This 19-year-old male player presented with pain in his dominant right shoulder. This was well localised to the acromioclavicular (ACJ) region and was associated with localised tenderness. He gave a history of an ACJ ‘sprain’ one year previously. He reported that the pain seemed to resolve after the initial trauma, however it recurred. The onset of further pain coincided with him starting a gym-based programme with his club’s fitness trainer.
An x-ray series from the time of the player’s initial presentation was unremarkable (a normal Zanca view is shown here). A repeat x-ray series, taken almost exactly one year later, shows that there has been interval change. There is irregularity of the distal end of the right clavicle consistent with healed bone resorption. The acromion is also slightly irregular at the acromioclavicular joint and this joint is wide. The coraco-clavicular interval remains normal.
This player was managed with a short period of oral NSAID, physiotherapy and relative rest. His symptoms slowly settled over a three month period. During this time, he was able to continue to train and play football but altered his upper body weight training to avoid press activity (bench press, military press and push ups).
Distal clavicle osteolysis should be considered as a possible cause of shoulder pain among football players. In this group the most common causes are likely to be post-trauma or be associated with repetitive microtrauma caused by weight training. As a result this condition should be considered in any patients who have ongoing pain following an ACJ injury. In general, treatment options include activity modification and time, corticosteroid injections or excision of the distal clavicle.
As in this case, x-rays can be very helpful for establishing a diagnosis (and may be the only imaging that is required). The most common finding is of osteopenia affecting the distal end of the clavicle (usually in the distal 2cm) with loss of the articular cortical margin. When further investigations are required, MRI is generally the modality of choice. Increased signal on T2 sequences about the distal clavicle and ACJ is the most common single finding. A diagnostic local anaesthetic injection can be a useful investigation technique when the diagnosis is in doubt.
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