Case of the Week 100 Case of the Week 100 (from Bill Hsu, DC, DACBR Toronto)(from Bill Hsu, DC, DACBR Toronto)

68 year old house wife with insidious onset 68 year old house wife with insidious onset on left clavicular pain of 2 month duration.on left clavicular pain of 2 month duration.

Constant achConstant ach Intensity - 3/10 day; 9/10 nightIntensity - 3/10 day; 9/10 night

Occasional referral to posterior scalp and Occasional referral to posterior scalp and left earleft ear

Aggravated by sleeping on left shoulderAggravated by sleeping on left shoulderRelieved with Lakota (Rx)Relieved with Lakota (Rx)

Physical ExaminationPhysical Examination NeurologicalNeurological

Normal cranial nerves, upper and lower extremities.Normal cranial nerves, upper and lower extremities. Range of MotionRange of Motion

C/SC/S Painful in active and passive left lateral flexion and left Painful in active and passive left lateral flexion and left

rotationrotation Left shoulderLeft shoulder

Painful at 90 degrees horizontal adduction and vertical Painful at 90 degrees horizontal adduction and vertical abductionabduction

Observation + PalpationObservation + Palpation Moderate swelling and tenderness along the superior-Moderate swelling and tenderness along the superior-

medial aspect of the left claviclemedial aspect of the left clavicle

What are the abnormal findings? DDX?What are the abnormal findings? DDX?

AnswersAnswers

Abnormal findings:Abnormal findings: The medial end of the left clavicle The medial end of the left clavicle

is sclerotic.is sclerotic. Mild narrowing the C5-6-7 disc Mild narrowing the C5-6-7 disc

spaces is noted with anterior spaces is noted with anterior osteophytes, hypertrophy of the osteophytes, hypertrophy of the C5-6 facet articulations as well as C5-6 facet articulations as well as the C6 uncinate processes.the C6 uncinate processes.

Intercalary bones are noted in the Intercalary bones are noted in the anterior aspects of the C5-6 and anterior aspects of the C5-6 and C6-7 disc spaces.C6-7 disc spaces.

DDX:DDX: Osteitis condensens of the left Osteitis condensens of the left

clavicle with the DDX of blastic clavicle with the DDX of blastic metastasis and osteomyelitis.metastasis and osteomyelitis.

Degenerative disc disease C5-6-7 Degenerative disc disease C5-6-7 with facet and uncovertebral with facet and uncovertebral arthrosis.arthrosis.

Here is the follow-up radiograph of the left shoulder showing the Here is the follow-up radiograph of the left shoulder showing the sclerosis. Round calcific densities are also noted in the upper lung sclerosis. Round calcific densities are also noted in the upper lung field, representing granulomas from an old infection such as TB or field, representing granulomas from an old infection such as TB or

Histoplasmosis.Histoplasmosis.

Follow up CT scans nicely showing the Follow up CT scans nicely showing the sclerotic left clavicle. (See next slide)sclerotic left clavicle. (See next slide)

Coronal CT slices also showing the sclerotic left clavicle and the Coronal CT slices also showing the sclerotic left clavicle and the narrowing of the left sternoclavicular joint space. However, the cortical narrowing of the left sternoclavicular joint space. However, the cortical bone on either side of the SC joint is intact, ruling out a septic arthritis bone on either side of the SC joint is intact, ruling out a septic arthritis

of this joint.of this joint.

DiagnosisDiagnosis

Osteitis condensans of the clavicle was Osteitis condensans of the clavicle was eventually confirmed with degenerative eventually confirmed with degenerative joint disease of the SC articulation.joint disease of the SC articulation.

OCCOCC

Typically femaleTypically female40’s40’sHistory of stressHistory of stressEtiology – unknownEtiology – unknownSymptomsSymptoms

Pain and swelling over SC jointPain and swelling over SC jointPain may located in neck, shoulder or anterior Pain may located in neck, shoulder or anterior

chest wallchest wall

OCCOCC

Clinical courseClinical course Intermittent flare-upsIntermittent flare-upsSpontaneous resolution*Spontaneous resolution*Pain usually reduced over time^Pain usually reduced over time^Swelling may persist^Swelling may persist^Sclerosis may improve slightlySclerosis may improve slightly

* Rev Rhum Engl Ed. 1995 Jul-Sep;62(7-8):501-6.

^Ann Acad Med Singapore 2004; 33:499-502