fracture of the distal clavicle from repetitive microtrauma (2,4).
  • Common MRI findings include bone edema and evidence of subchondral injury (2,4).
  • The pathophysiologic process in traumatic injuries is unknown.
Diagnosis
History
  • Insidious onset of aching in the AC joint
  • Athletes may have a history of remote trauma.
  • Activities placing repetitive stress to the joint may increase the risk.
  • In weight lifters, bench press, military press, shoulder shrugs, pushups, and clean-and-jerk may cause pain.
Physical Exam
  • Signs and symptoms:
    • Patient complains of a dull ache over the AC joint.
    • Mild swelling of the joint may be present.
    • Pain usually is worse at the beginning of the exercise period.
    • Any movement of the arm requiring 90 degrees or more of abduction causes pain.
    • Pain can radiate to the adjacent superior trapezius border and deltoid muscles.
  • Physical examination:
    • Tenderness over the AC joint
    • Positive cross-arm test: Forward flexion to 90 degrees and adduction of the arm cause pain. This compresses the AC joint.
    • Paxinos test: Arm at side resting against chest and hand over top of shoulder; thumb on acromion and fingers on clavicle and compressing them together; pain is a positive test.
    • Sometimes a trapezius spasm will be palpated.
    • Because it is common to have other shoulder pathology in conjunction with DCO, a local anesthetic injection to the AC joint can be helpful in achieving an accurate diagnosis (2)[C].
Diagnostic Tests & Interpretation
Imaging
  • Clavicular or Zanca view: 10 degrees of cephalic tilt; distal clavicular end will appear frayed; will see bony osteolysis, cystic changes, and translucency of the bone. Bilateral Zanca views are helpful in comparing the involved and uninvolved sides.
  • Technetium bone scan can be helpful as an additional test.
  • MRI can be used to rule out other pathology and often shows bone edema in the distal clavicle (4)[C].
Diagnostic Procedures/Surgery
Diagnostic injection into the AC joint with local anesthetic can be helpful in differentiating the cause of pain (2,5)[C].
Differential Diagnosis
  • AC joint trauma, osteoarthritis
  • Other shoulder pathology should be considered (eg, instability, impingement, rotator cuff tears, tendinitis, and labral disease).
  • Also includes hyperparathyroidism, rheumatoid arthritis, multiple myeloma, scleroderma, infection (septic arthritis, tuberculosis), rickets, eosinophilic granuloma, and other, more rare diseases including cleidocranial dysplasia, progeria, and pycnodysostosis.

P.131


Treatment
  • Acute treatment:
    • NSAIDs or other pain medications can be used as needed (2,5)[C].
    • Cessation of activity is often very effective in reducing pain (2,5)[C].
    • Therapeutic corticosteroid injection to the AC joint is often effective at reducing painful symptoms (2,5)[C].
    • Other symptomatic treatment such as ice can be helpful (2,5)[C].
  • Long-term treatment:
    • Activity modification (2,5)[C]
    • Often difficult in athletes
    • Activity modification by weight lifters should include decreased weight with increased repetitions or substitution of exercises.
    • Physical therapy should be instituted if there is evidence of other shoulder pathology. Rehabilitation also should include range-of-motion (ROM) therapy and strengthening exercises for the rotator cuff and scapulothoracic stabilizer muscles (5)[C].
    • Surgical resection may be considered for those not responding to conservative therapy.
Surgery/Other Procedures
  • Surgery is recommended for those who fail conservative treatment (2,5)[C].
  • Surgery may be performed open or arthroscopic.
  • Arthroscopic surgery involves less tissue dissection and faster rehabilitation times (2)[C].
  • Arthroscopic surgery can be completed directly through the AC joint or indirectly through the subacromial space. The direct approach allows faster return to activity (21 vs 42 days) (6)[B].
Ongoing Care
Follow-Up Recommendations
  • Referral to an orthopedic surgeon for failure of conservative treatment
  • Postoperative physical therapy:
    • Active ROM as tolerated
    • Shoulder strengthening
    • Return to sports as soon as symptoms allow; time frame depends on surgical approach.
References
1. Hawkins BJ, Covey DC, Thiel BG. Distal clavicle osteolysis unrelated to trauma, overuse, or metabolic disease. Clin Orthop Relat Res. 2000;370:208–211.
2. Schwarzkopf R, Ishak C, Elman M, et al. Distal clavicular osteolysis—a review of the literature. Bull NYU Hosp Jt Dis. 2008;66:94–101.
3. Scavenius M, Iversen BF. Nontraumatic clavicular osteolysis in weight lifters. Am J Sports Med. 1992;20:463–467.
4. Kassarjian A, Llopis E, Palmer WE. Distal clavicular osteolysis: MR evidence for subchondral fracture. Skeletal Radiol. 2006.
5. Rios CG, et al. Acromioclavicular joint problems in athletes and new methods of management. Clin Sports Med. 2008;27:763.
6. Charron KM, Schepsis AA, Voloshin I. Arthroscopic distal clavicle resection in athletes: a prospective comparison of the direct and indirect approach. Am J Sports Med. 2006.
Codes
ICD9
No specific ICD-9 code
  • 716.91 Shoulder arthritis
  • 810.03 Closed fracture of acromial end of clavicle
  • 840.9 Shoulder sprain
Clinical Pearls
  • Can resolve without surgery, but only a minority of cases produce satisfactory results, particularly when the athlete does not stop training long enough for the AC joint to heal.
  • Athletes can return to their former level of competition after surgical resection.


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