Unstable Sternoclavicular Joint

[rosie_clarke]

I have a 14 yr old patient who is a competitive swimmer who has recently developed (last six months) a very "unstable" SCJ.No history of trauma in the area. During simulated front crawl there is a very audible recurrent clunking in the Right SCJ which causes brief pain. He also experiences the clunking if he lifts up something with his right hand or puts his hands behind his back to stretch. He has very poor posture and scapular control so I have started him on a scapular control strengthening programme and have been attempting to strap the joint to increase the stability. So far any strapping we have done has been unsuccessful.
All the research I have found suggests this atraumatic spontaneous subluxation should resolve in time and that education and reassurance are the primary treatment options, surgury being a non-option due to poor outcomes etc.
I am wondering if everyone has encountered a problem like this before and how did they approach it? Any tips on strapping and direction of strapping?
Would appreciate any help or advice as am feeling a bit stuck!
Thanks
Rosie

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[iliastolos]

Hi Rosie!

Unfortunately, I have never met such a case before. After a quick literature review, I found that this recurrent atraumatic subluxation is very rare. The patient's age is indicative of a possible fracture at the epiphyseal plate which is misinterpreted without an x-ray or CT. I guess this has already been performed but if not it is highly recommended. If it is ligamentous laxity, I assume it will not be rehabilitated non-surgically. On the other hand, surgical intervention has many contras for this joint. As for taping, I have never learned or used it for the SC joint.

Therefore, I could only guess of what could help your patient. Stability at the SC joint is accomplished almost exclusively by the joint's ligaments and disc. Taking this into account, motor control training of the shoulder girdle might not have a high impact on SCJ stability. However, this joint participates in arm elevation and a therapist should definitely attempt to increase motor control of the area. PNF patterns and techniques might help you a lot in this. As for taping, I cannot think of a way to 'stabilize' the tape to a firm point. It could be the sternum or the ribs but again I doubt. Mobilization of the joint might help through a Mulligan-concept mobilization with movement during elevation of the arm. Try to palpate the direction of subluxation during active movement and then apply a sustained force against the direction of subluxation and repeat arm elevation. Just try to insist excessive motion, do not apply a high force and ask the patient if it's painful. There's no other way I could think of facilitating this movement. Classical interventions like ultrasound, TENS for pain etc don't think they should work.

I hope I helped in a way. I'll keep on searching.

Regards

[estherderu]

dear Rosie,

Is your young patient hypermobile, or is it juist this joint? This could make the treatment goals different.
I agree with Iliastoles that coordination,strength and stabilty probably needs to be enhanced. Consider the fact that this young persons body is probably in a "wrong" posture for most of the day.
I would suggest elastic taping (Cure-tape, KinesioTape,Kinesiology Tape, K-taping) on the joint. I would suggest applying a little tape around the joint. Make sure you tape the dermatome belonging to the joint. This sensory imput/ stimulus does not immobilise at all and could be of some help.

kind regards

Esther

[pudding_bowl]

I'v not seen a subluxed SC joint, I have however had stiff SC joint myself when I was 16 - 21 while I was doing alot of competitive rock climbing.

I used to manipulate my SC joint using ext rot at 90 degree abd and a deep breath in - I was taught this by a physio manip tutor as he suffered the same problem after heavy weight lifting and body building.

My thoughts: As we know the SC joint moves with the GH and AC joint - If the scapular is correctly stabilised and humeral movements are co-ordinated correctly then the SC joint will be in the best position to heal - so I feel the postural work that you are doing is well indicated. And perhaps you can look at - following how my and my tutors SC's had became stiff - a high level of strengthening around the shoulder while maintaining scapular position. I'm not saying it would work - as it's already subluxed, unless the strengthening can be done without causing excessive mobility, it may just cause further mobility.

good luck - very interesting case and it'd be good to hear how you achieve good results.

[msk101]

HI There,

I'd also suggest soft tissue work and stretches on muscles that would be likely to contribute to excessive strain on the SCJ such as the sterno-cleido, mastoid, pec minor and major. As a swimmer myself the pecs can be tight and over active particularly in a freestyle or butterfly swimer. Deep neck flexor control also necessary given postural issues and if they're weak then SCM will become overactive also. Perhaps a couple of weeks off swimming and actively restricting UL ROM (eg put a sling on) will let everything settle and over stretched joint capsules and ligaments settle while getting stuck into the postural and base level stability exercises. Could be interesting.

As for taping i'd be more inclined to not bother or else you'd need to do a foam compression donut over the joint with elastic tape on the diagonal right around under the axilla on the ribs from the opposite side, across the contralateral SCJ and back around over the back (like wearing a long strap hand bag slung over the head/shoulder)!!! uncomfortable but might provide some joint compressive force. wouldn't be able to swim with it though.

Hope that makes sense!
msk101

[Quickstart]

I hav just recently had a patient in with a very similar case, and I can tell you this: Physio alone will do squat! This needs and orthopaedic review.

My case: My teenage female patient presented with shoulder pain and a clunking collarbone two years ago. She is a competitive butterfly/freestyler. Attended a prolific sports physiotherapy practice and was diagnosed as having shoulder impingement syndrome and given a woefully inadequate RC strengthening programme.

I saw her eight months ago and diagnosed her as having multidirectional instability (as she has a hypermobility syndrome and an inferior GH sulcus sign) as well as having an unstable SC joint. We commenced a 'proper' RC programme focussing on scapular setting first and had some good gains. She got back in the pool, but was only in for two months before her clunking SC joint started playing up more. We tried taping, DTM, RC control, EMG biofeedback, mobilisations -- nothing helped.

I finally got her sent of to have a corticosteroid under radiographic imaging -- and immediate results. We confirmed our diagnosis and she got three months of complete pain relief. As the shot wore off the pain came back. I then organised a referral with a very prolific shoulder surgeon in Melbourne who specialises in instability and he agreed that she had a spontaneously subluxing SC joint and surgery is her only option for recovery. He has only performed this operation 16 times in his working life.

Because this condition is affecting her everyday life -- and because she wants to be a physio -- she is going to have the surgery. But it is complicated:

- Surgeon will go in, take a graft of what I assume is palmaris tendon, to use as the ligament graft. Then go in and use it to stabilise the SC joint. He then uses a metal plate to lock her SC joint in place which will render her unable to elevate her arm for 3 months. The plate then gets removed and we commence rehab. Because of the precarious location of the subclavian vein he has to have a vascular surgeon on standby.

Sorry for the long blog, but this has been a diffcult issue therefore I want to try to save you time, using my experiences. My boss -- who has 13 years of sports physio experience behind him -- has also never seen this condition before. So I want to share for others sakes.

My advice: Get a cortico done under radiographic guidance to confirm diagnosis. If it works find the best sporting shoulder surgeon you can find. And write a lengthy referral letter. My patient went against my advice and went to an orthopod closer to home who ran screaming from it. His oh-so-helpful advice was: "Stop swimming; take up gymnastics". And no, I'm not exaggerating here. I wish I was...

Feel free to ask any questions. As it is an intensely interesting case but a frustrating one.

[rosie_clarke]

Thank you for all your helpful replies. The patient has since had an orthopaedic consult who has advised him that it is not a surgical issue, apparently he has seen "loads" of unstable SCJs and that it is not as unusual as we had suggested (my senior has 25yrs MSK experience and has never seen one). He has told the patient that he can continue with all sports and that symptons should relieve in time.
This leaves us in a situation where the young patient has NO desire to continue with an exercise programme as the consultant did not specify directly that he should, even though he is still experiencing the same levels of pain.
To answer some of your questions, yes there is evidence of generalised ligamentous laxity. And altough yes we feel it would be beneficial to put the arm in a sling and immobilise for a couple of weeks this is not possible as it would restrict his school work hugely and keep him out of competitions, we know that he would not be compliant and it is unlikely we would get his parents on board unless we could promise results. Also because the orthopod was almost dismissive of the problem we feel that our opinions and advice may fall on deaf ears!

Thank you for all your help and if I'll keep you informed should we get a breakthrough !!!

[arcadiafades]

Hello everyone,
I thought I'd chime in on this conversation because I have an interesting point of view. I'm a pre-med student from the U.S. who has done freestyle BMX for 7 years, powerlifting for 4 years, and mixed martial arts for a little over a year. I also happen to have unstable SC joints. The subluxation or clunking sensation began in 2007; it was painless and remained so until February of this year. It allowed me a high degree of function including boxing and benching around 300 pounds. In February, I felt a ripping sensation at the joint and it dislocated. From February to June it was extremely unstable, it would flip out from the sternum quite a bit. I had reviewed all of the literature available, and when I say all of it, I mean every piece of literature out there. I even went to the Mayo Clinic in Jacksonville for a consult and I e-mailed Dr.Rockwood, the authority on SC joint problems. I had read up on a treatment called prolotherapy, where they inject irritating solutions to try to trick the body into laying down more collagen. I was skeptical but figured, what the hell, the only thing I had to lose was money. I went to Dr.Stein in Plantation, a previous ortho surgeon with 30 years of experience and he administered prolotherapy to both SC joints using a 15% dextrose solution. Five weeks later they called and asked how the joints were doing. I told them nothing happened and that it was bullshit, obviously very annoyed. The next week, the right SC joint stopped coming out. There would be pain and some aberrant movement at the end ROM, but the gross abnormal movement had stopped. Two months later, the side that had dislocated and remained unstable for close to 5 months, was now more stable than the left side. I continued the treatment every 4-6 weeks, progressing from dextrose to sodium morrhuate. I felt disheartened because the left SC joint had not responded and I figured once again, this is bullshit. A week after my last treatment with sodium morrhuate, the left joint had a significant increase in stability. It was still able to subluxate and clunk, but it took more to get it to do it. The right joint continued to get tighter and more stable. Two weeks ago I received platelet rich plasma into both joints, as this is the strongest solution containing the most growth factors. I believe the technique used is of the utmost importance. A straight injection of PRP into the joint space is probably going to do jackshit. It's the combination of the needle itself causing trauma to the capsule, followed with the PRP adhering to these capsular defects that causes a global change in SC joint stability. I know this because I visited another prolotherapist who used a different technique and it was no where near as effective as the first doctor, who used a "peppering" technique with the needle and you could feel the needle scraping bone. My biggest question was why this happened to me. I am not a hypermobile person, I score a 2 on the Beighton hypermobility scale. My parents score 0 and 1. My sister scores around 4 or 5, probably due to her age and the inherent laxity found in females. I was referred to Sheila Klausner, the PT for the U.S. Olympic swim team. She found severe restrictions in ROM, forward flexion = 145*, internal rotation= 15-20*. The posterior GH capsule was incredibly tight. The restriction in normal movement caused a compensatory reaction from the SC joints, which then resulted in a loss of proprioception, basically my SC joints would be in the wrong position and I'd regard it as "normal" because I didn't know any other way. I am still treating this currently, but I have found prolotherapy to be effective. I really believe it depends on the skill level of the practicioner though. As we know, ligament healing takes a long time, up to a year for remodeling to complete itself. This treatment is all about time and moderation. I am also using herbal poultices applied nightly to the area. It sounds hokey, but check out PubMed for some interesting results of herbal plasters applied to healing MCLs in rats. The ligaments healed with a higher ultimate tensile strength and a larger diameter. The morphological structure of the herb treated ligaments resembled the sham ligaments moreso than the control group (transected MCL, no herb plaster).

Bottom line: At least attempt prolotherapy before commiting to a surgery and check all restriction at the GH joint. He may be compensating or he may just be hypermobile all over. What is his Beighton score? Surgery may or may not be the answer to his problem considering the atraumatic nature of the condition.

[Edwin91]

Hi,
I too, have had unstable Sternoclavicular joints for over a year now. I can't remember when this happened or what caused it, since there is no pain, it just pops out of place when I move my right arm, and makes nasty clicking sounds. From the research I have done, I can tell you that with this type of injury, the only option you have is prolotherapy. I have been looking for solutions for this everywhere for a few months now, and have found absolutely nothing. Surgery is out of the question too because it would limit the ROM of the shoulder so much that sports will be out.
I have just had my 3 prolotherapy treatments and still see no improvements. But I read that it sometimes takes months to heal. I will update this forum when I see improvements with prolo.

[arcadiafades]

Just to give everyone an update: the prolotherapy treatments have stabilized my SCJs to the point where they no longer sublux with overhead motions.

I am currently writing a case report/lit. review with the doctor who treated me (I'm a premed student) and hope to have it published early next year.

I have documented a great deal of sternoclavicular joint research on my website:
The Forgotten Joint: Sternoclavicular Subluxation, Sternoclavicular Dislocation, Sternoclavicular Treament

It contains research on the SCJ, prolotherapy, my personal story, and a recovery blog.

[Taylor]

I hav just recently had a patient in with a very similar case, and I can tell you this: Physio alone will do squat! This needs and orthopaedic review.

My case: My teenage female patient presented with shoulder pain and a clunking collarbone two years ago. She is a competitive butterfly/freestyler. Attended a prolific sports physiotherapy practice and was diagnosed as having shoulder impingement syndrome and given a woefully inadequate RC strengthening programme.

I saw her eight months ago and diagnosed her as having multidirectional instability (as she has a hypermobility syndrome and an inferior GH sulcus sign) as well as having an unstable SC joint. We commenced a 'proper' RC programme focussing on scapular setting first and had some good gains. She got back in the pool, but was only in for two months before her clunking SC joint started playing up more. We tried taping, DTM, RC control, EMG biofeedback, mobilisations -- nothing helped.

I finally got her sent of to have a corticosteroid under radiographic imaging -- and immediate results. We confirmed our diagnosis and she got three months of complete pain relief. As the shot wore off the pain came back. I then organised a referral with a very prolific shoulder surgeon in Melbourne who specialises in instability and he agreed that she had a spontaneously subluxing SC joint and surgery is her only option for recovery. He has only performed this operation 16 times in his working life.

Because this condition is affecting her everyday life -- and because she wants to be a physio -- she is going to have the surgery. But it is complicated:

- Surgeon will go in, take a graft of what I assume is palmaris tendon, to use as the ligament graft. Then go in and use it to stabilise the SC joint. He then uses a metal plate to lock her SC joint in place which will render her unable to elevate her arm for 3 months. The plate then gets removed and we commence rehab. Because of the precarious location of the subclavian vein he has to have a vascular surgeon on standby.

Sorry for the long blog, but this has been a diffcult issue therefore I want to try to save you time, using my experiences. My boss -- who has 13 years of sports physio experience behind him -- has also never seen this condition before. So I want to share for others sakes.

My advice: Get a cortico done under radiographic guidance to confirm diagnosis. If it works find the best sporting shoulder surgeon you can find. And write a lengthy referral letter. My patient went against my advice and went to an orthopod closer to home who ran screaming from it. His oh-so-helpful advice was: "Stop swimming; take up gymnastics". And no, I'm not exaggerating here. I wish I was...

Feel free to ask any questions. As it is an intensely interesting case but a frustrating one.

Who ever wrote this post can you please email me, I have a posterior sternoclavicular dislocation and am desperately wanting someone who will do the surgery that you discussed about thank you Taylor at [email protected]

[huesg001]

Thankyou!! I'm a new grad physio with the same problem!

I have a subluxing L sternoclaviclar joint. Started about 3 years ago. I'd wake up in the morning and it would be 'out' and clunk around for about 10mins then settle. About 6 months ago I had it wrenched out playing basketball so much so that I can't lift my arm above 90 degrees without it popping. My shoulder posture is terrible but my SC joint now moves first whenever I try to reposition. It pops out before I can get my shoulder back. It's really disheartening because of the lack of muscular contributions to stablity of the joint.

It doesn't hurt but I'm more scared that it will contribute to problems down the track.

This thread is the first real information I've been able to find on it. I haven't heard of prolotherapy before - it might be a while before I consider it but at least I know about it!

Just wondering, has anyone else found that the presenting patient has a wide sternum? Because I have an abnormally wide sternum (sternum 3 finger widths between clavicular articulations). Any funny enough I was also a swimmer when I was younger and have recently stared back.

So thankyou! It's a relief to know that i'm not the only one out there

[Moserr]

HI All,

I personally have a client with an unstable SC joint with no pain, but constantly clicks in and out of place. My problem is that he has also broken, his clavicle on the same side and done a shoulder reconstruction 2 times on that side as well. Lets just say he's hung up his rugby boots everything was fine until recently when he took a nasty fall and hit his head stretching his neck muscles and hit his shoulder on a hard wooden surface, and got up not able to move his left arm above shoulder height and his SC joint got really lax again and the same with the shoulder joint. Everything is making crackling noises and popping in and out of place but pain free. He's done his time resting and a few physio sessions and the pain has lessened. , Can I get some advice on the the best excercises to strengthen and stabilize the SC joint before attempting to help him with a return to weight training .

[arcadiafades]

Moserr,

There are no exercises that will stabilize the sternoclavicular joint directly. It does not rely on dynamic stabilization like the GH joint. The muscles that attach to the area do not cross the joint, but rather pull it in their respective directions: subclavius pulls it down, SCM pulls up, clavicular portion of the pectoralis will have varied angles of pull, trapezius will elevate the lateral end of the clavicle and cause compression at the manubrial notch while pulling posterior on the clavicle. The sternoclavicular joint will continue to "do its thing" until the passive stabilization is restored via either a surgical reconstruction or regenerative injection therapy. If it is not causing pain, your main goal should be to work on the scapular stabilizers. Get his rhomboids and lower traps firing properly. This is of course only my opinion. It would be best to consult his ortho.

The Forgotten Joint: Sternoclavicular Dislocation, Subluxation, and Treatment

[slane52186]

Any updates on anybody that had SC joint instability? Mine is instable and i've started prolotherapy but not sure what to do next. It does not appear to be working... I'm at 28/yr male that had a good working shoulder until my sc joint randomly started popping in December 2013.

[findhan]

Any updates on anybody that had SC joint instability? Mine is instable and i've started prolotherapy but not sure what to do next. It does not appear to be working... I'm at 28/yr male that had a good working shoulder until my sc joint randomly started popping in December 2013.

Have a look at the site I posted here, Ive had lots of SC instability problems. Prolo may have worked for me but was marginal at best. Mine is on the mend though now but progress was painfully slow.

[Hockeyinheaven]

I'm an SC joint patient so I thought I'd reply w/ my condition. I'm 56 and have played men's beer league hockey all my adult life. About 7 years ago my rt. SC joint became inflamed, painful and swollen. I thought it was caused by shooting slapshots since that was the motion that made the pain and swelling flare up. I saw a shoulder surgeon and he shot me w/ cort in his office without imaging. That lasted a few years and then I had to go back for another. About 3 years ago my lt SC joint did the same thing. My dr. said my joints were arthritic. I seeked out a pain dr. that does prolotherapy in June '13 and he said he would shoot my SC joints w/ dextrose solution using fluoroscopy. The rt jt. was asymptomatic but the lt joint was painful and appeared w/ as a bumpy joint that would grind or pop when I moved my arm under load. The prolo seemed to cause more pain in te left joint and I begged him for a cort injection due to the intense pain. So to date, I've had 2 cort shots and 3 prolo shos in each joint. My ortho doc was reluctant to shoot my left joint 7 months ago. The pain has subsided but can still flare up if I shoot pucks or lay on that shoulder too long. So I'm not sure that dextrose prolo is very effective for arthritic SC joints, but cortisone injections definitely help. My right joint has been good for the last 3 years or so but I might request a shot for the left jt. This dr. is somewhat conservative as he makes me feel I'm making a deal with the devil. I wish there were more treatment options for this problem.

[estherderu]

dear hockeyplayer,
as a former hockeyplayer I can emphasize and understand your plight.
I am not so much in favour or putting anything in joints through injections and IF at all, then by a orthopedic surgeon only.
BUT I would only allow for 1 cortisone injection ever....have seen too many bad results after too much cortisone injections...

The best treatment is probably listening to your body and not doing the things that hurt you anymore.
There is a time to stop.... and take up something else less strenuous... sorry for this..

Esther

[Hockeyinheaven]

dear hockeyplayer,
as a former hockeyplayer I can emphasize and understand your plight.
I am not so much in favour or putting anything in joints through injections and IF at all, then by a orthopedic surgeon only.
BUT I would only allow for 1 cortisone injection ever....have seen too many bad results after too much cortisone injections...

The best treatment is probably listening to your body and not doing the things that hurt you anymore.
There is a time to stop.... and take up something else less strenuous... sorry for this..

Esther

thank you Ester! I do appreciate your advice, but I'm not quite to the point of quitting rec hockey. Hockey is like my cocaine, heroine and antidepressant all wrapped up into one neat little game! Ive been managing my SC symptoms by maintaining ROM and have learned what rotational arm movement causes the joint to catch and pop. I use heat and ice on a regular basis and do upper body weight work (light) to keep the muscle groups toned. I've cut way back on my playing time and also I'm aware of movements that make it worse. But my question is, wouldn't it be better to shoot a little steroid in there and calm down the pain and swelling than to have an inflamed joint that re-irritates with the wrong movement? The right joint has calmed down to no symptoms at all after 2 shots and prolotherapy. It was the first joint to present with pain and swelling. Then the left joint became inflamed ~3+ years later. It is now the problem joint.
I've had degenerative/arthritic joints in hands, wrist, hips, low back, but I treat them with exercise, ice/heat, and anti-inflammatories (diclofenac is my favorite). Most of these symptoms have passed and I've maintained a pretty active lifestyle.

[estherderu]

dear hockeyplayer.... I fully understand belief me
I have seen some serious damage done to muscles and joint because of too many steriod injections... but I am not a medical doctor.... I would suggest you ask you GP.
wishing you well. Esther

[mariasilva8866]

The Sternoclavicular (SC) joint is the only bony joint that connects the axial and appendicular skeletons. The SC joint is a plane synovial joint formed by the articulation of the sternum and the clavicle. Initial management is to try put the joint back into place. This generally requires admission to hospital and an anaesthetic.

[runningmom2]

Wondering if anyone is still monitoring this thread.... My teenaged daughter has an unstable SC joint similar to what has been described here ... no real pain, but it feels "weird" when it is out and it "clunks" audibly. She has resorted to stabilizing the joint with k-tape, and she says it seems to work really well in terms of it not popping out and in terms of how it feels (much more stable, even under load-bearing conditions, like her picking things up, etc.). So that's a nice, temporary solution, but I'm concerned the k-tape might have unforeseen consequences (e.g., weakening ligaments because they aren't being used as much, etc). Has anyone else tried k-tape with this condition? I'm thinking a trip to a PT is warranted, but I don't hold out much hope for them knowing what to do about it.... Looking into prolotherapy as well....

[sternoclavgal]

Rosie, im a 50 yr old irish woman with eds hypermobility , ive had a spontaneous sternoclavicular subluxation for over 20 years. i use a figure of 8 back brace to stabilise the joint when it pops, it heals somewhat for a year or rwo and then pops again, i have pursued orthrapaedic surgeons in ireland and they are afraid of it and will not investigate the injury. It is rare, every orthro ive met , ive had to educate about it. i have a special file i bring with me for them(!) its a debilitating injury, incredibly painful if the muscles are allowed spasm if not treated and will cause more subluxations(by the pressure of the spasams) in the neck if left alone.
a back brace and kino tape and physio are the best treatments ive been offered in ireland.Id be very glad to see physios discussing this more widely.

- - - Updated - - -

hi, id go with the tape, the ligaments need time to heal and if the tape is keeping the collarbone in the right place then that helps. your daughter should see a doctor though. there can sometimes be more serious complications depending on which way it dislocates, front or back.