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We present a rare case of rotator cuff injury and biceps tendinitis due to multiple osteochondromas of the shoulder of a 20-year-old woman. The patient presented with longstanding atraumatic anterior shoulder pain and rotator cuff weakness. Magnetic resonance imaging (MRI) revealed multiple osteochondromas of the scapula with protuberances present on the body, underside of acromion and in the bicipital groove. Diagnostic arthroscopy demonstrated a severely narrowed subacromial space with bursal fraying of the supraspinatus tendon laterally and a musculotendinous tear medially. Arthroscopic subacromial osteotomy and mini-open bicipital groove osteoplasty successfully eliminated the patient’s symptoms. Although true subacromial impingement is uncommon, particularly in this age category, persistent symptoms demand multiplanar imaging to rule out neoplastic causes of pain and functional deficit.
Osteochondromas are the most common benign musculoskeletal tumor and occur in adolescents and young adults.
Although most tumors remain asymptomatic and only require monitoring of cartilage cap growth as an indicator of rare malignant transformation, some grow in sensitive periarticular regions where they can disturb normal joint kinematics.
However, we found no reports of a scapular osteochondroma causing rotator cuff tear in young patients. We present a 20-year-old patient with 3 osteochondromas of the shoulder girdle causing subacromial impingement with a supraspinatus musculotendinous junction tear and biceps irritation.
Case report
A 20-year-old woman presented with atraumatic shoulder pain particularly in overhead movements with associated clicking phenomena. The past medical history was unremarkable beyond a previous solitary osteochondroma of the wrist diagnosed in childhood; there was no personal or family history of hereditary multiple exostosis. Clinical examination revealed symmetrical posture, physiological scapular positioning, and full range of motion of the glenohumeral and scapulothoracic articulations. The patient complained of a classical painful arc 80 to 120°. Impingement provocation tests were positive, and in Hawkins test, a palpable click was felt inside the shoulder joint. Jobe’s test was masked by pain and demonstrated 4/5 power, whereas the remaining rotator cuff examination revealed power comparable with the contralateral side. A small and tender mass was palpable in the bicipital groove, and biceps signs were positive. Plain radiographs were suggestive of a bony protuberance underneath arising from the acromion, but were otherwise unremarkable. MRI and computed tomography revealed an osteochondroma rising from the basi-acromion to meta-acromion junction displacing and compressing the supraspinatus muscle causing tendinosis (Figure 1, Figure 2, Figure 3, Figure 4, Video 1). A second small osteochondroma arose from the medial edge of the bicipital groove to compress the long head of biceps. A third osteochondroma was seen arising on the inferior scapular pole (Fig. 5, Video 1).
Figure 3T2 paracoronal MRI right shoulder, the points to subacromial osteochondroma with visible impinging of supraspinatus onto the glenohumeral joint. MRI, magnetic resonance imaging.
Because of the clear correlation between the imaging and clinical features, the patient underwent arthroscopic shoulder examination. During surgery, compression of the supraspinatus tendon against the glenohumeral joint was confirmed from an intra-articular posterior viewing portal (Fig. 6, Video 1). Marked inflammation of the subacromial bursa was evident as was bursal-sided fraying of the supraspinatus tendon (Fig. 7, Video 1). Passing the shoulder through a range of rotation and abduction demonstrated impingement and extension of the bursal fraying into the musculotendinous junction of the supraspinatus and a resultant full-thickness longitudinal tear. A lateral subacromial viewing portal was created, and an osteotomy was performed via the posterior portal followed by burring of the posterolateral acromion undersurface (Figs. 8 and 9, Video 1). The decompression allowed for smooth tendon passage under the acromion (Figs. 10 and 11, Video 1). The medial position and longitudinal orientation of the tear meant the tear did not require repair. A mini-open delto-pectoral approach to the bicipital groove was then performed. The distal position of the osteochondroma allowed mobilization and retraction of the long head of biceps tendon with minimal dissection. The integrity of the transverse humeral ligament and sheath was maintained. The osteochondroma was carefully osteotomized to restore the distal medial bicipital groove. The patient was provided a sling for comfort for one week, and active assisted shoulder physiotherapy was commenced immediately. The patient recovered full range of motion without impingement or groove pain. The third osteochondroma on the scapular body remained asymptomatic. Skeletal survey revealed an asymptomatic osteochondroma on the right fibula. With a total of 4 osteochondromas diagnosed, the patient was consulted for the possibility of multiple hereditary osteochondromatosis, further referral was recommended, and the decision for observation was made.
Figure 6Right shoulder arthroscopic intra-articular view from the posterior portal, top left impingement of the supraspinatus tendon on the superior glenoid.
Figure 8Right shoulder arthroscopy lateral viewing portal subacromial. Top left placement of osteotome through the posterior portal on the osteochondroma base.
Figure 9Right shoulder arthroscopy, posterior viewing portal. Introduction of burr from the lateral portal, resection of spur from the acromion undersurface.
Figure 11Right shoulder arthroscopy lateral viewing portal after decompression (the top part of the picture), in center below is visible musculotendinous tear of supraspinatus.
This is the first report of a rotator cuff tear due to subacromial osteochondroma in a young adult. Furthermore, our case demonstrates that these lesions may be underestimated in initial MRI and warrants early surgical arthroscopic intervention on a young population.
Subacromial impingement syndrome after osteochondromas in the subacromial space is very rare.
Clement et al reported an osteochondroma arising from the scapular spine in a 19-year-old that resulted in impingement and was successfully treated arthroscopically with a decompression, although no further pathologies were described during the surgery.
Çitlak et al described the consequences of a neglected subacromial osteochondroma arising from the acromion tip in a 34-year-old, pointing out that arthroscopic treatment was technically challenging and open surgical removal had to be performed, while the rotator cuff injury was chronic and unsalvageable.
Because of the known progressive nature of osteochondromas and previous reports of irreversible joint damage with extensive subacromial expansion, early arthroscopic intervention may play a role in preventing further deterioration of rotator cuff integrity from mechanical obstruction and impingement and might be considered despite the patient’s young age.
Subacromial impingement pain in young adults is uncommon with osteochondromas a rare cause.
-
Persistent symptoms demand further imaging and will allow surgery to limit pain and rotator cuff tear progression.
-
Most lesions can be addressed arthroscopically, but mini-open approaches may be required for less accessible regions or subtle lesions.
Disclaimers
Funding: No funding was disclosed by the authors.
Conflicts of interest: The authors, their immediate family, and any research foundation with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.
Arthroscopic video of surgery with key steps. Legend: 1. diagnostic arthroscopy intra-articular (00:00-01:21). 2. Diagnostic arthroscopy subacromial (01:22-01:57). 3. Diagnostic arthroscopy subacromial lateral view ½ (01:57-02:12). 4. Diagnostic arthroscopy subacromial lateral view 2/2 (02:13-02:25). 5. Osteotomy (02:25-02:50). 6. Burring (02:51-03:06). 7. Post decompression, rotator cuff tear (03:06-03:24). Narration: Diagnostic arthroscopy of the glenohumeral joint from a posterior viewing portal. The supraspinatus and long head of biceps insertion are intact. Superior and medial to the glenoid, there is clear compression and displacement of the supraspinatus tendon. The glenohumeral joint surface is unremarkable, there are no loose bodies, and the infraspinatus is intact. With abduction and rotation of the extremity, internal impingement of the supraspinatus tendon occurs. The diagnostic view is completed, showing an intact biceps pulley system and subscapularis tendon. The subacromial space is viewed from a posterior portal. The compressing osteochondroma on the medial side has caused a lateral partial tear and impingement lesion of the tendon. Elevation of the extremity shows the dynamic catching of the tendon. From a lateral viewing portal, the rotational rubbing of the frayed tendon on the lesion is shown. After careful decompression, the extent of tendon damage medial to the lesion is seen for the first time. An osteotome through the posterior portal is used to detach the lesion at its base. Further osteoplasty is completed with the burr. Care is taken not to injure the tendon. After decompression, the unrepairable full-thickness musculotendinous junction tear is viewed.
References
Bartoníček J.
Říha M.
Tuček M.
Osteochondroma of scapular body—trans-scapular technique of resection: a case report.
T2 paracoronal MRI right shoulder, the points to subacromial osteochondroma with visible impinging of supraspinatus onto the glenohumeral joint. MRI, magnetic resonance imaging.
T2 paracoronal MRI right shoulder, the points to subacromial osteochondroma with visible impinging of supraspinatus onto the glenohumeral joint. MRI, magnetic resonance imaging.
T2 paracoronal MRI right shoulder, the points to subacromial osteochondroma with visible impinging of supraspinatus onto the glenohumeral joint. MRI, magnetic resonance imaging.
Right shoulder arthroscopy lateral viewing portal subacromial. Top left placement of osteotome through the posterior portal on the osteochondroma base.
Right shoulder arthroscopy lateral viewing portal after decompression (the top part of the picture), in center below is visible musculotendinous tear of supraspinatus.
Arthroscopic video of surgery with key steps. Legend: 1. diagnostic arthroscopy intra-articular (00:00-01:21). 2. Diagnostic arthroscopy subacromial (01:22-01:57). 3. Diagnostic arthroscopy subacromial lateral view ½ (01:57-02:12). 4. Diagnostic arthroscopy subacromial lateral view 2/2 (02:13-02:25). 5. Osteotomy (02:25-02:50). 6. Burring (02:51-03:06). 7. Post decompression, rotator cuff tear (03:06-03:24). Narration: Diagnostic arthroscopy of the glenohumeral joint from a posterior viewing portal. The supraspinatus and long head of biceps insertion are intact. Superior and medial to the glenoid, there is clear compression and displacement of the supraspinatus tendon. The glenohumeral joint surface is unremarkable, there are no loose bodies, and the infraspinatus is intact. With abduction and rotation of the extremity, internal impingement of the supraspinatus tendon occurs. The diagnostic view is completed, showing an intact biceps pulley system and subscapularis tendon. The subacromial space is viewed from a posterior portal. The compressing osteochondroma on the medial side has caused a lateral partial tear and impingement lesion of the tendon. Elevation of the extremity shows the dynamic catching of the tendon. From a lateral viewing portal, the rotational rubbing of the frayed tendon on the lesion is shown. After careful decompression, the extent of tendon damage medial to the lesion is seen for the first time. An osteotome through the posterior portal is used to detach the lesion at its base. Further osteoplasty is completed with the burr. Care is taken not to injure the tendon. After decompression, the unrepairable full-thickness musculotendinous junction tear is viewed.
We present a rare case of rotator cuff injury and biceps tendinitis due to multiple osteochondromas of the shoulder of a 20-year-old woman. The patient presented with longstanding atraumatic anterior shoulder pain and rotator cuff weakness. Magnetic resonance imaging (MRI) revealed multiple osteochondromas of the scapula with protuberances present on the body, underside of acromion and in the bicipital groove. Diagnostic arthroscopy demonstrated a severely narrowed subacromial space with bursal fraying of the supraspinatus tendon laterally and a musculotendinous tear medially. Arthroscopic subacromial osteotomy and mini-open bicipital groove osteoplasty successfully eliminated the patient’s symptoms. Although true subacromial impingement is uncommon, particularly in this age category, persistent symptoms demand multiplanar imaging to rule out neoplastic causes of pain and functional deficit.
A 20-year-old woman presented with atraumatic shoulder pain particularly in overhead movements with associated clicking phenomena. The past medical history was unremarkable beyond a previous solitary osteochondroma of the wrist diagnosed in childhood; there was no personal or family history of hereditary multiple exostosis. Clinical examination revealed symmetrical posture, physiological scapular positioning, and full range of motion of the glenohumeral and scapulothoracic articulations. The patient complained of a classical painful arc 80 to 120°. Impingement provocation tests were positive, and in Hawkins test, a palpable click was felt inside the shoulder joint. Jobe’s test was masked by pain and demonstrated 4/5 power, whereas the remaining rotator cuff examination revealed power comparable with the contralateral side. A small and tender mass was palpable in the bicipital groove, and biceps signs were positive. Plain radiographs were suggestive of a bony protuberance underneath arising from the acromion, but were otherwise unremarkable. MRI and computed tomography revealed an osteochondroma rising from the basi-acromion to meta-acromion junction displacing and compressing the supraspinatus muscle causing tendinosis (Figure 1, Figure 2, Figure 3, Figure 4, Video 1Video 1). A second small osteochondroma arose from the medial edge of the bicipital groove to compress the long head of biceps. A third osteochondroma was seen arising on the inferior scapular pole (Fig. 5Fig. 5, Video 1Video 1).
Figure 1
3D reconstruction computer tomography. 3D, three-dimensional.
T2 paracoronal MRI right shoulder, the points to subacromial osteochondroma with visible impinging of supraspinatus onto the glenohumeral joint. MRI, magnetic resonance imaging.
Because of the clear correlation between the imaging and clinical features, the patient underwent arthroscopic shoulder examination. During surgery, compression of the supraspinatus tendon against the glenohumeral joint was confirmed from an intra-articular posterior viewing portal (Fig. 6Fig. 6, Video 1Video 1). Marked inflammation of the subacromial bursa was evident as was bursal-sided fraying of the supraspinatus tendon (Fig. 7Fig. 7, Video 1Video 1). Passing the shoulder through a range of rotation and abduction demonstrated impingement and extension of the bursal fraying into the musculotendinous junction of the supraspinatus and a resultant full-thickness longitudinal tear. A lateral subacromial viewing portal was created, and an osteotomy was performed via the posterior portal followed by burring of the posterolateral acromion undersurface (Figs. 8Figs. 8 and 99, Video 1Video 1). The decompression allowed for smooth tendon passage under the acromion (Figs. 10Figs. 10 and 1111, Video 1Video 1). The medial position and longitudinal orientation of the tear meant the tear did not require repair. A mini-open delto-pectoral approach to the bicipital groove was then performed. The distal position of the osteochondroma allowed mobilization and retraction of the long head of biceps tendon with minimal dissection. The integrity of the transverse humeral ligament and sheath was maintained. The osteochondroma was carefully osteotomized to restore the distal medial bicipital groove. The patient was provided a sling for comfort for one week, and active assisted shoulder physiotherapy was commenced immediately. The patient recovered full range of motion without impingement or groove pain. The third osteochondroma on the scapular body remained asymptomatic. Skeletal survey revealed an asymptomatic osteochondroma on the right fibula. With a total of 4 osteochondromas diagnosed, the patient was consulted for the possibility of multiple hereditary osteochondromatosis, further referral was recommended, and the decision for observation was made.
Figure 6
Right shoulder arthroscopic intra-articular view from the posterior portal, top left impingement of the supraspinatus tendon on the superior glenoid.
Right shoulder arthroscopy lateral viewing portal subacromial. Top left placement of osteotome through the posterior portal on the osteochondroma base.
Right shoulder arthroscopy lateral viewing portal after decompression (the top part of the picture), in center below is visible musculotendinous tear of supraspinatus.
This is the first report of a rotator cuff tear due to subacromial osteochondroma in a young adult. Furthermore, our case demonstrates that these lesions may be underestimated in initial MRI and warrants early surgical arthroscopic intervention on a young population.
Subacromial impingement syndrome after osteochondromas in the subacromial space is very rare.15x15Simonetti, I., Chianca, V., Ascione, F., Romano, A.M., and Pietto, F Di. Clavicular Osteochondroma: Extremely Rare Cause of Impingement Syndrome. J Orthop Case Reports. 2018;
8: 50–53https://doi.org/10.13107/jocr.2250-0685.1254 Crossref | PubMed | Google ScholarSee all References They have been described in several case reports with most tumor pedestals arising from the distal clavicle or scapular body.4x4Clarke, D.O., Crichlow, A., Christmas, M., Vaughan, K., Mullings, S., Neil, I. et al. The unusual osteochondroma: A case of snapping scapula syndrome and review of the literature. Orthop Traumatol Surg Res. 2017;
103: 1295–1298https://doi.org/10.1016/j.otsr.2017.01.019 Abstract | Full Text | Full Text PDF | PubMed | Scopus (4) | Google ScholarSee all References,8x8Frost, N.L., Parada, S.A., Manoso, M.W., Arrington, E., and Benfanti, P. Scapular osteochondromas treated with surgical excision. Orthopedics. 2010;
33: 804https://doi.org/10.3928/01477447-20100924-09 Crossref | PubMed | Scopus (26) | Google ScholarSee all References Older studies—although reporting successful treatment of impingement—have recommended an open surgical approach for complete resection.8x8Frost, N.L., Parada, S.A., Manoso, M.W., Arrington, E., and Benfanti, P. Scapular osteochondromas treated with surgical excision. Orthopedics. 2010;
33: 804https://doi.org/10.3928/01477447-20100924-09 Crossref | PubMed | Scopus (26) | Google ScholarSee all References,13x13Messinese, P., Vismara, V., Sircana, G., Campana, V., Mocini, F., Cardona, V. et al. Arthroscopic treatment of an unusual distal clavicle ostheochondroma causing rotator cuff impingement: Case report and literature review. Orthop Rev (Pavia). 2020;
12: 105–107https://doi.org/10.4081/or.2020.8683 Crossref | Scopus (1) | Google ScholarSee all References Clement et al reported an osteochondroma arising from the scapular spine in a 19-year-old that resulted in impingement and was successfully treated arthroscopically with a decompression, although no further pathologies were described during the surgery.6x6Clement, N.D., McBirnie, J.M., and Porter, D.E. Subacromial impingement syndrome in a patient with hereditary multiple exostosis: A case report. BMC Sports Sci Med Rehabil. 2013;
5: 20https://doi.org/10.1186/2052-1847-5-20 Crossref | PubMed | Scopus (0) | Google ScholarSee all References Furthermore, Kim et al described successful arthroscopic removal of a distal clavicle osteochondroma with no recurrence at two years.10x10Kim, D.W., Bae, K.C., Son, E.S., Baek, C.S., and Cho, C.H. Osteochondroma of the Distal Clavicle: A Rare Cause of Impingement and Biceps Tear of the Shoulder. Clin Shoulder Elbow. 2018;
21: 158–161https://doi.org/10.5397/cise.2018.21.3.158 Crossref | PubMed | Google ScholarSee all References We confirm these findings that arthroscopic early removal of subacromial osteochondromas is technically safe and efficient.12x12MacDermid, J.C., Ramos, J., Drosdowech, D., Faber, K., and Patterson, S. The impact of rotator cuff pathology on isometric and isokinetic strength, function, and quality of life. J Shoulder Elbow Surg. 2004;
13: 593–598https://doi.org/10.1016/j.jse.2004.03.009 Abstract | Full Text | Full Text PDF | PubMed | Scopus (178) | Google ScholarSee all References
Çitlak et al described the consequences of a neglected subacromial osteochondroma arising from the acromion tip in a 34-year-old, pointing out that arthroscopic treatment was technically challenging and open surgical removal had to be performed, while the rotator cuff injury was chronic and unsalvageable.3x3Çitlak, A., Akgün, U., Bulut, T., Aslan, C., Mete, B.D., and Şener, M. Subacromial osteochondroma: A rare cause of impingement syndrome. Int J Surg Case Rep. 2015;
6: 126–128https://doi.org/10.1016/j.ijscr.2014.12.010 Crossref | Scopus (6) | Google ScholarSee all References Because of the known progressive nature of osteochondromas and previous reports of irreversible joint damage with extensive subacromial expansion, early arthroscopic intervention may play a role in preventing further deterioration of rotator cuff integrity from mechanical obstruction and impingement and might be considered despite the patient’s young age.9x9Jacobsen, J.R., Jensen, C.M., and Deutch, S.R. Acromioplasty in patients selected for operation by national guidelines. J Shoulder Elbow Surg. 2017;
26: 1854–1861https://doi.org/10.1016/j.jse.2017.03.028 Abstract | Full Text | Full Text PDF | PubMed | Scopus (2) | Google ScholarSee all References
Conclusion
-
Subacromial impingement pain in young adults is uncommon with osteochondromas a rare cause.
-
Persistent symptoms demand further imaging and will allow surgery to limit pain and rotator cuff tear progression.
-
Most lesions can be addressed arthroscopically, but mini-open approaches may be required for less accessible regions or subtle lesions.
Disclaimers
Funding: No funding was disclosed by the authors.
Conflicts of interest: The authors, their immediate family, and any research foundation with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.
Arthroscopic video of surgery with key steps. Legend: 1. diagnostic arthroscopy intra-articular (00:00-01:21). 2. Diagnostic arthroscopy subacromial (01:22-01:57). 3. Diagnostic arthroscopy subacromial lateral view ½ (01:57-02:12). 4. Diagnostic arthroscopy subacromial lateral view 2/2 (02:13-02:25). 5. Osteotomy (02:25-02:50). 6. Burring (02:51-03:06). 7. Post decompression, rotator cuff tear (03:06-03:24). Narration: Diagnostic arthroscopy of the glenohumeral joint from a posterior viewing portal. The supraspinatus and long head of biceps insertion are intact. Superior and medial to the glenoid, there is clear compression and displacement of the supraspinatus tendon. The glenohumeral joint surface is unremarkable, there are no loose bodies, and the infraspinatus is intact. With abduction and rotation of the extremity, internal impingement of the supraspinatus tendon occurs. The diagnostic view is completed, showing an intact biceps pulley system and subscapularis tendon. The subacromial space is viewed from a posterior portal. The compressing osteochondroma on the medial side has caused a lateral partial tear and impingement lesion of the tendon. Elevation of the extremity shows the dynamic catching of the tendon. From a lateral viewing portal, the rotational rubbing of the frayed tendon on the lesion is shown. After careful decompression, the extent of tendon damage medial to the lesion is seen for the first time. An osteotome through the posterior portal is used to detach the lesion at its base. Further osteoplasty is completed with the burr. Care is taken not to injure the tendon. After decompression, the unrepairable full-thickness musculotendinous junction tear is viewed.
Arthroscopic video of surgery with key steps. Legend: 1. diagnostic arthroscopy intra-articular (00:00-01:21). 2. Diagnostic arthroscopy subacromial (01:22-01:57). 3. Diagnostic arthroscopy subacromial lateral view ½ (01:57-02:12). 4. Diagnostic arthroscopy subacromial lateral view 2/2 (02:13-02:25). 5. Osteotomy (02:25-02:50). 6. Burring (02:51-03:06). 7. Post decompression, rotator cuff tear (03:06-03:24). Narration: Diagnostic arthroscopy of the glenohumeral joint from a posterior viewing portal. The supraspinatus and long head of biceps insertion are intact. Superior and medial to the glenoid, there is clear compression and displacement of the supraspinatus tendon. The glenohumeral joint surface is unremarkable, there are no loose bodies, and the infraspinatus is intact. With abduction and rotation of the extremity, internal impingement of the supraspinatus tendon occurs. The diagnostic view is completed, showing an intact biceps pulley system and subscapularis tendon. The subacromial space is viewed from a posterior portal. The compressing osteochondroma on the medial side has caused a lateral partial tear and impingement lesion of the tendon. Elevation of the extremity shows the dynamic catching of the tendon. From a lateral viewing portal, the rotational rubbing of the frayed tendon on the lesion is shown. After careful decompression, the extent of tendon damage medial to the lesion is seen for the first time. An osteotome through the posterior portal is used to detach the lesion at its base. Further osteoplasty is completed with the burr. Care is taken not to injure the tendon. After decompression, the unrepairable full-thickness musculotendinous junction tear is viewed.
References
1Bartoníček, J., Říha, M., and Tuček, M. Osteochondroma of scapular body—trans-scapular technique of resection: a case report. J Shoulder Elbow Surg. 2018;
27: e348–e353https://doi.org/10.1016/j.jse.2018.08.004
3Çitlak, A., Akgün, U., Bulut, T., Aslan, C., Mete, B.D., and Şener, M. Subacromial osteochondroma: A rare cause of impingement syndrome. Int J Surg Case Rep. 2015;
6: 126–128https://doi.org/10.1016/j.ijscr.2014.12.010
4Clarke, D.O., Crichlow, A., Christmas, M., Vaughan, K., Mullings, S., Neil, I. et al. The unusual osteochondroma: A case of snapping scapula syndrome and review of the literature. Orthop Traumatol Surg Res. 2017;
103: 1295–1298https://doi.org/10.1016/j.otsr.2017.01.019
5Cleeman, E., Auerbach, J.D., and Springfield, D.S. Tumors of the shoulder girdle: A review of 194 cases. J Shoulder Elbow Surg. 2005;
14: 460–465https://doi.org/10.1016/j.jse.2005.02.003
6Clement, N.D., McBirnie, J.M., and Porter, D.E. Subacromial impingement syndrome in a patient with hereditary multiple exostosis: A case report. BMC Sports Sci Med Rehabil. 2013;
5: 20https://doi.org/10.1186/2052-1847-5-20
7Clement, N.D., Ng, C.E., and Porter, D.E. Shoulder exostoses in hereditary multiple exostoses: Probability of surgery and malignant change. J Shoulder Elbow Surg. 2011;
20: 290–294https://doi.org/10.1016/j.jse.2010.07.020
9Jacobsen, J.R., Jensen, C.M., and Deutch, S.R. Acromioplasty in patients selected for operation by national guidelines. J Shoulder Elbow Surg. 2017;
26: 1854–1861https://doi.org/10.1016/j.jse.2017.03.028
10Kim, D.W., Bae, K.C., Son, E.S., Baek, C.S., and Cho, C.H. Osteochondroma of the Distal Clavicle: A Rare Cause of Impingement and Biceps Tear of the Shoulder. Clin Shoulder Elbow. 2018;
21: 158–161https://doi.org/10.5397/cise.2018.21.3.158
12MacDermid, J.C., Ramos, J., Drosdowech, D., Faber, K., and Patterson, S. The impact of rotator cuff pathology on isometric and isokinetic strength, function, and quality of life. J Shoulder Elbow Surg. 2004;
13: 593–598https://doi.org/10.1016/j.jse.2004.03.009
14Padua, R., Castagna, A., Ceccarelli, E., Bondì, R., Alviti, F., and Padua, L. Intracapsular osteochondroma of the humeral head in an adult causing restriction of motion: A case report. J Shoulder Elbow Surg. 2009;
18: e30–e31https://doi.org/10.1016/j.jse.2008.09.008
15Simonetti, I., Chianca, V., Ascione, F., Romano, A.M., and Pietto, F Di. Clavicular Osteochondroma: Extremely Rare Cause of Impingement Syndrome. J Orthop Case Reports. 2018;
8: 50–53https://doi.org/10.13107/jocr.2250-0685.1254
16Tepelenis, K., Papathanakos, G., Kitsouli, A., Troupis, T., Barbouti, A., Vlachos, K. et al. Osteochondromas: An updated review of epidemiology, pathogenesis, clinical presentation, radiological features and treatment options. In Vivo (Brooklyn). 2021;
35: 681–691https://doi.org/10.21873/INVIVO.12308
17Tomo, H., Ito, Y., Aono, M., and Takaoka, K. Chest wall deformity associated with osteochondroma of the scapula: A case report and review of the literature. J Shoulder Elbow Surg. 2005;
14: 103–106https://doi.org/10.1016/j.jse.2004.03.007
points to subacromial osteochondroma with visible impinging of supraspinatus onto the glenohumeral joint. MRI, magnetic resonance imaging.
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