Boston University Medical Center, Boston, MA 02118, USA.
BACKGROUND: The clinical success of arthroscopic distal clavicle resection for
athletes has been well documented. There are, however, no published studies
that prospectively compare the recovery rates in athletes as well as the
outcomes of the indirect versus direct approaches. HYPOTHESIS: Both procedures
are equally successful; however, the direct approach affords faster return to
sports. STUDY DESIGN: Randomized controlled clinical trial; Level of evidence,
2. METHODS: Thirty-eight consecutive athletes with osteolysis of the distal
clavicle or isolated posttraumatic arthrosis of the acromioclavicular joint
without instability underwent arthroscopic distal clavicle resection. The
patients were randomized into 2 groups: a direct superior approach and an
indirect subacromial approach. American Shoulder and Elbow Surgeons and
Athletic Shoulder Scoring System scores were measurable outcomes. RESULTS:
Thirty-four athletes were available for a minimum 2-year follow-up. The 2
groups were similar, including preoperative American Shoulder and Elbow
Surgeons and Athletic Shoulder Scoring System scores. Both groups demonstrated
significant improvement in both scores at final follow-up when compared with
preoperative scores (P < .001). The direct group demonstrated higher American
Shoulder and Elbow Surgeons (82 vs 64) and Athletic Shoulder Scoring System
(74 vs 56) scores at week 2 (P < .001) and week 6 (American Shoulder and Elbow
Surgeons, 88 vs 77; Athletic Shoulder Scoring System, 87 vs 73) (P < .001). At
final follow-up, both groups demonstrated excellent clinical outcomes, even
though there was a statistical difference in scores, with the direct group
scoring better (American Shoulder and Elbow Surgeons, 95.7 vs 91.2; Athletic
Shoulder Scoring System -94.9 vs 88.3). The direct group demonstrated faster
return to sports (mean, 21 days) than the indirect group (mean, 42 days) (P <
.001). Radiographic analysis demonstrated an equivalent resection. One patient
in each group had a clinically insignificant increase in coracoclavicular
distance. CONCLUSIONS: Both the direct superior approach and the indirect
subacromial approach to the arthroscopic distal clavicle resection result in
successful clinical outcome with clinically insignificant difference at final
follow-up. Athletes treated with the direct superior approach improved faster
clinically and returned to sports earlier.
Department of Radiology, Division of Musculoskeletal Radiology, Yawkey Center,
6th floor Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114,
USA, akassarjian@partners.org.
PURPOSE: To investigate the association between distal clavicular osteolysis
and subchondral fractures of the distal clavicle at MRI. MATERIALS AND METHODS:
This study was approved by the hospital human research committee, which waived
the need for informed consent. Three radiologists retrospectively analyzed 36
shoulder MR examinations in 36 patients with imaging findings of distal
clavicular osteolysis. The presence of a subchondral fracture of the distal
clavicle, abnormalities of the acromioclavicular joint, rotator cuff tears and
labral tears were assessed by MRI. These cases were then compared with 36
age-matched controls. RESULTS: At MRI, 31 of 36 patients (86%) had a
subchondral line within the distal clavicular edema, consistent with a
subchondral fracture. Of the 36 patients, 32 (89%) had fluid in the
acromioclavicular joint, while 27 of 36 patients (75%) had cysts or erosions
in the distal clavicle. There were 13 patients (36%) with associated labral
tears, while eight patients (22%) had partial-thickness rotator cuff tears. In
the control group one of 36 (3%) had a subchondral line (P<0.05), while ten of
36 (28%) had rotator cuff tears and 13 of 36 (36%) had labral tears. These
latter two were not statistically significant between the groups. CONCLUSION:
A distal clavicular subchondral fracture is a common finding in patients with
imaging evidence of distal clavicular osteolysis. These subchondral fractures
may be responsible for the propensity of findings occurring on the clavicular
side of the acromioclavicular joint.
Diagnostic Imaging Resident, Department of Radiology, Logan College of
Chiropractic, Chesterfield, Mo 63006-1065, USA.
OBJECTIVE: To discuss a case of osteolysis of the distal clavicle (ODC) in a
29-year-old male chiropractic student who showed interval radiographic and
clinical evidence of healing. CLINICAL FEATURES: The patient complained of
intermittent left-sided shoulder pain of 8 months' duration that was
exacerbated while performing spinal-manipulative procedures. A radiographic
examination showed changes consistent with osteolysis involving the distal
clavicle. INTERVENTION AND OUTCOME: A conservative treatment regimen of
physiotherapy, nutritional supplementation, and activity modification resulted
in an interval reduction in symptomatology and radiographic findings on serial
examinations, ultimately resolving both abnormal clinical and radiographic
findings after approximately 14 months of treatment. We specifically observed
normalization of the acromioclavicular (AC) joint dimension. CONCLUSIONS: In
contrast to the posttreatment radiographic outcome seen in our patient, ODC
classically does not result in complete resolution of radiographic findings or
normalization of AC joint dimension, and such radiographic normalization of
joint space is currently not reported in the literature. This case report
serves to document and to show this unique occurrence.
Department of Orthopedics, Second Affiliated Hospital, Medical College,
Zhejiang University, Hangzhou 310009, China. huimintao@hotmail.com
Post-traumatic osteolysis (PTOL) is a very rare disease occurring after acute
trauma or repetitive micro-trauma, which is characterized by persistent pain
in the injured site. In this study, we reported 7 patients, in whom osteolysis
developed in the distal clavicle, pubis and ischium.
Department of Radiology, Wake Forest University School of Medicine,
Winston-Salem, NC 27157-1088, USA.
The acromioclavicular (AC) joint is a synovial joint that is predisposed to
painful syndromes because of mechanical stress or developmental variation. It
is often overlooked in the evaluation of patients with shoulder pain, however.
Isolated AC joint pathology was studied on magnetic resonance imaging scans of
patients with symptoms suggesting rotator cuff pathology. The conditions
identified included osteoarthritis, distal clavicle osteolysis, and os
acromiale syndrome.
The Shoulder Institute, Century City, California, USA. Kellemsbc@global.net
PURPOSE: The goal of the study was to evaluate the long-term outcome of
combined arthroscopic distal clavicle excision and subacromial decompression.
TYPE OF STUDY: Retrospective, long-term cohort evaluation. METHODS: Twenty
patients with an average follow-up of 6 years (range, 3.9 to 9 years) were
reviewed. All patients had ipsilateral impingement syndrome and
acromioclavicular joint disease at the time of surgery and underwent
arthroscopic subacromial decompression combined with arthroscopic distal
clavicle excision. All patients returned for evaluation in person, in addition
to filling out a questionnaire incorporating the University of California, Los
Angeles (UCLA), and Constant scoring systems. Preoperative and postoperative
radiographs were available for all patients. RESULTS: Postoperatively, all
patients had pain relief and were satisfied with the result. The average
postoperative UCLA Shoulder score was 29.8 +/- 0.6, compared with 17.5 +/- 3.0
before surgery (P =.001). The Constant Shoulder score averaged 98.5 +/- 2.1
postoperatively, compared with 70.5 +/- 11.2 preoperatively (P =.001). There
was 100% good to excellent results using both scoring systems. Individual
components of the UCLA scoring system (pain, function, and power) all showed
significant postoperative improvement (P =.001). Constant categories of pain,
activities of daily living, range of motion, and power also improved.
Follow-up radiographs showed maintenance of the resected distal clavicle in 19
patients. Five patients (25%) had radiographic evidence of calcific density
distal to the resected clavicle but were asymptomatic. CONCLUSIONS: The
long-term results of arthroscopic resection of the distal clavicle with
concomitant subacromial decompression are uniformly good or excellent.
Impingement and acromioclavicular joint disease frequently coexist and should
be identified and treated concurrently.
Department of Nuclear Medicine, Bnai-Zion Medical Center, Technion-Israel
Institute of Technology, Haifa, Israel.
Osteolysis of distal clavicle (ODC) may occur in patients who experience
repeated stress or microtrauma to the shoulder. This entity has clinical and
radiological findings similar to post-traumatic ODC. We describe a case of
successful treatment of stress-induced ODC with CT-guided injection of
corticosteroid and anesthetic drug into the acromioclavicular joint.
University of Wisconsin Medical School, Madison, USA.
Fractures of the humerus, scapula and clavicle usually result from a direct
blow or a fall onto an outstretched hand. Most can be treated by
immobilization. Dislocation of the humerus, strain or sprain of the
acromioclavicular and sternoclavicular joints, and rotator cuff injury often
can be managed conservatively. Recurrence is a problem with humerus
dislocation, and surgical management may be indicated if conservative
treatment fails. Rotator cuff tears are often hard to diagnose because of
muscle atrophy that impairs the patient's ability to perform diagnostic
maneuvers. Chronic shoulder problems usually fall into one of several
categories, which include impingement syndrome, frozen shoulder and biceps
tendonitis. Other causes of chronic shoulder pain are labral injury,
osteoarthritis of the glenohumeral or acromioclavicular joint and, rarely,
osteolysis of the distal clavicle.
Department of Orthopaedic Surgery, Naval Hospital, Bremerton, WA 98312-1898,
USA.
Osteolysis of the distal clavicle has been reported to occur from traumatic,
atraumatic (overuse), or systemic causes. Three patients with bilateral
osteolysis of the distal clavicles whose osteolysis did not fit these
etiologic categories were evaluated. Clinical, imaging, and laboratory
evaluations were nonspecific, and histologic sections of the distal clavicle
showed evidence of chronic inflammation with reactive change of the articular
surface. Patients either had complete resolution or marked improvement of
their symptoms after bilateral distal clavicle resection at mean followup of 5
years 3 months. These cases of osteolysis of the distal clavicle represent a
category of this disorder not previously described.
Human Performance Laboratories, University of Memphis, Memphis, TN.
OBJECTIVE: To determine injury types, natures, anatomical locations,
recommended amount of time missed, and injury rates during weightlifting
training. DESIGN AND SETTING: We collected and analyzed medical injury records
of resident athletes and during numerous training camps to generate an injury
profile. SUBJECTS: Elite US male weightlifters who were injured during
training at the United States Olympic Training Centers. MEASUREMENTS: United
States Olympic Training Center weightlifting injury reports from a 6-year
period were analyzed. Data were expressed as percentages and were analyzed via
x(2) tests. RESULTS: The back (primarily low back), knees, and shoulders
accounted for the most significant number of injuries (64.8%). The types of
injuries most prevalent in this study were strains and tendinitis (68.9%).
Injuries of acute (59.6%) or chronic (30.4%) nature were significantly more
common than recurrent injuries and complications. The recommended number of
training days missed for most injuries was 1 day or fewer (90.5%). Injuries to
the back primarily consisted of strains (74.6%). Most knee injuries were
tendinitis (85.0%). The majority of shoulder injuries were classified as
strains (54.6%). Rates of acute and recurring injuries were calculated to be
3.3 injuries/1000 hours of weightlifting exposure. CONCLUSIONS: The injuries
typical of elite weightlifters are primarily overuse injuries, not traumatic
injuries compromising joint integrity. These injury pattems and rates are
similar to those reported for other sports and activities.
PMID: 16558570 [PubMed - as supplied by publisher]
Orthopedic Associates, LLC, St. Louis, Missouri, USA.
Most injuries sustained during strength training are mild strains that resolve
with appropriate rest. More severe injuries include traumatic shoulder
dislocations, tendon ruptures of the pectoralis major, biceps, and triceps;
stress fractures of the distal clavicle, humerus, radius, and ulna; traumatic
fractures of the distal radius and ulna in adolescent weightlifters; and
compressive and stretch neuropathies. These more severe injuries are usually
the result of improperly performing a strength training exercise. Educating
athletes regarding proper strength-training techniques serves to reverse
established injury patterns and to prevent these injuries in the first place.
Recognizing the association of anabolic steroid use to several of the injury
patterns further reinforces the need for medical specialists to counsel
athletes against their use. With the increasing use of supplements such as
creatine, the incidence and nature of strength-training injuries may change
further. Greater emphasis on the competitive performance of younger athletes
undoubtedly will generate enthusiasm for strength training at earlier ages in
both sexes. The importance of proper supervision of these young athletes by
knowledgeable persons will increase. As the popularity of strength training
grows, there will be ample opportunity to continue to catalog the injury
patterns associated with this activity.
Department of Orthopaedic Surgery, Lenox Hill Hospital, New York, New York.
Peripheral nerve lesions are uncommon but serious injuries which may delay or
preclude an athlete's safe return to sports. Early, accurate anatomical
diagnosis is essential. Nerve lesions may be due to acute injury (e.g. from a
direct blow) or chronic injury secondary to repetitive microtrauma (entrapment).
Accurate diagnosis is based upon physical examination and a knowledge of the
relative anatomy. Palpation, neurological testing and provocative manoeuvres
are mainstays of physical diagnosis. Diagnostic suspicion can be confirmed by
electrophysiological testing, including electromyography and nerve conduction
studies. Proper equipment, technique and conditioning are the keys to
prevention. Rest, anti-inflammatories, physical therapy and appropriate
splinting are the mainstays of treatment. In the shoulder, spinal accessory
nerve injury is caused by a blow to the neck and results in trapezius
paralysis with sparing of the sternocleidomastoid muscle. Scapular winging
results from paralysis of the serratus anterior because of long thoracic nerve
palsy. A lesion of the suprascapular nerve may mimic a rotator cuff tear with
pain a weakness of the rotator cuff. Axillary nerve injury often follows
anterior shoulder dislocation. In the elbow region, musculocutaneous nerve
palsy is seen in weightlifters with weakness of the elbow flexors and
dysesthesias of the lateral forearm. Pronator syndrome is a median nerve
lesion occurring in the proximal forearm which is diagnosed by several
provocative manoeuvres. Posterior interosseous nerve entrapment is common
among tennis players and occurs at the Arcade of Froshe--it results in
weakness of the wrist and metacarpophalangeal extensors. Ulnar neuritis at the
elbow is common amongst baseball pitchers. Carpal tunnel syndrome is a common
neuropathy seen in sport and is caused by median nerve compression in the
carpal tunnel. Paralysis of the ulnar nerve at the wrist is seen among
bicyclists resulting in weakness of grip and numbness of the ulnar 1.5 digits.
Thigh injuries include lateral femoral cutaneous nerve palsy resulting in loss
of sensation over the anterior thigh without power deficit. Femoral nerve
injury occurs secondary to an iliopsoas haematoma from high energy sports. A
lesion of the sciatic nerve may indicate a concomitant dislocated hip. Common
peroneal nerve injury may be due to a direct blow or a traction injury and
results in a foot drop and numbness of the dorsum of the foot. Deep and
superficial peroneal nerve palsies could be secondary to an exertional
compartment syndrome. Tarsal tunnel syndrome is a compressive lesion of the
posterior tibial nerve caused by repetitive dorsiflexion of the ankle--it is
common among runners and mountain climbers.(ABSTRACT TRUNCATED AT 400 WORDS)
