Sternoclavicular Joint Pain

Indications and Clinical Considerations

The sternoclavicular joint can serve as a source of pain that often can mimic pain of cardiac origin. The sternoclavicular joint is a true joint and is susceptible to the development of arthritis, including osteoarthritis, rheumatoid arthritis, ankylosing spondylitis, Reiter syndrome, and psoriatic arthritis ( Fig. 104.1 ). The joint is often traumatized during acceleration–deceleration injuries and blunt trauma to the chest. With severe trauma, the joint may sublux or dislocate ( Fig. 104.2 ). Overuse or misuse can also result in acute inflammation of the sternoclavicular joint, which can be quite debilitating. The joint is also subject to invasion by tumor from primary malignancies, including thymoma, or from metastatic disease.

Physical examination reveals that the patient will vigorously attempt to splint the joint by keeping the shoulders stiffly in neutral position. Pain is reproduced by active protraction or retraction of the shoulder, as well as full elevation of the arm. Shrugging of the shoulder also may reproduce the pain. The sternoclavicular joint may be tender to palpation and feel hot and swollen if acutely inflamed. The patient may also report a clicking sensation with movement of the joint.

Plain radiographs are indicated for all patients with pain thought to be emanating from the sternoclavicular joint to rule out occult bony disease, including tumor. On the basis of the patient’s clinical presentation, additional testing may be indicated, including complete blood cell count, prostate-specific antigen, sedimentation rate, and antinuclear antibody testing. Magnetic resonance imaging and/or ultrasound of the joint is indicated if joint instability is suspected and to clarify the diagnosis ( Fig. 104.3 ). The injection technique described later serves as both a diagnostic and a therapeutic maneuver.

Clinically Relevant Anatomy

The sternoclavicular joint is a double-gliding joint with an actual synovial cavity ( Fig. 104.4 ). Articulation occurs among the sternal end of the clavicle, the sternal manubrium, and the cartilage of the first rib. The clavicle and sternal manubrium are separated by an articular disk ( Fig. 104.5 ). The joint is reinforced in front and back by the sternoclavicular ligaments (see Fig. 104.4 ). Additional support is provided by the costoclavicular ligament, which runs from the junction of the first rib and its costal cartilage to the inferior surface of the clavicle. The joint is dually innervated by both the supraclavicular nerve and the nerve supplying the subclavius muscle. Posterior to the joint are a number of large arteries and veins, including the left common carotid and brachiocephalic vein and, on the right, the brachiocephalic artery ( Fig. 104.6 ). These vessels are susceptible to needle-induced trauma if the needle is placed too deeply.

The serratus anterior muscle produces forward movement of the clavicle at the sternoclavicular joint, with backward movement at the joint produced by the rhomboid and trapezius muscles. Elevation of the clavicle at the sternoclavicular joint is produced by the sternocleidomastoid, rhomboid, and levator scapulae. Depression of the clavicle at the joint is produced by the pectoralis minor and subclavius muscles.