|
|
|
|
|
|
 |
 |
 |
|
 |
|
 |
|
 |
|
 |
|
 |
|
|
CASE OF THE MONTHDiagnostic challenges from your case files
Capt Patrick L. Gray, USAF, BSC, MPACCaptain Gray is the senior physician assistant assigned to the 75th Medical Operations Squadron at Hill Air Force Base, Utah.CASEMr. M. is a 42-year-old black man who presented to the family practice clinic with about 10 weeks of right shoulder pain that he described as a dull ache in the front of the shoulder. The pain did not keep him up at night, but he had trouble sleeping on his right side. The pain was always present but became worse when he reached for things directly in front of him or lifted weights. The pain did not radiate. He denied any specific trauma to the shoulder or any numbness or tingling in the distal upper extremity. Shortly after the pain began, he started taking 800 mg of ibuprofen three times a day with very minimal relief. He was still taking this medication when he came to the clinic for evaluation. History Two weeks previously, Mr. M. was given a diagnosis of impingement syndrome, along with an injection of 40 mg of triamcinolone and 3 cc of 2% lidocaine into the right acromioclavicular (AC) joint. He reported immediate relief of the pain, but the relief lasted only 2 days. Mr. M. has a history of alcoholism but has been sober for 13 months. After he stopped drinking, he began a very intense workout routine at a local gym. He originally carried 120 lb on a 6-ft frame but is now a fit 165 lb with very defined musculature. Exam On physical examination, the right shoulder appeared similar to the left shoulder, with no redness, swelling, ecchymosis, muscle wasting, or asymmetry. There was a full active and passive range of motion, with tenderness during cross-body adduction. No tenderness to movement against resistance was noted except in cross-body adduction. The AC joint was tender to palpation. No bony tenderness, obvious bony abnormalities, or crepitus was noted. The patient did not demonstrate any apprehension of recurrent dislocation. Special testing was not extensive. Apley's scratch test in both internal and external rotation was normal. There was no anterior or posterior instability or laxity of the joint, nor any winging of the scapula. A plain radiograph was obtained (see Figure 1).
What is your diagnosis?
DISCUSSIONMr. M. has atraumatic osteolysis of the distal clavicle. The plain film showed no arthritis or AC joint dislocation, no fractures, and no soft-tissue swelling. Loss of the subchondral bone detail was visible in the distal aspect of the clavicle, and resorption appeared to be occurring, resulting in an apparent widening of the AC joint. The diagnosis was suggested by the history and confirmed by the radiographic findings. Treatment Mr. M. was referred to an orthopedic surgeon, who felt that the patient's failure to respond to the NSAID or the corticosteroid injection indicated that he would probably not respond to conservative or nonsurgical treatment. The surgeon performed an arthroscopic resection of the distal clavicle. On the second postoperative day, simple physical therapy (passive range of motion and pendulum exercises) was started, and active range of motion was started in the first postoperative week. The patient quickly progressed to light work schedules within 10 days and was back to a full workload with minimal restrictions on lifting within 3 weeks. He was evaluated by the orthopedic surgeon at 5 weeks postoperatively and released to full duty with no restrictions. On a follow-up visit to the clinic, Mr. M. reported that he is back in the gym and feels great. Comment Osteolysis of the distal clavicle is a pathologic process involving resorption of the distal clavicle. It usually occurs after trauma, but atraumatic osteolysis can be caused by the repetitive microtrauma of weight lifting.1 The diagnosis is made primarily by history and physical examination, and repeated mechanical microtrauma is key. Pain localized to the AC joint and radiographs or bone scans showing pathology in the distal clavicle are diagnostic.2 The condition is most likely self-limiting and will resolve within 1 to 2 years if activity is restricted or modified. Medical therapy includes NSAIDs; corticosteroid injections are often used but usually provide little long-term benefit. While the outcome of conservative treatment is good, most patients cannot or will not limit their activities over a long period. Surgical treatment is well tolerated and can involve an open or arthroscopic technique; the latter provides a quicker return to full activity and a better cosmetic outcome. REFERENCES 1. Scavenius M, Iversen BF. Nontraumatic clavicular osteolysis in weight lifters. Am J Sports Med. 1992;20:463-467. 2. Seymour EQ. Osteolysis of the clavicular tip associated with repeated minor trauma to the shoulder. Radiology. April 1977;123:56.
|
