Monday, 1 April 2013

"Weightlifter's Shoulder" - Distal Clavicle Osteolysis - Resection Surgery - Page 4 - Bodybuilding.com Forums

Since we're discussing anatomy of the AC Joint, I found this amazing picture that really helps depict the joint in a better way:



In our surgery, the end of the clavicle, as seen in the picture, was removed. Now we just need the ligaments around that joint to heal and the bone structure itself to heal. Inside that joint ligament sack, or whatever you call it, scar tissue will form, creating another joint. This takes time, lol.

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    Bursa

    I am also of the opinion that it doesn't grow back, but the scar tissue serves as cushion. Crusher, I still think you are jumping the gun a little bit. I was able to go back to martial arts (judo, more specifically) within a little while. My boxing workouts at the time weren't too bad, I think the most uncomfortable were hooks. They caused the most rubbing. Again, it isn't the impact that will bother you the most provided you maintain a proper distance from the bag. It will definitely feel sore at first, but sore doesn't mean something is wrong. The last thing you want to do is miss, however. It requires more muscle and ligament strength to slow the arm down without impact. If you feel like you have to hit the bag, exercise control and some restraint.
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    So, are you saying I WILL or WILL NOT be able to compete in amateur boxing again one day?

    Also, what do you fellas think of my 3 questions:

    1) During my distal clavicle resection 4 weeks ago my doc removed my bursa. My doc said that the bursa grows back. However, dbrunner00 said the bursa doesn't grow back and scar tissue fills where the bursa was. What is the real story with this? Does the bursa grow back? And if it does, is it grown back by now (at 4 weeks post op)? If not now, how long until it grows back? If dbrunner00 is right (that scar tissue replaces the bursa), will the scar tissue do just as a good job as the bursa?

    2) In 4-6 weeks I will start doing my rotator cuff/scapular training exercises. Is there any exercises I can do that specifically target the AC joint area so that I can strengthen the scar tissue that will be formed where the excised AC joint was? Is their any way to strengthen that area so I can firm up the scar tissue?

    3) For the next 4-6 weeks I will completely baby the arm. I will no longer do anything foolish. I will not get into scuffles or pick up dumbells or throw any punches. I will ice the shoulder many times throughout the day and I will continue to take Motrin during this time. I'm hoping by doing this that this will enable all the post surgery inflammation to subside, the bone to heal, the bursa to grow back healthy, and for scar tissue to lay down and firm up where the excised AC joint was. In your professional opinion, if I do this for the next 4-6 weeks, will I than be able to start my rotator cuff/scapular training exercises training exercises relatively PAIN FREE? Is there a chance if I do this for the next 4-6 weeks that alot of my discomfort will be down and alot of healing will have happened?

    grebnehtor, I asked my doc about the clicking and he said it's probably just the scar tissue that is forming where the excised AC joint was. He said that should go away with time.
    Last edited by Crusher80; 06-04-2007 at 11:36 AM.
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    I played football from 4 years old till first spring of college, played "sandlot" football all that time, wrestled, raced motocross from 5-12, worked construction, shod and broke horses, lifted weights from 18-41, and have been a competitive powerlifter for the past four years.

    I have suffered quite a few injuries and known others who have as well, BUT have NEVER seen so many cases of shoulder surgeries as this thread has shown. Something many of you need to realize is that doctors are ALWAYS WILLING to perform surgeries. There is a lot of money in sugery.

    Alot of the nagging injuries that some of you get surgeries for mainly require rest and attention to form and capabilities. Also, some pains just have to be overlooked and gotten used to. I have had many things happen that I HAD to work through and some things that I realized if I like the sport I have to just DEAL with it. Talk to some professional athletes and see what they deal with as a normal course of a day. It will blow your minds what kind of pain many people live with and finally just disregard because the mind overcomes it.

    Always bear in mind that doctors love to perform surgeries.

    Crusher80....man it seems that you are intent on believing that you have "permanently" damaged yourself. Quit focusing on it. It takes time and it's gonna take some teeth-gritting and powering through some things and teh knowledge of when to just take it easy. Listening to the body is the hardest thing to do sometimes. Good luck.
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    Originally Posted by BigJohn308 View Post
    I played football from 4 years old till first spring of college, played "sandlot" football all that time, wrestled, raced motocross from 5-12, worked construction, shod and broke horses, lifted weights from 18-41, and have been a competitive powerlifter for the past four years.

    I have suffered quite a few injuries and known others who have as well, BUT have NEVER seen so many cases of shoulder surgeries as this thread has shown. Something many of you need to realize is that doctors are ALWAYS WILLING to perform surgeries. There is a lot of money in sugery.

    Alot of the nagging injuries that some of you get surgeries for mainly require rest and attention to form and capabilities.
    Always bear in mind that doctors love to perform surgeries.

    Crusher80....man it seems that you are intent on believing that you have "permanently" damaged yourself. Quit focusing on it. It takes time and it's gonna take some teeth-gritting and powering through some things and teh knowledge of when to just take it easy. Listening to the body is the hardest thing to do sometimes. Good luck.
    ^^^^^
    This I completely agree with and consider it rep worthy...

    However...


    Originally Posted by BigJohn308 View Post

    ...Also, some pains just have to be overlooked and gotten used to. I have had many things happen that I HAD to work through and some things that I realized if I like the sport I have to just DEAL with it. Talk to some professional athletes and see what they deal with as a normal course of a day. It will blow your minds what kind of pain many people live with and finally just disregard because the mind overcomes it.
    ^^^^^


    This I consider to be Negligent advice... (No Offense.)

    For one... No one here, short of you is a Professional athlete... Maybe some are aspiring etc... But unless there's a dollar amount invested in the process... This is First and foremost going to be about quality of life... And "Living with Pain." Is no where on Maslow's Hierarchy of Needs.

    *****

    As someone who's played sports at a Semi-Pro level, who's seen a fair share of injuries, I personally strongly encourage all of you to take any painful occurance as a serious matter...

    And before you make ANY DECISION to "Live With It" You first consult MULTIPLE doctors, and make ABSOLUTELY CERTAIN that you understand 100% why you're going to make the conscious choice to live with a pain that may have LIFE LONG circumstances.

    ****

    While on the one hand it's important to buck up during an injury phase, it's also equally important to temper that pro-active drive with body knowledge, wisdom and the foresight to live a long healthy life.
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    Originally Posted by Crusher80 View Post
    So, are you saying I WILL or WILL NOT be able to compete in amateur boxing again one day?

    Also, what do you fellas think of my 3 questions:

    1) During my distal clavicle resection 4 weeks ago my doc removed my bursa. My doc said that the bursa grows back. However, dbrunner00 said the bursa doesn't grow back and scar tissue fills where the bursa was. What is the real story with this? Does the bursa grow back? And if it does, is it grown back by now (at 4 weeks post op)? If not now, how long until it grows back? If dbrunner00 is right (that scar tissue replaces the bursa), will the scar tissue do just as a good job as the bursa?

    2) In 4-6 weeks I will start doing my rotator cuff/scapular training exercises. Is there any exercises I can do that specifically target the AC joint area so that I can strengthen the scar tissue that will be formed where the excised AC joint was? Is their any way to strengthen that area so I can firm up the scar tissue?

    3) For the next 4-6 weeks I will completely baby the arm. I will no longer do anything foolish. I will not get into scuffles or pick up dumbells or throw any punches. I will ice the shoulder many times throughout the day and I will continue to take Motrin during this time. I'm hoping by doing this that this will enable all the post surgery inflammation to subside, the bone to heal, the bursa to grow back healthy, and for scar tissue to lay down and firm up where the excised AC joint was. In your professional opinion, if I do this for the next 4-6 weeks, will I than be able to start my rotator cuff/scapular training exercises training exercises relatively PAIN FREE? Is there a chance if I do this for the next 4-6 weeks that alot of my discomfort will be down and alot of healing will have happened?

    grebnehtor, I asked my doc about the clicking and he said it's probably just the scar tissue that is forming where the excised AC joint was. He said that should go away with time.
    1. As I understand it, once removed the Bursa is gone for good... However the Fibrous scar tissue that replaces it should be just as good... If not better. (I could be wrong about this.) But either way, as I understand it you should be okay.

    2. Just do what your doc/physio/PT tells you to do...

    The only thing I would note... Is that ONLY ONCE YOU HAVE FULLY RETURNED TO 100% and have been cleared to go back into the weight room, MANY WEEKS FROM NOW... That one armed DB Bent rows, done with form tighter than a Nun's Choochie and slower than an episode of reading rainbow hosted by Forrest Gump... Will help you build scapular stability.


    3. No one can give you a time table answer that you can count on, except your doc/other specialist...

    Just be patient and treat the shoulder well, and that time table will be shorter than if you return to wrecklessness.
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    Originally Posted by BigJohn308 View Post
    I have suffered quite a few injuries and known others who have as well, BUT have NEVER seen so many cases of shoulder surgeries as this thread has shown. Something many of you need to realize is that doctors are ALWAYS WILLING to perform surgeries. There is a lot of money in sugery.

    Alot of the nagging injuries that some of you get surgeries for mainly require rest and attention to form and capabilities. Also, some pains just have to be overlooked and gotten used to. I have had many things happen that I HAD to work through and some things that I realized if I like the sport I have to just DEAL with it. Talk to some professional athletes and see what they deal with as a normal course of a day. It will blow your minds what kind of pain many people live with and finally just disregard because the mind overcomes it.

    Always bear in mind that doctors love to perform surgeries.
    I agree...yet disagree with your post.

    You're right, doctors make money when they do surgeries. The more they do, the more they make. So obviously it's in their financial best interest to do surgeries. However, if a doctor isn't going to do a surgery on you, he's gonna do it on someone who needs it. The point I'm trying to make is, doctors are going to do surgeries and make money no matter what. There are plenty of people who NEED the surgeries done and the doctors are busy enough working on them. They don't need to do surgeries on people who don't need it to make money. They make enough money, trust me.

    As to your other point. I had very serious injuries the last year and a half. I've had surgeries for an umbilical hernia and a torn pectoral tendon. I also had an acromioplasty and a distal clavicle resection. ALL of those surgeries I needed. I got second and even third opinions from doctors before I went under the knife for each of them. So I just didn't jump into having surgery. If I was just some couch potato who sat on his rear end and never worked out, I would've just took the pain and never had the surgeries I did. But, I am not a couch potato. I lift weights, run, occasionally wrestle, and I used to amateur box. Not to mention, I work a job where I have to be able to restrain and fight people. So, if I never had those surgeries, I would have never been able to even THINK about doing those activities again.

    As much as I respect your 'it's just a strain-suck it up-no pain-no gain attitude', there comes a point when you have to be intelligent enough to know the difference between being hurt...and being injured. I was injured and based on what I've read in this thread, these fellas were injured as well. I agree with you that some aches and pains you just have to live with. But there's a difference between a sprained ankle and a completley torn pecotral tendon. Big difference.

    Also, you made mention of the pain that pro athletes have to live with each day. Have you ever read the sports page? How many times do you see 'so-and-so is going to be out for x-amount of months with such-and-such surgery'? Pro athletes get surgeries more than anybody. Why? Not because they're hurt. Because they're injured.

    When I first got injured, I had to check my ego at the door and say 'I'm injured, I need surgery, it's gonna be long recovery and rehab, hopefully I'll come out of this OK.'

    I'm not a stupid person. I know I will never be physically what I was. The shoulder will never be the same. But maybe with proper healing and rehab I will one day be able to perform and enjoy those activities I love again.
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    Originally Posted by Nainoa View Post
    ^^^^^
    This I completely agree with and consider it rep worthy...

    However...




    ^^^^^


    This I consider to be Negligent advice... (No Offense.)

    For one... No one here, short of you is a Professional athlete... Maybe some are aspiring etc... But unless there's a dollar amount invested in the process... This is First and foremost going to be about quality of life... And "Living with Pain." Is no where on Maslow's Hierarchy of Needs.

    *****

    As someone who's played sports at a Semi-Pro level, who's seen a fair share of injuries, I personally strongly encourage all of you to take any painful occurance as a serious matter...

    And before you make ANY DECISION to "Live With It" You first consult MULTIPLE doctors, and make ABSOLUTELY CERTAIN that you understand 100% why you're going to make the conscious choice to live with a pain that may have LIFE LONG circumstances.

    ****

    While on the one hand it's important to buck up during an injury phase, it's also equally important to temper that pro-active drive with body knowledge, wisdom and the foresight to live a long healthy life.
    No offense taken...I thought my statement about "listening to the body" covered the "just power through any injury" idea. I would ever suggest not seeking medical advice, however, as you know when we decide to do things above and beyond what "normal" folks do we have to live with certain aches and pains.

    I am far from a "pro", I am just a competitor. As far as "quality of life" as it relates to some pain, I agree. The main thing is teh level of pain versus what we want to do. Life is a spectrum. We find a balance that suits us. I could definetly remain absolutely pain free if I chose to not do some of the things that I do (of all the things I did earlier in life, oh well, too late for that HAHA), but I choose to do certain things that require me to overlook soem aches and pains. I take Naprosyn daily to help with the inflammation brought about by a "rough/active" life.

    Over the course of my life I have learned to listen to my body well. I know when to go to the doctor, when to ease up, and when to just ice take a naprosyn and move on.

    Again, I stated that "listening to the body" was important.
    Last edited by BigJohn308; 06-04-2007 at 06:37 PM.
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    Originally Posted by Crusher80 View Post
    I agree...yet disagree with your post.

    You're right, doctors make money when they do surgeries. The more they do, the more they make. So obviously it's in their financial best interest to do surgeries. However, if a doctor isn't going to do a surgery on you, he's gonna do it on someone who needs it. The point I'm trying to make is, doctors are going to do surgeries and make money no matter what. There are plenty of people who NEED the surgeries done and the doctors are busy enough working on them. They don't need to do surgeries on people who don't need it to make money. They make enough money, trust me.

    As to your other point. I had very serious injuries the last year and a half. I've had surgeries for an umbilical hernia and a torn pectoral tendon. I also had an acromioplasty and a distal clavicle resection. ALL of those surgeries I needed. I got second and even third opinions from doctors before I went under the knife for each of them. So I just didn't jump into having surgery. If I was just some couch potato who sat on his rear end and never worked out, I would've just took the pain and never had the surgeries I did. But, I am not a couch potato. I lift weights, run, occasionally wrestle, and I used to amateur box. Not to mention, I work a job where I have to be able to restrain and fight people. So, if I never had those surgeries, I would have never been able to even THINK about doing those activities again.

    As much as I respect your 'it's just a strain-suck it up-no pain-no gain attitude', there comes a point when you have to be intelligent enough to know the difference between being hurt...and being injured. I was injured and based on what I've read in this thread, these fellas were injured as well. I agree with you that some aches and pains you just have to live with. But there's a difference between a sprained ankle and a completley torn pecotral tendon. Big difference.

    Also, you made mention of the pain that pro athletes have to live with each day. Have you ever read the sports page? How many times do you see 'so-and-so is going to be out for x-amount of months with such-and-such surgery'? Pro athletes get surgeries more than anybody. Why? Not because they're hurt. Because they're injured.

    When I first got injured, I had to check my ego at the door and say 'I'm injured, I need surgery, it's gonna be long recovery and rehab, hopefully I'll come out of this OK.'

    I'm not a stupid person. I know I will never be physically what I was. The shoulder will never be the same. But maybe with proper healing and rehab I will one day be able to perform and enjoy those activities I love again.

    Apparently you skipped over my point of listening to your body as being very important

    I assure you doctors do many many surgeries that are not necessary. If you do not believe that, well thats your perogative.

    I wish you luck with your recovery.
    Last edited by BigJohn308; 06-04-2007 at 06:50 PM.
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    "First Do No Harm"

    Originally Posted by BigJohn308 View Post
    I played football from 4 years old till first spring of college, played "sandlot" football all that time, wrestled, raced motocross from 5-12, worked construction, shod and broke horses, lifted weights from 18-41, and have been a competitive powerlifter for the past four years.

    I have suffered quite a few injuries and known others who have as well, BUT have NEVER seen so many cases of shoulder surgeries as this thread has shown. Something many of you need to realize is that doctors are ALWAYS WILLING to perform surgeries. There is a lot of money in sugery.

    Alot of the nagging injuries that some of you get surgeries for mainly require rest and attention to form and capabilities. Also, some pains just have to be overlooked and gotten used to. I have had many things happen that I HAD to work through and some things that I realized if I like the sport I have to just DEAL with it. Talk to some professional athletes and see what they deal with as a normal course of a day. It will blow your minds what kind of pain many people live with and finally just disregard because the mind overcomes it.

    Always bear in mind that doctors love to perform surgeries.

    Crusher80....man it seems that you are intent on believing that you have "permanently" damaged yourself. Quit focusing on it. It takes time and it's gonna take some teeth-gritting and powering through some things and teh knowledge of when to just take it easy. Listening to the body is the hardest thing to do sometimes. Good luck.
    I agree with you.

    Doctors love to perform surgeries, but not out of context. They will first use conservative treatment then go towards surgical treatment. Something they call the Hamorobic Code "First Do No Harm." My doctor wouldn't perform surgery unless two months had passed between my initial complaining visit and a follow up cortisone shot. They will preform surgery at your discression.

    I am a water sports person, not a football player. My sport requires me to have the most adapt joints and tendons possible so I can preform 100%. Because of the pain I had for 1 year, the pain that I endured time, time, and time again, I got this surgery. I can't just use "brute" force to knock people over and win, or use my leg strength to explode off a field, I need to have the healthiest shoulders possible. I need to, at a moments notice, adapt my entire body's muscular structure to glide across a pool, at the same time, have enough strength to hold off people grabbing and pushing my body throughout the course of the game. My AC Joint hindered this, and in order to play, I needed surgery. This is why I had surgery.
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    Crusher's Future

    Noone can tell you the limitations, if any, you will face in the future. All you can do now is everything possible to recover fully. Set some small goals and work to achieve them. It will take several months to know anything. Listen to your doctor and PT.
    It almost seems as though you want us to give you bad news. We keep giving you the positives and you focus on the negative. Take a positive outlook on things, the success of your recovery may depend on it. You may want to take the first step and convince yourself that you will recover and be able to do all the activities you did before. Once you believe in yourself, the rest gets easier. You wouldn't have stepped in the ring before thinking that you were going to lose, would you? This may all sound a little corny, but maybe it needs to be said. It sounds like you have had a few injuries, a lot of us have. No reason to be in such a state of despair.
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  11. #103
    Registered User Crusher80's Avatar
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    I hope your right Icamino. I miss weightlifting and boxing more than you know.

    I would like to find out if the bursa does indeed grow back or if scar tissue replaces it. I will be researching like a mdadman and I will also ask my doctor again. I would like to ask you guys a favor. Can you guys help me find this out? i'm sure if we all do a little research and ask our docs, than we can find the true answer.

    Thanks fellas.
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  12. #104
    OG of Saginaw, MISChigan lil_how_how's Avatar
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    I've checked numerous forums and the common consensus is that the bursa does indeed actually grow back. Whether that's completely true or not I'm not 100% sure on, but I suspect that it does.
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  13. #105
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    I have full range of motion and I think my popping sounds are going away. When I go back to weightlifting, I know the sounds should finally dissipate. Every morning my shoulder is sore less and less, however the soreness is still there. Today marks the three and a half week mark since my surgery, and honestly, I can't wait to get back to lifting, I am itching so bad. I have been using the elastic band to do strengthening exercises too, and I think that helps build that muscle torn by the cannula needles used during my arthoscopy.

    As for Crusher's problem, I have surched numerous doctor websites and they mention that the bursa does grow back. I believe the bursa is a fluid sack between the subacromium and rotator cuff. Good luck with finding more concrete info and recovery.

    How is your shoulder feeling these days Crusher?
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  14. #106
    Rocky Training Mod Nainoa's Avatar
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    Originally Posted by grebnehtor View Post
    I have full range of motion and I think my popping sounds are going away. When I go back to weightlifting, I know the sounds should finally dissipate. Every morning my shoulder is sore less and less, however the soreness is still there. Today marks the three and a half week mark since my surgery, and honestly, I can't wait to get back to lifting, I am itching so bad. I have been using the elastic band to do strengthening exercises too, and I think that helps build that muscle torn by the cannula needles used during my arthoscopy.

    As for Crusher's problem, I have surched numerous doctor websites and they mention that the bursa does grow back. I believe the bursa is a fluid sack between the subacromium and rotator cuff. Good luck with finding more concrete info and recovery.

    How is your shoulder feeling these days Crusher?
    Nice... Sounds like you're healing nicely, and your inflamation is going down!

    ****
    Have you had any time with a PT to discuss the long term game plan for your return to 100%... Or is that still too early in your doc's recovery plan?
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  15. #107
    Doug B. dbrunner00's Avatar
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    Sorry, Been

    Sorry for bailing out, folks. I've been in Alaska for the last few days.

    OK Crusher, in order.

    1) My Doctor told me that the Bursa does not grow back. It's been removed, not damaged. Scar tissue will fill the void and serve the same function. There may be a misunderstanding on this one. I can't seem to find anything definitive on the WEB, either. I'm not a doctor, so I'll pass on giving a definitive answer.

    2) I don't know of any specific set of exercises that can target the area. At least not until it's healed. At that time, you can get into various front delt moves that will build up the mass in that area. I don't know if it will build up the scar tissue, but lifting normally causes tendons and ligaments to thicken.

    3) Good Plan. Be a wimp for awhile. Let it heal. It will take longer than 6 weeks, though. As far as "Pain Free", that's a matter of definition. Will moving it bring you to your knees intears? No, probably not. Will it hurt? Yep. You're stretching scar tissue. It's normally not very flexible. There will some pain and discomfort. If it's of any help, I considered the pain rather minor. It was beyond simple joint or muscle stiffness and it did hurt like Hell. But, if you take your time and stretch though it, it's easily manageable.

    Keep the Ice Pack ready. You're going to need it.

    Good Luck. Have Patience. I Bench Pressed 205, today. Up from 185 last week. And, I was throwing a pair of 60lb Dumbbelss on an Inclined Press, 3X10. No Pain.
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  16. #108
    Doug B. dbrunner00's Avatar
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    Wink Sorry, been out of town.

    Sorry for bailing out, folks. I've been in Alaska for the last few days.

    OK Crusher, in order.

    1) My Doctor told me that the Bursa does not grow back. It's been removed, not damaged. Scar tissue will fill the void and serve the same function. There may be a misunderstanding on this one. I can't seem to find anything definitive on the WEB, either. I'm not a doctor, so I'll pass on giving a definitive answer. All I can really tell you is that my shoulder feels great.

    2) I don't know of any specific set of exercises that can target the area. At least not until it's healed. At that time, you can get into various front delt moves that will build up the mass in that area. I don't know if it will build up the scar tissue, but lifting normally causes tendons and ligaments to thicken.

    3) Good Plan. Be a wimp for awhile. Let it heal. It will take longer than 6 weeks, though. As far as "Pain Free", that's a matter of definition. Will moving it bring you to your knees in tears? No, probably not. Will it hurt? Yep. You're stretching scar tissue. It's normally not very flexible. There will some pain and discomfort. If it's of any help, I considered the pain rather minor. It was beyond simple joint or muscle stiffness and it did hurt like Hell. But, if you take your time and stretch though it, it's easily manageable.

    Keep the Ice Pack ready. You're going to need it. You might want to consider using the larger one that I mentioned earlier. It seems to work better, as well as faster.

    Good Luck. Have Patience. I Bench Pressed 205, today. Up from 185 last week. And, I was throwing a pair of 60lb Dumbbells on an Inclined Press, 3X10. No Pain.
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  17. #109
    Registered User lcamino's Avatar
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    Good for you db

    Amazingly, the incline has been my best friend since the surgery. Maybe a bit psychological, but have never really felt the most comfortable piling the pounds on the flat bench. Dumbells always allowed me to find my own way and arc. Just a thought db.
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    Registered User Crusher80's Avatar
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    Originally Posted by dbrunner00 View Post
    Good Plan. Be a wimp for awhile. Let it heal. It will take longer than 6 weeks, though. As far as "Pain Free", that's a matter of definition. Will moving it bring you to your knees in tears? No, probably not. Will it hurt? Yep. You're stretching scar tissue. It's normally not very flexible. There will some pain and discomfort. If it's of any help, I considered the pain rather minor. It was beyond simple joint or muscle stiffness and it did hurt like Hell. But, if you take your time and stretch though it, it's easily manageable.
    I'm more concerned about if I'll ever be able to throw a punch again pain free. In your guys honest opinion will I ever be able to box and throw punches again without my shoulder being in pain? Should I forget about ever getting back into boxing again?

    Because I gotta tell you, since the surgery, the few times I have tried to throw a punch...my shoulder HURTS LIKE HELL!!!
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  19. #111
    Doug B. dbrunner00's Avatar
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    Cool Didn't work for me

    Originally Posted by lcamino View Post
    Amazingly, the incline has been my best friend since the surgery. Maybe a bit psychological, but have never really felt the most comfortable piling the pounds on the flat bench. Dumbells always allowed me to find my own way and arc. Just a thought db.
    I've heard that from a couple of people. But, I think you're in that treasured minority. You lucky S.O.B. ;-)

    I had quite a bit of pain, under heavy load, in an inclined movement. The pain was not in or around the clavicle. It was at the front and below the Acronium. However, the swelling was around the clavicle resectioning. It may be that the inflammation was simply using that area as a vent or exit. I was limited to about 30lbs, maximum, for weeks. I started at about 20lbs, but could never get past the pain. It wasn't so much that it really hurt, but it felt like I was doing damage during the move. Almost as though something was getting pinched, or a tearing sensation. Rather unnerving. However, I did have fairly good luck with a Declined movement. Pulling or pushing down was seldom painful, unless I went stupid with the poundage. And, I could do some respectable weight with a Pec Dec or Flies.

    Once the pain quit, just last week, I've started to really enjoy the incline, again. Between the simple joy of pain free strain, the act of being able to lift again is quite invigorating. Being able to get a good pump in the upper chest, just below the calvicles again is also a plus.

    And, I have to also admit that I don't go too crazy on the Bench Press. I've always used it as a loading for the chest. A wide grip, but taking it deep, just before banging it off the sternum. I've found that this works the Pecs and front delts quite well. I guess it's a matter of how you're built and technique.

    But, the surgery kept me from this until just last week. I seemed to have healed in steps. It was not linear. I'm still approaching this with a high degree of caution. I've gotten this far, I'm not going to jump in and screw it up, again.

    But D**N!!!! Does it ever feel good to be able to move again. I feel ten years younger. At my age, I'll take anything I can get. ;-)

    Old Fart - 52/230 - about 26 weeks Post Op
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  20. #112
    Doug B. dbrunner00's Avatar
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    Wink Don't Do That

    Originally Posted by Crusher80 View Post
    I'm more concerned about if I'll ever be able to throw a punch again pain free. In your guys honest opinion will I ever be able to box and throw punches again without my shoulder being in pain? Should I forget about ever getting back into boxing again?

    Because I gotta tell you, since the surgery, the few times I have tried to throw a punch...my shoulder HURTS LIKE HELL!!!
    Sounds stupid, but don't throw the punch. ;-) The area that was worked on is the primary usage in the punch movement.

    That did sound rather bombastic, didn't it. Sorry.

    Crusher, you're as bad as a young dog on a short leash. ;-) You want to get out there and play so bad you can taste it. So, you keep pulling hard. You keep testing the injury, hoping that it's healed overnight. Not going to happen. It's going to take weeks and even months to heal back to full power. For normal day to day usage, I was relatively pain free within a couple of months. Note: I did say normal day to day usage. That does not include boxing, MMA, weight lifting or wrestling with bad guys. What it does include is picking up a coffee cup and the paper, or putting on a shirt and doing my job which is not that physical, normally. Keep in mind that I also went back to full work two months after a quintuple by pass. I'm educated, I never claimed to be smart. ;-)

    Right now, I could go a few rounds on a heavy bag with little or no pain, in my shoulders. I'm about 6 months out from surgery. I'm also 25 years older than you and hopefully you're in better shape. ;-)

    Follow the therapists and let it heal. If you keep testing it, hard, you delay complete healing. Like I said before, I'm not a doctor. I can only tell you what seemed to work well for me. I found that stretching the injured area, gently REPEAT GENTLY, seemed to work best. High Reps with itty bitty weights forces a pump that gets nutrients into the affected area. This also seemed to help with the healing. It was also recommended practice by my therapists.

    Have patience and don't worry. I know, much easier said than done. Follow your therapists and do the work. Take your time and do it right. If you do as you should, you can get yourself a new heavy bag for Christmas and wail on it. You should be back to at least 90% power by that time, if you don't do anything:

    Foolish
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    Man, where's a thesaurus when you need one. ;-) And I still haven't gotten a handle on this soap box, yet.
    Last edited by dbrunner00; 06-08-2007 at 01:39 PM.
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  21. #113
    Registered User Crusher80's Avatar
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    I have a question for all you guys that had this surgery that are back to lifting: can you guys do wide grip lat pulldowns ( http://www.exrx.net/WeightExercises/...tPulldown.html ) and close grip lat pulldowns ( http://www.exrx.net/WeightExercises/...pPulldown.html ) PAIN FREE right now? Or does doing those two lifts hurt too much to do them?

    What about seated cable rows ( http://www.exrx.net/WeightExercises/...SeatedRow.html )? Can you guys do them pain free?
    Last edited by Crusher80; 06-07-2007 at 10:37 PM.
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  22. #114
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    Newbie

    Hey guys, I'm new to this forum - I signed up because I saw this thread on shoulder osteolysis.

    A little background. I am 35 and have lifted since I was around 15, sometimes fairly heavy (although I've no idea what qualifies as heavy in this forum - perhaps you guys would scoff at my strength). Anyway, for years I have had to deal with shoulder osteolysis. The story may be familiar to some of you. I had pain on bench, it got worse and worse, I tried to push through til eventually I couldn't do anything, I went to a doctor, he gave me a cortisone shot, I was better for a few weeks, then the condition recurred, I went to another doctor, then to another... Finally it was diagnosesed as osteolysis and they said "Hey just stop lifting. It will go away." Which it did. Except... it came back as soon as I started again. Anyway, I have started and stopped for probably around ten years now, always searching for a way to adjust my routine to get around the problem, sometimes with limited success but never lasting success. I am on around my tenth return from a long layoff. Current preventive measures include no upright rows, limting motion on military presses to nothing below ear level, limiting motion on bench to stopping around an inch or a little more above the chest, icing after every workout, and lots of advil. But of course, my shoulder still hurts and I am sure that within a couple months I will have to quit again.

    So I have some questions.

    1 - I know this is osteolysis and is a bone problem rather than muscle or tendon problem, but has anyone had any luck trying rehabilitation rather than surgery? The doctors pretty much say no, nothing is going to help shy of surgery or a long layoff, but I still wonder.

    2 - So - we like distal clavicle resection - right? It works, and one day not too long (2 or 3 months) after a return to the room is possible and from there a return to full strength and size? What is the cost? Anyone know what the chances of having it covered under medical insurance is?

    3 - One excellent shoulder surgeon in Dallas actually told me he didn't want to do a distal clavicle resection because I had bad shoulder arthritis and if he did the surgery and I returned to lifting eventually the arthritis would get me and the shoulder would have to be replaced. He advised never doing any kind of pressing movement again. Despite the fact that everyone thinks he is the world's greatest shoulder surgeon for sports related problems, I have not taken his advice - would you? Anybody think he is right and I should just forget lifting and find some other athletic pastime? Anybody else gotten advice like this?

    4 - Does anyone have anything to add regarding my current regimen for avoiding the shoulder problems? Anything else to avoid? Any novel ways of hitting the chest and shoulder without aggravating the injury?

    5 - What do you guys think of the standard - nonlifter's - advice - just don't lift as heavy? I mean, I have certainly tried going light on various occasions, but there are at least two problems. One, if you go light and work to failure, it still aggravates the hell out of the shoulder. Two, you just can't get big going light, and maybe it makes me a neanderthal, but I have always been about big muscles.

    Thanks for listening. Any advice is much appreciated.
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    Rocky Training Mod Nainoa's Avatar
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    Originally Posted by Felagund View Post
    Hey guys, I'm new to this forum - I signed up because I saw this thread on shoulder osteolysis.

    A little background. I am 35 and have lifted since I was around 15, sometimes fairly heavy (although I've no idea what qualifies as heavy in this forum - perhaps you guys would scoff at my strength). Anyway, for years I have had to deal with shoulder osteolysis. The story may be familiar to some of you. I had pain on bench, it got worse and worse, I tried to push through til eventually I couldn't do anything, I went to a doctor, he gave me a cortisone shot, I was better for a few weeks, then the condition recurred, I went to another doctor, then to another... Finally it was diagnosesed as osteolysis and they said "Hey just stop lifting. It will go away." Which it did. Except... it came back as soon as I started again. Anyway, I have started and stopped for probably around ten years now, always searching for a way to adjust my routine to get around the problem, sometimes with limited success but never lasting success. I am on around my tenth return from a long layoff. Current preventive measures include no upright rows, limting motion on military presses to nothing below ear level, limiting motion on bench to stopping around an inch or a little more above the chest, icing after every workout, and lots of advil. But of course, my shoulder still hurts and I am sure that within a couple months I will have to quit again.

    So I have some questions.

    1 - I know this is osteolysis and is a bone problem rather than muscle or tendon problem, but has anyone had any luck trying rehabilitation rather than surgery? The doctors pretty much say no, nothing is going to help shy of surgery or a long layoff, but I still wonder.

    2 - So - we like distal clavicle resection - right? It works, and one day not too long (2 or 3 months) after a return to the room is possible and from there a return to full strength and size? What is the cost? Anyone know what the chances of having it covered under medical insurance is?

    3 - One excellent shoulder surgeon in Dallas actually told me he didn't want to do a distal clavicle resection because I had bad shoulder arthritis and if he did the surgery and I returned to lifting eventually the arthritis would get me and the shoulder would have to be replaced. He advised never doing any kind of pressing movement again. Despite the fact that everyone thinks he is the world's greatest shoulder surgeon for sports related problems, I have not taken his advice - would you? Anybody think he is right and I should just forget lifting and find some other athletic pastime? Anybody else gotten advice like this?

    4 - Does anyone have anything to add regarding my current regimen for avoiding the shoulder problems? Anything else to avoid? Any novel ways of hitting the chest and shoulder without aggravating the injury?

    5 - What do you guys think of the standard - nonlifter's - advice - just don't lift as heavy? I mean, I have certainly tried going light on various occasions, but there are at least two problems. One, if you go light and work to failure, it still aggravates the hell out of the shoulder. Two, you just can't get big going light, and maybe it makes me a neanderthal, but I have always been about big muscles.

    Thanks for listening. Any advice is much appreciated.
    From my time dealing with Osteolysis, reasearching it, talking with the guys I met via-therapy waiting room other internet forums, talking around the gym, and such... It seems there are some people who get it and it's always there...

    It's kind of like there are 2 different types Osteolysis... Traumatic and A-Traumatic...

    In my Case I was developed A-Traumatic Os... And then injured my shoulder, which took it the rest of the way.

    I know this is a belly dumper for you... But all the guys with A-traumatic Os... The guys who had no injury associated with their problem... They were all long term sufferers.

    It would go away and comeback based on activity. And the only ones who found any relief of symptoms had the DCR.

    ****

    I can tell you to take Flat Bench completely out of your routine, and it will slow down the onset of Os...

    I'm exclusively Incline DB bench, and dips, and I don't feel a thing wrong with my shoulder, after cessation of activity allowed it to heal.

    ****

    In all honesty though... If you've been battling this for 10 years, and it's the same result over and over again... It's time for the DCR.

    ****

    As for the doc who mentioned a shoulder replacement... This worries me in that it means he's talking about the Glenhumeral region of the shoulder...

    Do you also have something going on "Inside the Socket."
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    Rocky Training Mod Nainoa's Avatar
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    Originally Posted by Crusher80 View Post
    I have a question for all you guys that had this surgery that are back to lifting: can you guys do wide grip lat pulldowns ( http://www.exrx.net/WeightExercises/...tPulldown.html ) and close grip lat pulldowns ( http://www.exrx.net/WeightExercises/...pPulldown.html ) PAIN FREE right now? Or does doing those two lifts hurt too much to do them?

    What about seated cable rows ( http://www.exrx.net/WeightExercises/...SeatedRow.html )? Can you guys do them pain free?
    Dude... I'm seriously going to start negging you, if you don't let up this obsession with lifting while injured, or trying to find short cuts to get back into the weight room...

    From now until your doctor tells you the only thing you should be posting related to your injury is #1. What your doctor said. #2. How your rehab is going. #3. How much you enjoy all the cardio you're doing.

    Which BTW, if you ever want to be any kind of decent fighter, then you must know that Cardio fitness makes a champ more than his punching power.
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  25. #117
    Doug B. dbrunner00's Avatar
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    Gotta buy into this one

    Originally Posted by Nainoa View Post
    From my time dealing with Osteolysis, reasearching it, talking with the guys I met via-therapy waiting room other internet forums, talking around the gym, and such... It seems there are some people who get it and it's always there...

    It's kind of like there are 2 different types Osteolysis... Traumatic and A-Traumatic...

    In my Case I was developed A-Traumatic Os... And then injured my shoulder, which took it the rest of the way.

    I know this is a belly dumper for you... But all the guys with A-traumatic Os... The guys who had no injury associated with their problem... They were all long term sufferers.

    It would go away and comeback based on activity. And the only ones who found any relief of symptoms had the DCR.

    ****

    I can tell you to take Flat Bench completely out of your routine, and it will slow down the onset of Os...

    I'm exclusively Incline DB bench, and dips, and I don't feel a thing wrong with my shoulder, after cessation of activity allowed it to heal.

    ****

    In all honesty though... If you've been battling this for 10 years, and it's the same result over and over again... It's time for the DCR.

    ****

    As for the doc who mentioned a shoulder replacement... This worries me in that it means he's talking about the Glenhumeral region of the shoulder...

    Do you also have something going on "Inside the Socket."
    Mine started out as aggrivation and worked it's way up to a full wailer. I couldn't do dips or Inclines. I think it centers around the axact area of the damage. In my case, the shoulder had filled with bone spurs. The photos looked like the joint had been packed with black sand, right under the Acronium.

    I think that once you get to a point of the damage, anything will aggrivate it. I never did find a way to work around it, heavy or light. I went through about 4 months of therapy exercises. It helped to a point. But, after I reached that point, they became useless. Lifting the arm outward or rotating it away from my body was a screamer. I actually couldn't do it.

    For my own opinion, I think that the condition was already developing and a tad too much on the bench finally pushed it over the edge. IMHO that once it starts, it can't really be stopped or worked around. It least that was true in my case.

    As far as laying off for awhile, you said you've had 10 come backs. Doesn't work real well, does it? ;-) The damage is there and it's not going away. Laying off will not cure it. This isn't a muscle or tendon, it's bone. It will not heal. It has to be modified.

    A DCR may be the answer, but the Arthritis thing will be a concern. I was also warned that if the shoulder started hurting again, it would probably be arthritis. But, then again, I'm an old fart. It was worth the risk for me.

    As far as the "Go Heavy or Go Home" mentality. That's going to be a judgement call. I was throwing about 250 or so, before my injury, on the bench. IMHO, if you're over 200lbs and you can throw your own body weight, you're not doing too bad. I'm sure that at least a few of the folks in this forum are in the 300+ class, easily. That's too much for my old bones. I've had pretty good luck with Push Down on the cables.I max out the machine, but I think it still might be considered towards the "Light" class. I can rap out about 8 set of 15 at max weight and get a pretty good pump and burn. It allowed me to keep and even build some strenght after my surgery.

    I would suggest taking a serious look at the surgery, and maybe a couple of opinions. Just because the Doctor walks on water, doesn't make him infallible. There may be newer techniques out there. If your Doctor is worth his salt, he'll probably encourage you to check around and with other Doctors. The artificial shoulder is a new twist, to me. I don't know anybody that has one. So, I don't have any real data to form an opinion. I have several relatives with artificial knees, included two in my own father. (Something else I get to look forward to) But, nothing on shoulders.
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    Nainoa

    Don't worry about it being a "dumper." Just looking for informed opinions. If I can return to full strength after the surgery, then that is actually good nes, especially if the recovery only takes a few months. As to whether I have an "inside the socket" problem, I don't really know. I just know he said I had some pretty bad arthritis, though it could perhaps be cleaned up a bit if they did the DCR.

    It is funny that the exercises you mention are actually pretty bad ones for me. I flat do not do dips anymore. I used to come way, way down and they forced my shoulders way back. Incline DB press is a favorite of mine, but my shoulder always feels it. Meanwhile, I have learned to adjust some on flat bench and it is not so bad. I used to shift the weight back onto my shoulders, which have always been disproportionately strong, but now I concentrate more on pure pecs. Military presses are where I have the real problem. But how do you build shoulders without them? Sometimes I will go to the hammer strength machine to take a little of the pressure off, but I jsut don't feel like I can get away without SOME free weight shoulder presses.

    I think it was dbrunner who talked a little bit about weights. Just for background, I used to do my bench sets at about 335, maxing out right around 400, though I never do one rep sets. Yesterday I did a set with 295 after having been back in the room for about a month. I don't know if this sounds heavy or not. I am a big, heavy guy, so this is really not all that much weight for me. Certainly, I know plenty of guys much lighter who go much heavier. I think I would be happy if I could get back to sets with 335, and maybe 100 or 110 lb dumbbell military presses. That and get my weight back down to around 245 at the same time. I'm never going to be a real, huge, shredded bodybuilder - I just like being a big, strong guy.
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    A little 411 clarification

    Originally Posted by Felagund View Post
    Don't worry about it being a "dumper." Just looking for informed opinions. If I can return to full strength after the surgery, then that is actually good nes, especially if the recovery only takes a few months. As to whether I have an "inside the socket" problem, I don't really know. I just know he said I had some pretty bad arthritis, though it could perhaps be cleaned up a bit if they did the DCR.
    Okay... See here's what doesn't match up...

    Shoulder Arthritis = Usually in the AC joint, but can be in the socket... Bone deformation from Prolonged Chronic Osteolysis is not an uncommon diagnosis for AC arthritis.

    Shoulder Replacement = Damage to the Glenhumeral socket, where they remove the upper head of the humerus bone, and replace it with metal (Often having to do a little work on the Glenoid (Socket).

    ****

    The shoulder is (In Laymens terms) two joints... The Glenhumeral (Ball and Socket) and the AC joint

    So if one was to take the world "Shoulder Replacement" out of your previous post... Then it all makes sense, and I say you're looking at all thumbs up for the DCR
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    Doug B. dbrunner00's Avatar
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    Might be a good call

    Originally Posted by Nainoa View Post
    Okay... See here's what doesn't match up...

    Shoulder Arthritis = Usually in the AC joint, but can be in the socket... Bone deformation from Prolonged Chronic Osteolysis is not an uncommon diagnosis for AC arthritis.

    Shoulder Replacement = Damage to the Glenhumeral socket, where they remove the upper head of the humerus bone, and replace it with metal (Often having to do a little work on the Glenoid (Socket).

    ****

    The shoulder is (In Laymens terms) two joints... The Glenhumeral (Ball and Socket) and the AC joint

    So if one was to take the world "Shoulder Replacement" out of your previous post... Then it all makes sense, and I say you're looking at all thumbs up for the DCR

    Might be a good call. The way my condition was explained to me, was that the Clavicular problem was aggrivating the Acronial. The constant banging and scraping of the Clavicle into the Acronium was helping to generate the bone spurs under the Acronium. This turned the Bursa into shredded clam and forced it's removal. It also filled a good part of the joint with the bone spurs, the black sand I mentioned earlier. I think the proper term is Acronial Arthrosis. That sounds remarkably like Acronial Arthritis. So, as another laymen, I think a surgery similar to what I had may do a world of good. It involved a Clavicular AND Acronial Resectioning. Basically, he scraped out the Glenhumeral and polished up the bone, along with removing 1cm of the clavicle.

    May be worth exploring.
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Ligaments attach the clavicle to the acromion in the AC joint

Ligaments attach the clavicle to the acromion in the AC joint. Two ligaments connect the clavicle to the scapula by attaching to the coracoid process, a bony knob that sticks out of the scapula in the front of the shoulder.
http://www.eorthopod.com/sites/default/files/images/shoulder_anatomy_ligaments01.jpg



Distal Clavicle Osteolysis Associated Injuries, Complications / Differential Diagnosis| ATCgenius

Distal Clavicle Osteolysis Associated Injuries / Differential Diagnosis Distal Clavicle Osteolysis Complications
  • Instability(excessive resection)
  • Continued symptoms (inadequate resection)
  • Ectopic calcification
  • Reactive bursitis
  • Clavicle/acromion fracture
  • Infection

Distal Clavicle Osteolysis | ATCgenius




ICD-9 Classification / Treatment
Etiology / Epidemiology / Natural History Associated Injuries / Differential Diagnosis
Anatomy Complications
Clinical Evaluation Follow-up Care
Xray / Diagnositc Tests Review References

synonyms: distal clavicle osteolysis, weight lifter's shoulder,

Distal Clavicle Osteolysis ICD-9
  • 715.11 = osteoarthritis shoulder region
Distal Clavicle Osteolysis Etiology / Epidemiology / Natural History
  • Repetitive overhead activity / throwing can lead to microtrauma to the AC joint and osteolysis of the distal clavicle.
  • Most often occurs in weightlifters/body builders and football players. Also occurs in hockey players (Norfray JF, AJSM 1977;5:275) has been reported in lacrosse players.
  • More often occurs in men, but has been reported in female bodybuilders.
Distal Clavicle Osteolysis Anatomy
  • Diarthrodial joint which contains meniscus
Distal Clavicle Osteolysis Clinical Evaluation
  • Pain localized to the AC joint which is exacerbated by overhead motion and cross-body adduction.
  • AC tenderness
  • Cross-body Adduction Test: arm is maximally adducted with the arm in 90 of forward elevation. Pain localized to the AC joint indicates AC joint patholgy.
Distal Clavicle Osteolysis Xray / Diagnositc Tests
  • AP, scapular lateral and axillary views show spurring, sclerosis and narrowing of AC joint
  • AC joint best viewed with Zanca view.
  • Weighted views indicated if instability is a concern.
  • AC joint local anesthetic and corticosteriod injection often indicated to confirm diagnosis. Relief of symptoms after injection confirms AC joint pathology as the cause of symptoms.
Distal Clavicle Osteolysis Classification / Treatment
  • Non-operative treatment: NSAIDS, physical therapy, activity modifications, ACJ injections
  • Operative: indicated for failure of non-operative treatment (6 months). See Distal Clavicle Resection technique. Can be done via subacromial approach or direct anterior approach (Charron KM, AJSM 2007;35:53).
Distal Clavicle Osteolysis Associated Injuries / Differential Diagnosis
Distal Clavicle Osteolysis Complications
  • Instability(excessive resection)
  • Continued symptoms (inadequate resection)
  • Ectopic calcification
  • Reactive bursitis
  • Clavicle/acromion fracture
  • Infection
Distal Clavicle Osteolysis Follow-up Care
  • Post-op: sling as needed with pendulum ROM exercises.
  • 1 week: Start PT focused on ROM and strengthening. AAROM, PROM.  AROM, free weights start to 3 weeks. Avoid cross-body adduction for 6 weeks.
  • 6 weeks: progressive sport specific activity.
  • 3 months: Return to sport / full activities.
  • IF in association with SAD, or RTC repair use those rehab protocols.
  • Outcomes: average 18.7month followup 100% return to sport (average 3.2 days) and to their preoperative weight training program (average, 9.1 days). (Auge WK, AJSM 1998;26:189).
Distal Clavicle Osteolysis Review References

Distal clavicular osteolysis: a review ... [Bull NYU Hosp Jt Dis. 2008] - PubMed - NCBI

Source

Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York, NY 10003, USA.

Abstract

Acute distal clavicular osteolysis was first described in 1936. Since then, distal clavicular osteolysis (DCO) has been separated into traumatic and atraumatic pathogeneses. In 1982 the first series of male weight trainers who developed ADCO was reported. The association of weightlifting and ADCO is especially important considering how routine a component weights are to the male athlete's training. The pathogenesis of DCO has often been debated.

The most widely accepted etiology involves a connection between microfractures of the subchondral bone and subsequent attempts at repair, which is consistent with repetitive microtrauma.

Symptoms usually begin with an insidious aching pain in the AC region that is exacerbated by weight training. On examination, patients have point tenderness over the affected AC joint and pain with a cross-body adduction maneuver. Although DCO may seem like an easy and quick diagnosis, one must rule out other possibilities. Avoidance of provocative maneuvers, modification of weight training techniques, ice massage, and nonsteroidal anti-inflammatory drugs (NSAID) constitute the basis of initial treatment. Much of the literature supports the same general indications for surgery. These include point tenderness of the AC joint, evident abnormal signs with AC joint scintigraphy and AC radiographs, lack of response to conservative treatment, and an unwillingness to give up or modify weight training or manual labor. Distal clavicle resection has provided good results. Distal clavicle osteolysis is a unique disease most likely due to an overuse phenomenon.

PMID:
18537776
[PubMed - indexed for MEDLINE]
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Distal clavicular osteolysis

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Orthopaedic Services Shoulder

What is distal clavicular osteolysis?

Distal clavicular osteolysis, or DCO, is an overuse injury that occurs at the distal (end) of the clavicle (collarbone), leading to slow dissolution and resorption.  Although the cause is unclear, it appears to be consistent with a stress reaction or fracture at the site of considerable forces, and it is typically among weight-lifting athletes.

How our shoulder experts can help

Our shoulder experts will diagnose and treat your condition using the latest advances in orthopaedic technology. To request an appointment with our physicians, please call 202-787-5601.

How does DCO occur?

DCO usually results from repeated trauma, such as with weightlifting. Less commonly, a traumatic event, such as falling on the shoulder, can precipitate its development.

What increases risk?

  • Contact sports, weightlifting or racket sports
  • Possibly with previous shoulder separation, sprain or dislocation

What are the symptoms of DCO?

Diffuse discomfort or ache, tenderness and swelling at the end of the collarbone or the acromioclavicular (AC) joint (the top of the shoulder) are common. Symptoms are usually insidious, without a history of discrete trauma. Pain and aching are related directly to specific exercises, most commonly dips, flies, push-ups and bench press. Pain may be worse when crossing the arm towards the opposite body, such as when washing the opposite axilla (armpit).

How is DCO diagnosed?

Typical symptoms of pain over the AC joint, focal tenderness, pain with forcing the arm across the body (cross-body adduction test) and X-rays showing dissolution of the clavicle with seeming joint space enlargement, is characteristic of this condition.

Are there any special tests?

Imaging studies are rarely needed because of the straightforward presentation of this condition.  However, there are two studies that may be helpful in confirming pathology of this joint:
  • A bone scan, in which a minimally radioactive dye is injected into the arm by IV. The dye is taken up at sites where there is significant metabolic activity.  In the case of DCO, uptake at the AC joint would be expected to be rather dramatic, and clearly different from the opposite AC joint by comparison.
  • Selective injection technique, in which local anesthetic is infiltrated into the AC joint, may be helpful if the symptoms are relived following the injection.

How is DCO treated?


Non-operative treatment: Many patients can be treated by backing off on activities that provoke their symptoms. For example instead of lifting heavy weights, the bench press may be done with increasing repetitions and decreasing the amount of weight.  Gripping the bar at a greater distance may decrease the symptoms.  Pain medications, ice after activity and judicious use of cortisone injection are all important components of non-operative management.
Operative treatment: In the weight-lifting population, non-operative treatment is often ineffective; DCO requires surgical intervention.  Persistent symptoms that have failed to respond to non-operative treatment, particularly among those who are unable or unwilling to alter their activities, may justify surgical intervention.  Surgery involves removal of the end of the clavicle (collar bone), either via open technique or more commonly, via arthroscopy.  The amount removed is usually no more than a centimeter, which prevents abutment of the bone surfaces and removes all inflammatory debris from within the joint.  Surgery is very successful in resolving the pain, allowing the athlete to fully return to the activity without experiencing any weakness.

What are the complications of treatment?


Possible complications of non-operative treatment include:
  • Persistent symptoms
  • Inability to participate in their sport or be competitive

Possible complications of operative treatment include:
  • Surgical complications not specifically associated with AC joint resection, such as pain, bleeding (uncommon), infection (<1percent), nerve injury (uncommon), stiffness, problems with anesthesia, and inability to return to previous level of pre-injury activity.
  • Complications specific to surgical treatment of DCO, which include persistent symptoms, inadequate resection or overly generous resection.

When can you return to your sport/activity?

You may consider returning as soon as you are comfortable. Most overhead athletes will require 4-6 weeks before they begin to throw. Weight-lifting may be started as soon as the pain permits, which may be in the first few weeks for some patients.

How can DCO be prevented?

  • Limit amount and frequency of weightlifting
  • Vary weightlifting routine
  • Avoid trauma to the shoulder, such as with tackling
  • Maintain appropriate conditioning, including shoulder strength, endurance, flexibility and cardiovascular fitness
  • Use proper techniques when falling, tackling, and weightlifting
  • Ensure proper use and fit of protective equipment

Direct Arthroscopic Distal Clavicle Resection

A Technical Review

Abstract

Degenerative change involving the acromioclavicular (AC) is frequently seen as part of a normal aging process. Occasionally, this results in a painful clinical condition. Although AC joint symptoms commonly occur in conjunction with other shoulder pathology, they may occur in isolation. Treatment of isolated AC joint osteoarthritis is initially non-surgical. When such treatment fails to provide lasting relief, surgical treatment is warranted. Direct (superior) arthroscopic resection of the distal (lateral) end of the clavicle is a successful method of treating the condition, as well as other isolated conditions of the AC joint. The following article reviews appropriate patient evaluation, surgical indications and technique.

INTRODUCTION

Symptomatic osteoarthritis (OA) of the AC joint can be treated effectively with both non-surgical and surgical means. Historically, patients that have failed nonoperative management have been treated with resection of the distal clavicle, typically through an open superior incision.14,19,31,33 With the acceptance of the arthroscopic treatment of shoulder pathology, many surgeons now prefer arthroscopic resection of the distal clavicle. Technically, arthroscopic resection of the distal clavicle is feasible either from a direct (superior) approach, in which the instrumentation and dissection remains entirely intra-articular, or from a bursal approach, which is usually performed concomitantly with acromioplasty, subacromial bursectomy, and/or rotator cuff repair. Occasionally, AC joint arthrosis occurs in isolation; in these situations, it may be preferred to avoid trauma to the subacromial region, thereby minimizing postoperative inflammation and scarring, and potentially reducing recovery time. The following review article discusses appropriate patient selection, technique, and expected results when performing a direct arthroscopic distal clavicle resection.

ANATOMY

The AC joint is a diarthrodial joint formed by the medial facet of the acromion and the lateral, or distal, end of the clavicle, both of which are covered with hyaline cartilage. The joint has a variable degree of inclination in both sagittal and coronal planes. There is an intra-articular fibrocartilaginous disk of variable size and shape; a complete disk is noted in less than 10% of the population.4,15 Developmentally, there is no physeal plate at the distal clavicle. The articular cartilage of the distal clavicle may function in the longitudinal growth of the clavicle.12
Stability of the AC joint is primarily provided by the capsular ligaments that are located anterior, posterior, superior, and inferior.15,20,21 The superior AC ligament is the strongest and blends with the fascial attachments of the deltoid and trapezius muscles. The capsular ligaments provide anteroposterior (horizontal) stability of the distal clavicle.7,22,30 Slight upward and downward movement between the clavicle and acromion results in approximately 20 degrees of rotational movement between the two structures; however, this is likely variable on an individual level.12 The capsular insertion is approximately 1.5 cm medial from the end of the distal clavicle; therefore, resections of greater than 2 cm can compromise horizontal stability. The vertical stability of the distal clavicle is provided by the coracoclavicular (CC) ligaments, which are injured in moderate to high grade (i.e. II-V) AC joint separations.

NATURAL HISTORY

It is well documented that the fibrocartilaginous disk of the AC joint deteriorates with age. This natural aging process begins in the second decade of life.4 Several studies have demonstrated such changes in cadaveric studies or radiographic or magnetic resonance imaging of asymptomatic patients.9,17–18,23,25–28 Despite the abundant evidence that degenerative changes at the AC joint are common with aging, little is understood about the likelihood that such changes will eventually result in clinical symptoms.
In a study of 100 patients with osteoarthritis of other joints, there was a 70% incidence of AC joint tenderness. Treatment was provided for 30 consecutive patients in the series with intra-articular corticosteroid injections with successful results.32 The long-term efficacy of injection therapy for AC arthritis is unclear. While the previous study demonstrated success, others have found such injections provide only short-term relief, with a majority of patients ultimately requiring surgical treatment.10

EVALUATION

History

A detailed history is critical to making an accurate diagnosis of AC joint pathology. Pain is universally the chief complaint. The patient should be questioned to determine the onset, location, and character of pain. In addition, a history of prior trauma or surgery should be excluded. Finally, previous treatment, and the response to that treatment, should be known.
Pain associated with isolated AC joint arthrosis or synovitis is typically anterosuperior in location, in direct proximity to the joint itself. Not infrequently, the pain may radiate anterior, posterior, proximal, or distal, and may mimic pain experienced with other shoulder conditions, such as rotator cuff tears, subacromial or subcoracoid impingement, bicipital tendonitis, or labral or other intra-articular pathology. Most commonly, pain is described as a dull ache, but may be sharp or burning. Symptoms are usually activity related but may be present either at rest or during the night, and patients may experience symptoms when sleeping on the affected shoulder.
The patient should be asked about typical activities that produce symptoms. Using the affected arm across the body (in shoulder adduction) or behind the back (such as reaching a wallet or tucking in a shirt) may be particularly bothersome. As well, reaching with the arm elevated or overhead can produce pain, not unlike that associated with impingement pathology. The patient may also describe crepitation that localizes to the AC joint with certain maneuvers. However, such mechanical sensations can be difficult to localize and should be correlated during the physical examination.

Physical Examination

The examination begins with a thorough inspection of the entire shoulder girdle. Male patients should have the shirt removed, while female patients should be appropriately gowned to leave the shoulder girdle exposed. The resting posture of the shoulder is assessed, including the sternoclavicular (SC) joint, clavicle, AC joint, scapula, and surrounding musculature. Prior incisions should be documented, particularly in the region of the AC joint. Occasionally, the AC joint may demonstrate swelling, hypertrophic change, or resting deformity consistent with prior AC joint ligamentous injury.
Anatomic landmarks should be palpated for tenderness. This includes the SC joint, AC joint, acromion, proximal humerus, and periscapular region. Palpation tenderness at the AC joint is the hallmark of the condition. However, this should be compared to the unaffected side. As well, the patient may not have direct tenderness at the joint on examination, but should be asked whether the joint is the typical location of pain.
Next, shoulder range of motion is assessed. Movement in forward elevation, abduction, external rotation (both adducted and abducted) and internal rotation are documented. In patients with isolated AC joint pathology, there typically is no primary limitation to shoulder movement. As well, scapular control and scapulohumeral rhythm are evaluated to rule out underlying neurologic injuries or dysfunction. Additionally, strength and function of the rotator cuff, deltoid, trapezius and distal extremity are assessed.
Finally, specific tests to elicit isolated AC joint symptoms are performed. There are three tests which are utilized. First, the cross-body adduction test is performed with the arm in 90° elevation and maximal adduction across the body. The maneuver increases contact pressure at the AC joint and often reproduces symptoms. Second, the active compression test is performed with the arm in 90° elevation and 10-15° adduction, with the arm in maximal internal rotation with the thumb pointed down. Likewise, this maneuver loads the AC joint and often reproduces pain. It must be determined the pain is located mainly at the AC joint, as this test is also used to demonstrate superior labral pathology.16 Finally, pain reproduced at the AC joint with the arm in maximal internal rotation is a common finding, and may be the most sensitive test. Ranging the shoulder through full circumduction may also reproduce pain and crepitation at the AC joint.

Imaging

A standard radiographic series is obtained on all patients with a chief complaint of shoulder pain. In general, a series of four views are recommended that will evaluate for most degenerative and inflammatory conditions of the shoulder. Typically, true anteroposterior (AP) views of the glenohumeral joint with the humerus in both internal and external rotation, supraspinatus outlet, and axillary radiographs are obtained. In addition, when the clinician desires a specific evaluation of the AC joint, a Zanca radiograph is preferred, which is taken in the AP plane of the joint with a 10 degree cephalic tilt.34 This view is also particularly helpful in the postoperative evaluation of a distal clavicle resection.
Further imaging is often performed prior to considering surgical treatment. Magnetic resonance imaging (MRI) is preferred due to its ability to evaluate both bone and soft tissue. MRI of the shoulder allows detailed visualization of the rotator cuff, subacromial and subdeltoid bursae, acromion, greater tuberosity, coracoid process, subcoracoid interval, and medial clavicle. Intra-articular contrast may be used when further detail of the glenohumeral chondral surfaces or glenoid labrum is desired. It is important to include T2 weighted sequences that will demonstrate edema of the distal clavicle and medial acromion. Such findings are more suggestive of symptomatic AC joint arthrosis than are hypertrophic changes (i.e., osteophyte formation) alone.25 In addition, MRI allows evaluation of the coracoclavicular (CC) ligaments in situations where the patient has AC joint symptoms following a prior type I or II AC separation. Such an evaluation may be helpful in determining treatment in these instances. It is recommended that patients with prior AC joint injuries, even in the remote past, be thoroughly examined for residual distal clavicular instability. Caution should be exercised in selecting such patients for the procedure, as it has been demonstrated that such patients are at higher risk for postoperative failure.2,6

NONSURGICAL TREATMENT

Nonsurgical modalities include medical management with nonsteroidal anti-inflammatories (NSAIDs) and analgesics, local modalities such as moist heat, ice, or ultrasound, and physical rehabilitation to correct underlying rotator cuff or intra-articular pathology, or periscapular dysfunction. When associated conditions have been either ruled out or corrected, the ideal form of treatment of isolated AC joint arthrosis or synovitis is an intra-articular corticosteroid injection. When symptoms have persisted beyond 6 months despite transiently effective injections, surgical treatment of the problem is reasonable.

SURGICAL INDICATIONS

The indication for surgical treatment of AC joint arthrosis is the failure of nonsurgical management to return the patient to the desired level of daily work and recreational functioning. With regard to isolated treatment of the AC joint (i.e., with open or arthroscopic resection of the distal clavicle), it cannot be overemphasized that the key to an appropriate surgical indication is making an accurate preoperative diagnosis. This is again done with a specific and detailed history, physical examination, evaluation of pertinent radiographic and MRI images, and a documented clinical response to diagnostic and therapeutic injections.

TECHNIQUE

The author prefers patient positioning in the beach chair position; however, the procedure may be alternatively be performed in the lateral decubitus position. A regional interscalene block for shoulder surgery is utilized. Care is taken to position the head and neck in neutral, and all potential peripheral pressure areas are thoroughly padded. The patient is given appropriate preoperative antibiotics. The shoulder is draped sterile using a standard arthroscopic shoulder drape that provides excellent exposure and collects excess fluid during the procedure. Bony landmarks are then marked, which is critical to creating the precise portals necessary to perform the procedure. The scapular spine, coracoid process, acromion, and clavicle are all accurately drawn.
The standard portals for direct arthroscopic resection of the distal clavicle are typically 1.5 centimeters directly anterior and posterior to the AC joint itself. In larger patients with thicker subcutaneous tissue, the portals must be referenced further from the joint, such that the instruments will track beneath the skin for a distance, thus entering the joint at the appropriate location.
The joint initially is localized using two 22 gauge needles and a 10 cc syringe with normal saline. The needles are directed into the joint from anterior and posterior, and fluid injected to distend the joint. With appropriate placement, the anterior needle should allow outflow from the joint, suggesting accurate portal location. The skin is then incised in the desired locations with a #11 blade. The joint is initially inspected with a 2.7mm arthroscope (i.e., used for ankle or wrist arthroscopy) through the posterior portal. A needle is then utilized to create an anterior portal using an outside in technique. The portal is created with a #11 blade and widened at the level of the joint capsule with a blunt obturator. A 3.5 mm full radius resector is used to remove any inflammatory tissue or remaining meniscal remnants which may be present. A tissue ablation device (TurboVac 90, Arthrocare, USA) is used to subperiosteally expose the lateral end of the clavicle in its entirety from the level of the anterior capsule to the posterior capsule. As well, the bone must be exposed from inferior to superior, while keeping the respective capsular attachments intact. Maintaining the integrity of the capsular attachments minimizes the amount of bleeding and trauma into the subacromial space, thereby decreasing postoperative pain and shortening the recovery period. As well, preserving the posterior and superior aspects of the capsule avoids creating iatrogenic distal clavicular horizontal instability. This is particularly important in the unusual situation where the procedure is being performed following a previous type I or II AC separation (see previous text).
Once the lateral clavicle is exposed and any impinging soft tissue removed, the surgeon may switch to visualization with a standard 4.0 mm arthroscope, if the patient's anatomy allows. Resection of the distal clavicle is then performed with a 6.5 mm oval bur, beginning anterior and working toward the posterior aspect of the joint. If the joint space is excessively narrow to begin with, resection may be started with a smaller bur (i.e. 3.5mm round), before progressing to the larger bur. Care is taken to create an even resection from superior to inferior; typically, 6-7 mm of bone is removed, which has been shown to be adequate to prevent bone to bone contact with rotation of the scapula.30
The arthroscope is then moved to the anterior AC joint portal, to allow complete visualization of the posterior aspect of the distal clavicle and posterior capsule. If necessary, the ablation device is used to further expose the posterior clavicle. The bur is then used through the posterior portal to complete an even resection of bone, and confirm adequate decompression of the posterior portion of the joint. This step is critical, as a common technical error is inadequate visualization and resection of the posterior clavicle when performing the procedure arthroscopically.
Finally, in situations where it is desirable to inspect the glenohumeral joint as part of the same procedure, this can be done through a standard posterior portal established in the soft spot just medial and inferior to the posterolateral corner of the acromion. The anterior AC joint portal may be used for outflow and instrumentation, or a more standard anterior glenohumeral portal can be established. Such an inspection may or may not be preferred, depending upon the index of suspicion of intra-articular pathology based on clinical exam or by imaging modalities.
The portals are closed with nylon suture and standard dressings applied. The patient is placed in a Cryocuff (Aircast, USA) for postoperative comfort and to minimize swelling, as well as protect the arm while the regional block remains effective. It is typically discontinued 3-4 days after surgery. The patient begins gentle postoperative therapy 3-5 days after surgery, performing active assisted range of motion exercises within their tolerance level. The level of therapy is progressed to full active motion and isometrics in the ensuing 7-10 days. Typically, the patient progresses to a strengthening protocol 3 to 4 weeks post surgery. Most patients can expect full recovery in 8 to 10 weeks post surgery.
Postoperative radiographs, consisting of a Zanca and axillary lateral view, are obtained to confirm the clavicular resection has been adequate. Alternatively, these can be obtained immediately postoperatively or intraoperatively, depending on the confidence level of the surgeon. The author recommends the routine use of intra-operative fluoroscopy or plain radiography when the technique is being used for resection of distal clavicle nonunions or excision of ectopic bone. This avoids the unwanted complication of inadequate resection, which may lead to continued symptoms postoperatively.

RESULTS

The results of direct arthroscopic distal clavicle resection have been published previously. In a series of 29 patients with isolated AC joint arthrosis, 93% had excellent or good results at minimum 2 year follow up.6 This is consistent with the extensive reported literature evaluating either open distal clavicle resection,14,19,31,33 or arthroscopic resections performed using the more common bursal approach.1,5,8,11,13,24,29 A higher incidence of failure has been demonstrated in patients with prior AC joint instability (i.e., previous type II AC separation).2,6

CASE EXAMPLES

Patient One

A 39-year-old female was referred for evaluation of persistent anterosuperior shoulder pain 6 months following prior arthroscopic subacromial decompression. The patient was active in racquet sports and bowling, and reported discomfort with rotational and overhead movements of the shoulder. In particular, overhead weighted presses, pushups, and reaching behind the back were inciting activities.
Physical examination demonstrated healed prior arthroscopic portals and no resting deformity of the shoulder. Range of motion was full in all planes, although maximal internal rotation behind the back produced pain specifically at the AC joint. Neer and Hawkins impingement signs were negative. Cross body adduction and active compression tests reproduced symptoms at the AC joint. No signs of generalized laxity or pathologic glenohumeral instability were evident.
Standard radiographs demonstrated prior acromioplasty and relatively minimal degenerative change of the AC joint (Figure 1). An MRI was obtained which revealed brightly enhancing edema pattern of the distal clavicle and medial acromion, with associated subchondral cystic change (Figures 2A-C). No rotator cuff, bicipital, or labral pathology was identified.
Figure 1
Supraspinatus outlet view in patient one demonstrating a flat acromial morphology consistent with successful prior arthroscopic acromioplasty. Patient continued to complain of anterosuperior shoulder pain.
Figure 2Figure 2Figure 2
T2-weighted coronal (A), sagittal (B), and axial (C) MRI sequences of patient one. Note the edema pattern of the distal clavicle and medial acromion, with subchondral cyst formation.
The patient underwent a diagnostic and therapeutic AC injection of 4cc 1% plain Lidocaine and 1cc of depomedrol, which demonstrated complete resolution of symptoms. Other nonsurgical treatment included scheduled NSAID use, modification of activity, and rotator cuff and periscapular strengthening. She experienced lasting relief for roughly 5 to 6 weeks, with gradual return of pain. A subsequent injection produced similar results in terms of duration and clinical efficacy.
When her symptoms again recurred, the patient then elected to proceed with arthroscopic distal clavicle resection. Postoperative radiographs demonstrated adequate clavicular resection (Figure 3). The patient underwent standard postoperative protection and physiotherapy, and returned to full activity without restriction at 8 weeks following surgery. At 6 months, she continues to be pain free and pleased with the outcome.
Figure 3
Postoperative Zanca radiograph of patient one after arthroscopic distal clavicle resection. Note the even resection of bone.

Patient Two

A 61-year-old male presented with an 8 month history of left anterosuperior shoulder pain of gradual onset. He reported an AC joint separation suffered roughly 23 years prior that was treated nonsurgically without complication. He denied subjective instability to the distal clavicle with functional activities, which included weight training, swimming, hunting, and fishing. Once again, pain was particularly noted when reaching across the body or behind the back.
Physical examination demonstrated moderate hypertrophic change at the AC joint, but no superior translation of the distal clavicle relative to the acromion. There were no previous incisions. Range of motion and strength of the shoulder were symmetric to the contralateral side, and impingement signs were negative. There was no gross manual translational instability of the distal clavicle, although slight crepitation in this region was produced with circumduction of the shoulder. Positive tests included cross-body adduction and active compression, with pain located specifically at the AC joint.
Standard radiographs demonstrated maintenance of the AC joint space, but marked hypertrophic degenerative change (Figure 4). MRI demonstrated an effusion of the AC joint with a moderate edema pattern on T2 weighted sequences (Figure 5). The coracoclavicular ligaments were demonstrated and intact on sagittal oblique sequences (Figure 6). The remaining bone, cartilage, and rotator cuff were normal in appearance.
Figure 4
Preoperative AP radiograph of patient two demonstrating hypertrophic degenerative change of the AC joint.
Figure 5
T2-weighted coronal MRI sequence of patient two demonstrating edema pattern of the medial acromion and fluid within the AC joint space.
Figure 6
T2-weighted sagittal MRI sequence. Note the intact coracoclavicular ligaments. The patient had suffered a prior AC joint separation.
This patient likewise underwent a diagnostic and therapeutic AC injection of 4cc 1% plain Lidocaine and 1cc of depomedrol, which demonstrated complete resolution of symptoms. He experienced lasting relief for roughly 7 to 8 months, with gradual return of pain. A subsequent injection produced similar improvement for 2 months. He also elected to proceed with arthroscopic distal clavicle resection (Figure 7A-C).
Postoperative radiographs demonstrated adequate bone resection and no obvious translation of the clavicle relative to the acromion (Figure 8). He underwent a standard postoperative protocol and returned to swimming and other functional activities at 8 weeks following surgery. He remains pain free at one year following surgery, with no complaints of mechanical instability of the distal clavicle.
Figure 8
Postoperative Zanca radiograph of same patient demonstrating distal clavicle resection. Again, note even bone resection and avoidance of excessive bone removal, particularly in the setting of a prior AC joint injury.

SUMMARY

Direct arthroscopic resection of the distal clavicle is an acceptable method of treating osteoarthrosis or synovitis of the AC joint that has failed to respond to a reasonable course of nonoperative treatment. Other AC joint disorders, such as distal clavicle osteolysis or nonunion of the distal clavicle, may also be treated with this technique. The procedure should only be performed when it is determined preoperatively that the AC joint is the isolated area of pathology. The only exception to this is the rare situation when it is preferred to diagnostically inspect the glenohumeral joint, but not perform extensive work either there, or in the subacromial or subcoracoid space. In comparison to other techniques, it allows precise resection of bone with minimal trauma to the surrounding soft tissue structures, which may decrease postoperative discomfort and shorten the recovery time. In addition, the procedure is quite pleasing from a cosmetic standpoint, and minimizes scar irritation from clothing or luggage straps that may occur with a larger superior incision.