eMedicine Specialties > Orthopedic Surgery > Shoulder

Distal Clavicle Osteolysis

Author: Brett D Owens, MD, Chief, Sports Medicine and Shoulder Service, William Beaumont Army Medical Center
Coauthor(s): Robert Q Terrill, MD, Assistant Professor, Department of Orthopedic Surgery, University of Massachusetts Medical Center; Anthony Schena, MD, Consulting Surgeon, ProSports Orthopedics; Associate Professor, Department of Orthopedics, Tufts Medical School
Contributor Information and Disclosures

Updated: Mar 19, 2009

Introduction

History of the Procedure

Distal clavicle osteolysis (see images below) was first described in 1936 as a condition secondary to acute shoulder trauma. Today, distal clavicle osteolysis is described as a sequela of trauma associated with contact sports, falls, and motor vehicle accidents.

An anteroposterior radiograph of a 26-year-old ma...

An anteroposterior radiograph of a 26-year-old male weight lifter with symptomatic distal clavicle osteolysis that responded to conservative measures.

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An anteroposterior radiograph of a 26-year-old ma...

An anteroposterior radiograph of a 26-year-old male weight lifter with symptomatic distal clavicle osteolysis that responded to conservative measures.


Left distal clavicle excision for distal clavicle...

Left distal clavicle excision for distal clavicle osteolysis performed with a bone-cutting shaver placed in the anterior portal as viewed from the direct posterior-superior portal.

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Left distal clavicle excision for distal clavicle...

Left distal clavicle excision for distal clavicle osteolysis performed with a bone-cutting shaver placed in the anterior portal as viewed from the direct posterior-superior portal.


In 1959, this condition was reported in an air-hammer operator without evidence of acute trauma. In 1982, Cahill reported on 45 male athletes with distal clavicle osteolysis, confirming repetitive microtrauma as an etiology.1 Forty-four of Cahill's patients were weight lifters.

Problem

Distal clavicle osteolysis is a pathologic process involving resorption of subchondral bone in the distal clavicle. The condition usually presents as pain localized to the acromioclavicular (AC) joint.2

Frequency

Though more than 100 cases have been reported in the US literature, distal clavicle osteolysis may be an underdiagnosed disorder. The incidence has increased with the growth in popularity of weight training in the past 20 years.3 As more women are participating in competitive and recreational weight lifting and sports that involve overhead throwing, more women are presenting with cases of distal clavicle osteolysis.4

Etiology

Different theories concerning the etiology of distal clavicle osteolysis have emerged:

  • The first theory proposed an autonomic neurovascular origin, as 1 author noted the presence of ipsilateral anisocoria in 4 out of 8 patients.
  • A theory set forth in another report proposed synovial invasion of the subchondral bone.
  • Cahill noted the presence of microfractures in the subchondral bone in 50% of his cases, and proposed that repetitive microtrauma caused subchondral stress fractures and remodeling.1 Cahill's theory is currently the most accepted one.

Pathophysiology

There is 1 case report of hypertrophic synovial tissue that migrated across the articular cartilage and invaded subchondral bone, but most specimens show disruption of articular cartilage, subchondral cyst formation, and evidence of increased osteoclastic activity.5

Presentation

Most patients present with pain over the distal end of the clavicle and AC joint that usually is described as a dull ache. Patients with an etiology of trauma report a specific event as the start of their symptoms. In patients with repetitive/overuse injuries, pain is exacerbated by athletic or work activity. Weight lifters report most symptoms occurring with the bench press and related exercises.6

Upon physical examination, patients have point tenderness over the affected AC joint, and cross-chest maneuvers elicit pain. Usually, the AC joint is not unstable; however, crepitation may be present. Range of motion (ROM) of the glenohumeral joint should be full.

The differential diagnosis must include metabolic (hyperparathyroidism), autoimmune (rheumatoid arthritis), and neoplastic (multiple myeloma) etiologies. As distal clavicle osteolysis is usually a unilateral condition, inflammatory disease should be considered in bilateral cases.

Indications

Patients in whom conservative treatment fails or who refuse to limit their activities are candidates for surgical treatment.

Relevant Anatomy

The acromioclavicular (AC) joint is a diarthrodial joint. The capsule of the AC joint is reinforced by the superior and inferior AC ligaments, with additional stability provided by the coracoclavicular ligaments. A fibrocartilaginous disk is present between the convex distal clavicle and the flat acromion, both of which are covered by hyaline cartilage.

Contraindications

The only contraindications noted are those general to surgery. Most surgical approaches are best performed with general anesthesia; therefore, patients with risks associated with general anesthesia should continue with nonoperative therapy.

More on Distal Clavicle Osteolysis

Overview: Distal Clavicle Osteolysis
Workup: Distal Clavicle Osteolysis
Treatment: Distal Clavicle Osteolysis
Follow-up: Distal Clavicle Osteolysis
Multimedia: Distal Clavicle Osteolysis
References
Further Reading
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References

  1. Cahill BR. Osteolysis of the distal part of the clavicle in male athletes. J Bone Joint Surg Am. Sep 1982;64(7):1053-8. [Medline].

  2. 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. [Medline].

  3. Scavenius M, Iversen BF. Nontraumatic clavicular osteolysis in weight lifters. Am J Sports Med. Jul-Aug 1992;20(4):463-7. [Medline].

  4. Matthews LS, Simonson BG, Wolock BS. Osteolysis of the distal clavicle in a female body builder. A case report. Am J Sports Med. Jan-Feb 1993;21(1):150-2. [Medline].

  5. Brunet ME, Reynolds MC, Cook SD. Atraumatic osteolysis of the distal clavicle: histologic evidence of synovial pathogenesis. A case report. Orthopedics. Apr 1986;9(4):557-9. [Medline].

  6. Tao HM, Chen J, Ji YY. Post-traumatic osteolysis of the distal clavicle, pubis and ischium in 7 patients. Chin J Traumatol. Aug 2004;7(4):247-52. [Medline].

  7. Kassarjian A, Llopis E, Palmer WE. Distal clavicular osteolysis: MR evidence for subchondral fracture. Skeletal Radiol. Jan 2007;36(1):17-22. [Medline].

  8. Shaffer BS. Painful conditions of the acromioclavicular joint. J Am Acad Orthop Surg. May-Jun 1999;7(3):176-88. [Medline].

  9. Flatow EL, Cordasco FA, Bigliani LU. Arthroscopic resection of the outer end of the clavicle from a superior approach: a critical, quantitative, radiographic assessment of bone removal. Arthroscopy. 1992;8(1):55-64. [Medline].

  10. Flatow EL, Duralde XA, Nicholson GP. Arthroscopic resection of the distal clavicle with a superior approach. J Shoulder Elbow Surg. Jan-Feb 1995;4(1 Pt 1):41-50. [Medline].

  11. Auge WK, Fischer RA. Arthroscopic distal clavicle resection for isolated atraumatic osteolysis in weight lifters. Am J Sports Med. Mar-Apr 1998;26(2):189-92. [Medline].

  12. Freedman BA, Javernick MA, O'Brien FP, Ross AE, Doukas WC. Arthroscopic versus open distal clavicle excision: comparative results at six months and one year from a randomized, prospective clinical trial. J Shoulder Elbow Surg. Jul-Aug 2007;16(4):413-8. [Medline].

  13. Nuber GW, Bowen MK. Arthroscopic treatment of acromioclavicular joint injuries and results. Clin Sports Med. Apr 2003;22(2):301-17. [Medline].

  14. Zawadsky M, Marra G, Wiater JM. Osteolysis of the distal clavicle: long-term results of arthroscopic resection. Arthroscopy. Sep 2000;16(6):600-5. [Medline].

  15. Rabalais RD, McCarty E. Surgical treatment of symptomatic acromioclavicular joint problems: a systematic review. Clin Orthop Relat Res. Feb 2007;455:30-7. [Medline].

  16. 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. Jan 2007;35(1):53-8. [Medline].

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Keywords

clavicle osteolysis, shoulder pain, overuse injury, shoulder trauma, shoulder microtrauma, chronic shoulder pain, collarbone pain, broken collarbone, collar bone microtrauma, clavicle fracture

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Contributor Information and Disclosures

Author

Brett D Owens, MD, Chief, Sports Medicine and Shoulder Service, William Beaumont Army Medical Center
Brett D Owens, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, and Society of Military Orthopaedic Surgeons
Disclosure: Nothing to disclose.

Coauthor(s)

Robert Q Terrill, MD, Assistant Professor, Department of Orthopedic Surgery, University of Massachusetts Medical Center
Robert Q Terrill, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Orthopaedic Surgeons, American Society for Surgery of the Hand, and Massachusetts Medical Society
Disclosure: Nothing to disclose.

Anthony Schena, MD, Consulting Surgeon, ProSports Orthopedics; Associate Professor, Department of Orthopedics, Tufts Medical School
Anthony Schena, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons and Arthroscopy Association of North America
Disclosure: genzyme Honoraria Speaking and teaching

Medical Editor

Cato T Laurencin, MD, PhD, Van Dusen Chair Professor of Academic Medicine, Distinguished Professor of Orthopaedic Surgery, and Chemical, Materials, and Biomolecular Engineering, University of Connecticut
Cato T Laurencin, MD, PhD is a member of the following medical societies: American Academy of Orthopaedic Surgeons
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Pekka A Mooar, MD, Professor, Department of Orthopedic Surgery, Temple University School of Medicine
Pekka A Mooar, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons
Disclosure: Nothing to disclose.

CME Editor

Dinesh Patel, MD, FACS, Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital
Dinesh Patel, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association of Physicians of Indian Origin, American College of International Physicians, and American College of Surgeons
Disclosure: Nothing to disclose.

Chief Editor

Mary Ann E Keenan, MD, Professor, Vice Chair for Graduate Medical Education, Department of Orthopedic Surgery, University of Pennsylvania School of Medicine; Chief of Neuro-Orthopedics Program, Department of Orthopedic Surgery, Hospital of the University of Pennsylvania
Mary Ann E Keenan, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Orthopaedic Foot and Ankle Society, American Society for Surgery of the Hand, and Orthopaedic Rehabilitation Association
Disclosure: Nothing to disclose.

 
 
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