Case of the Week 100 (from Bill Hsu, DC, DACBR Toronto) 68 year old house wife with insidious onset on left clavicular pain of 2 month duration. Constant ach Intensity - 3/10 day; 9/10 night Occasional referral to posterior scalp and left ear Aggravated by sleeping on left shoulder Relieved with Lakota (Rx)

Physical Examination Neurological Range of Motion Normal cranial nerves, upper and lower extremities. Range of Motion C/S Painful in active and passive left lateral flexion and left rotation Left shoulder Painful at 90 degrees horizontal adduction and vertical abduction Observation + Palpation Moderate swelling and tenderness along the superior-medial aspect of the left clavicle

What are the abnormal findings? DDX?

Answers Abnormal findings: DDX: The medial end of the left clavicle is sclerotic. Mild narrowing the C5-6-7 disc spaces is noted with anterior osteophytes, hypertrophy of the C5-6 facet articulations as well as the C6 uncinate processes. Intercalary bones are noted in the anterior aspects of the C5-6 and C6-7 disc spaces. DDX: Osteitis condensens of the left clavicle with the DDX of blastic metastasis and osteomyelitis. Degenerative disc disease C5-6-7 with facet and uncovertebral arthrosis.

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

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

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

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

OCC Typically female 40’s History of stress Etiology – unknown Symptoms Pain and swelling over SC joint Pain may located in neck, shoulder or anterior chest wall

OCC Clinical course Intermittent flare-ups Spontaneous resolution* Pain usually reduced over time^ Swelling may persist^ Sclerosis may improve slightly ^Ann Acad Med Singapore 2004; 33:499-502 * Rev Rhum Engl Ed. 1995 Jul-Sep;62(7-8):501-6.