Sprain of the sternoclavicular joint/ligaments

This is usually the result of an injury such as a fall on the outstretched hand or on the shoulder. Occasionally, a sprain is the result of overuse, which mainly occurs in arthrotic joints.

Pain is felt unilaterally over the lateral manubrial angle and may radiate into the clavicular area. It can be elicited by active and passive elevation of the scapula and by all passive movements of the arm. Resisted movements are negative. Passive horizontal adduction – an accessory test – is the most painful movement. On palpation there is tenderness over the joint line or in the ligaments.

Posterior sternoclavicular syndrome

This rare disorder may arise spontaneously in middle-aged people and usually causes a misleading clinical picture.

Patients complain of unilateral pain at the base of the neck. Surprisingly, the pain is felt more posteriorly and not at the sternoclavicular joint itself, which suggests a lesion of the cervical spine. Nevertheless, clinical examination of the neck does not localize the problem: there is usually full range on passive movements and no pain on active and resisted movements. Both active and passive elevation of the arm is painful. Sometimes it is even hard to achieve full range. All other movements of the arm are normal, except for passive horizontal adduction which is most painful. Clinical examination of the shoulder girdle is required. Pain is elicited by active and passive elevation of the shoulder. Resisted shoulder elevation is negative, which excludes the trapezius and levator scapulae muscles. No pain is found on palpation of the anterior portion of the sternoclavicular joint.

Arthrosis

Arthrosis of the sternoclavicular joint is common.² It occurs mainly in postmenopausal women. The chief complaint is cosmetic: there is a visible thickening of the joint. The pain, if any, is minor ³. Elevation of the arm is limited as the result of the limitation of the shoulder girdle movement. Movements of the shoulder girdle are uncomfortable but not really painful.

Radiography shows degenerative changes (osteophytes, bone cysts, hyperostosis and diminution of the joint line), most pronounced at the inferior aspect of the clavicular head. Occasionally calcification is seen in the ligaments.⁴

For the overuse phenomenon in arthrosis an intra-articular injection of triamcinolone acetonide can be given.

Rheumatoid arthritis

Rheumatic conditions may also affect the sternoclavicular joint. This often occurs in ankylosing spondylitis.⁵ It gives rise to the same clinical pattern as in a sprain, but local swelling from synovial thickening is present. A progressive ankylosis develops with pronounced limitation of movement in the shoulder girdle. Other sites of rheumatoid arthritis should bring the disorder in mind, although the sternoclavicular joint may be the first joint affected.

Septic arthritis

Bacterial agents such as Staphylococcus aureus, Streptococcus group B and Brucella spp. have been isolated in septic arthritis of the sternoclavicular joint.^6,7 Septic arthritis occurs in elderly patients with a deficient immune system, with rheumatoid arthritis and diabetes mellitus, and in drug addicts.^8–10 The patient usually has fever, chills and sweating, and complains of pain and swelling in the sternoclavicular area, sometimes at the base of the neck. In about 20% a local, warm and erythematous mass is present at the joint because of abscess formation.^11–13

A combination of neck signs, shoulder signs and shoulder girdle signs is found on examination:

There is an elevated erythrocyte sedimentation rate and tomography or CT scan are mostly likely to show bony erosions and destructive changes at the medial end of the clavicle and the clavicular aspect of the sternum.

Sprain of the first costotransverse joint

The patient complains of unilateral pain at the base of the neck elicited by certain movements of the arm and shoulder. On examination pain is elicited by active and passive side flexion away from the painful side and resisted flexion towards the painful side. Flexion may also be positive.

Such a pattern – in fact a contractile tissue pattern – draws attention to the scaleni muscles. In this case the lesion does not lie in the scaleni but in the structure to which the muscle is attached. Pain is also present on active and passive elevation of the arm and the scapula, resulting in a mixed pattern of neck, shoulder and shoulder girdle signs.

Stress fracture of the first rib

Pain occurs spontaneously and is felt unilaterally at the base of the neck and in the scapulopectoroclavicular area. The clinical picture is typical. There are neck, shoulder girdle and shoulder signs. In the neck a ‘contractile tissue pattern’ is found: pain on active and passive side flexion towards the painless side, combined with pain on resisted side flexion towards the painful side. All scapular movements are more or less painful and active elevation of the arm is impossible because of the pain: the arm stops at the horizontal. Passive elevation is full but painful. Radiography is confirmative (see also p. 237).