Shoulder injuries during weightlifting III: Distal clavicle osteolysis

Distal clavicle osteolysis is a shoulder condition that often goes unrecognized. The high prevalence of shoulder injuries in weightlifters, along with more common injuries such as rotator cuff injuries or labral injuries, leads to delayed or even missed diagnosis of distal clavicle osteolysis.

Epidemiological data on distal clavicle osteolysis are limited, although the prevalence is estimated at 5% in the general population.

Distal clavicle osteolysis can be traumatic, secondary to trauma, or atraumatic and due to overuse. It is a rare injury overall, but highly prevalent in weightlifters and athletes with overhead activities. It results from overuse and repetitive loading of the acromioclavicular joint (the joint between the clavicle and the acromion of the scapula).

This repeated loading causes minor trauma to the subchondral bone (the bone beneath the cartilage of a joint), which leads to cystic changes in the subchondral bone, alteration of the articular cartilage, and continued attempts at repair with increased osteoclastic activity (osteoclasts are the cells responsible for resorbing bone tissue).

As we saw in previous articles, the bench press is once again the leading exercise causing injury, especially high-intensity bench presses, along with overhead activities and sports that require them: volleyball, tennis, swimming, or basketball, among others. In the case of weightlifters, we have both risk factors.

According to the various studies reviewed, the risk of distal clavicle osteolysis when performing the bench press increases with frequency (more than once per week), intensity (loads of more than 1.5 times body weight), and duration (more than five years of practice).

Patients suffering from distal clavicle osteolysis often report a dull, unilateral or bilateral aching pain in the acromioclavicular joint, which worsens with horizontal adduction. Their sports activities (especially bench presses, push-ups, and hanging exercises) worsen the pain, and ceasing the activity relieves it.

Plain radiographs may show changes in the acromioclavicular joint consisting of small cysts or bone loss at the articular end of the clavicle (osteolysis). Some authors emphasize the importance of MRI, arguing that up to 50% of cases show no significant radiological changes. MRI may reveal cortical erosions, soft tissue inflammation, joint widening, or bone edema.

First-line treatment for distal clavicle osteolysis is conservative. Activity modification or avoidance, nonsteroidal anti-inflammatory drugs, physical therapy, and ultrasound-guided intra-articular corticosteroid injections in the acromioclavicular joint are the main treatments used. Ultrasound-guided intra-articular corticosteroid injections, while therapeutic, can help us correctly identify the primary source of pain.

Conservative treatment is usually successful in 90% of cases, but often requires complete cessation of activity, a circumstance that is not always possible or desired by the lifter, especially in elite lifters.

In these cases, or if conservative treatment fails, surgical resection of the distal end of the clavicle is indicated. The literature reports excellent postoperative results, with return to sports activity in most patients.