Sternoclavicular Joint Disorders

The sternoclavicular joint (SCJ) is the only bony articulation connecting the axial and appendicular skeleton. It is a plane synovial joint formed by the articulation between the sternum and the clavicle. Owing to the articulation between the medial clavicle and the manubrium of the sternum together with the first costal cartilage, the joint has limited osseous stability. A dense fibrocartilaginous intra-articular disc divides the joint into two distinct synovial compartments.

The intra-articular ligament provides joint stability and prevents medial displacement of the clavicle. This ligament originates at the junction of the first rib and the sternum and passes through the SCJ to attach to the superior and posterior aspect of the clavicle. The anterior and posterior sternoclavicular ligaments limit anterior and posterior translation of the medial clavicle. These ligaments arise from the anterior and posterior aspects of the clavicle and attach to the corresponding surfaces of the manubrium. The joint is also supported superiorly by the interclavicular ligament, which connects the superomedial parts of both clavicles.

The blood supply to the SCJ is via articular branches from the internal thoracic and suprascapular arteries.The SCJ is innervated by branches of the medial supraclavicular nerve. The brachiocephalic trunk, common carotid artery and internal jugular vein lie directly posterior to the SCJ. [1]

Mechanism of Injury / Pathological Process

Symptomatic SCJ disorders are uncommon [3][4][5] and usually result from high-energy trauma [6]. Patients with SCJ dysfunction are typically classified by mechanism as traumatic or atraumatic.

Traumatic

Traumatic injuries range from minor subluxations to complete dislocations. SCJ injuries are rare and infrequently seen in physiotherapy practice. Complete dislocation is unusual [7] because substantial force in a specific vector is required to disrupt the joint. Typical mechanisms include falls, sports injuries and road traffic accidents. Anterior SCJ dislocation is more common [8][9]. Posterior dislocation has serious clinical implications because adjacent neurovascular structures may be compromised [10].

Direct trauma from a lateral fall onto the shoulder transmits force through the clavicle to the SCJ and can produce either an anterior or posterior force at the SCJ depending on arm position [11].

Atraumatic

The SCJ is susceptible to the same disease processes that affect other synovial joints, including degenerative osteoarthritis, rheumatoid arthritis, infection and spontaneous subluxation. Incidental SCJ osteoarthritis is frequently observed on CT, particularly in older adults [3]. A thorough history is essential to identify the presence of non-musculoskeletal disorders [1].

SCJ disorders may also occur secondary to abnormal scapulothoracic mechanics and aberrant scapular kinematics [11].

Non-Traumatic Causes of Pain and Swelling in the SCJ

• Osteoarthritis: Most common pathology

• Inflammatory causes:

• Seropositive (e.g., reactive arthritis following infection elsewhere)

• Seronegative (e.g., ankylosing spondylitis, Reiter’s syndrome, psoriatic arthritis)

• Septic: Infection

• Crystal-induced: Gout and pseudogout

Other causes:

• Friedrich’s disease (spontaneous osteonecrosis of the medial clavicle)

• Condensing osteitis (benign sclerosis of the clavicle without SCJ involvement)

• SAPHO syndrome (synovitis, acne, pustulosis, hyperostosis and osteitis)

• Ewing sarcoma, squamous cell carcinoma/adenocarcinoma [8]

Clinical Presentation

Traumatic

Patients typically report pain and swelling. With mild sprains or subluxations, there may be a complaint of joint instability. With dislocations, a visible step-off deformity at the SCJ is often observed.

Posterior dislocations may present with more severe symptoms such as a sensation of tracheal or oesophageal compression, dyspnoea, choking, dysphagia or a feeling of neck tightness. In severe cases, posterior dislocation can lead to shock or pneumothorax, and if untreated, complications such as thoracic outlet syndrome and vascular compromise may occur [12].

Classification of Injury Types [8][9]

• Type I injury: Mild to moderate pain associated with upper-limb movement. Instability is typically absent. The joint is tender to palpation and may be mildly swollen.

• Type II injury: Partial tears of supporting ligaments. The joint may sublux under manual stress but does not dislocate. Greater swelling and pain than Type I.

• Type III injury: Complete dislocation (anterior or posterior). Severe pain exacerbated by any upper-limb movement. The shoulder on the affected side may appear protracted relative to the contralateral side. Patients often hold the arm adducted against the body, supported by the opposite hand.

• 

Atraumatic [1]

• SCJ osteoarthritis (OA): Pain and swelling at the SCJ exacerbated by palpation, shoulder abduction and/or horizontal shoulder flexion. Other findings include osteophyte prominence at the medial clavicle, crepitus or a fixed subluxation. Degeneration increases with age; postmenopausal women are at higher risk.

• SCJ rheumatoid arthritis (RA): Swelling, tenderness, crepitus and painful, restricted shoulder motion. Synovitis, pannus formation, bony erosions and disc degeneration may be present. Often polyarticular and bilateral.

• SCJ infection: Pain, swelling, tenderness, fever, chills and/or night sweats. Diagnosis is confirmed by joint aspiration or biopsy. Septic arthritis occurs in patients with RA, sepsis, infected central lines, alcoholism or HIV, and in immunocompromised, dialysis or intravenous drug-using patients.

• Spontaneous anterior subluxation: A “pop” or sudden subluxation of the medial clavicle, often in adolescents and young adults with ligamentous laxity, commonly with humeral elevation.

• Seronegative spondyloarthropathies: Ankylosing spondylitis, psoriatic arthritis, Reiter’s syndrome or colitic arthritis. Age <40 years, asymmetric large-joint involvement, absence of serum autoantibodies. Unilateral SCJ swelling, tenderness and pain at full arm abduction.

• Sternocostoclavicular hyperostosis: Local pain, swelling and warmth over the SCJ. Often bilateral; shoulder motion may be impaired.

• Condensing osteitis: Focal pain and swelling, usually unilateral in late childbearing-age women. Radiographs show sclerosis and enlargement of the medial clavicle.

• Friedrich’s disease (aseptic osteonecrosis): Discomfort, swelling and crepitus at the SCJ without trauma or infection; reduced ipsilateral shoulder mobility.

Key Differences Among Non-Traumatic SCJ Disorders [11][8]

Systemic joint diseases

• Osteoarthritis: >50 years; normal blood tests; OA changes on imaging

• Rheumatoid arthritis: Women, all ages; RF may be positive; normal imaging or erosions

• Seronegative spondyloarthropathies: Men <40; HLA-B27 positive; normal imaging or erosions

• Crystal arthropathies: Men >40; inflammatory synovial fluid, elevated ESR (acute); secondary OA changes, soft-tissue calcification

Infectious conditions

• Septic arthritis/osteomyelitis: All ages; systemic symptoms and positive labs; periosteal changes

Specific joint diseases

• SAPHO syndrome: Middle-aged adults; dermatologic findings, mildly elevated ESR/CRP; erosions and enthesial ossification

Signs and Symptoms of SCJ Dysfunction [11][13]

• Tenderness to palpation

• Local swelling

• Local pain during elevation beyond 100°

• Pain with active protraction and retraction

• Referred pain to the neck, shoulder and/or arm

Differential Diagnosis [1][10][14]

• Osteoarthritis

• Rheumatoid arthritis

• Septic arthritis

• Atraumatic subluxation

• Seronegative spondyloarthropathies

• Crystal deposition diseases

• Sternocostoclavicular hyperostosis

• Condensing osteitis

• Friedrich’s disease (aseptic osteonecrosis)

• SCJ/ACJ dysfunction

• Sternal fracture

• Clavicle fracture

• Anterior SCJ dislocation

• Posterior SCJ dislocation

Biomechanics

The clavicle is anteriorly convex at its medial end and anteriorly concave laterally. It helps maintain the subacromial space during arm elevation. The clavicle rotates posteriorly and elevates during shoulder flexion, scaption and arm elevation [15]. Posterior rotation of the clavicle elevates its lateral end at the acromioclavicular joint, lifting the acromion and maintaining the subacromial space during overhead elevation.

During scaption (approximately 30° anterior to the coronal plane), there is about 20° of posterior clavicular rotation to elevate the lateral clavicle and optimise subacromial clearance.

Posterior rotation is a key joint motion that must be assessed. As elevation increases, posterior rotation increases [16]. Increased posterior clavicular rotation occurs with arm elevation and scaption. Posterior tipping of the clavicle is associated with posterior rotation and scapular elevation; therefore, scapulothoracic motion may be limited when SCJ dysfunction is present [15].

These movements influence the acromion and, ultimately, the subacromial space, clavicle and SCJ. Even small motion restrictions at the SCJ can cause larger distal movement limitations [11].

Scapular movements associated with arm elevation:

• Upward rotation (inferior angle moves away from the midline)

• External rotation of the scapula (medial border approximates the thoracic wall)

• Posterior tilt as the inferior angle moves towards the thoracic wall

These movements depend on thoracic spine mobility.

Scapular motion during elevation:

Serratus anterior is crucial for scapular function. It contributes to:

• Upward rotation

• Posterior tilt

• External rotation of the scapula

• Scapular protraction

Protraction and retraction at the shoulder are associated with SCJ elevation and tension in the costoclavicular ligament. Depression increases disc contact within the SCJ and tension in the interclavicular ligament. Retraction is limited by the anterior sternoclavicular ligament and some disc compression.

Protraction and retraction of the clavicle occur with internal and external rotation of the scapula.

Influence of the Thoracic Spine on Upper-Limb Motion

• Significant trunk extension occurs during elevation (12–15° with bilateral elevation; 6.7–8° with unilateral elevation) [17]

• Trunk side-bending and axial rotation occur during unilateral elevation [17]

• Contributes to 55% of upper-limb force production

• Upper-limb injury risk is three-fold higher with reduced thoracic rotation flexibility [18]

• Including thoracic rotation in prevention programmes reduces shoulder injury rate by 28% [19]

• The thoracic spine contributes 80% of upper-limb rotation

Assessment of the SCJ

Diagnostic Investigations

Standard radiographs are indicated in the initial assessment of SCJ disorders [1]. CT is recommended when osseous destruction or calcification is suspected. MRI provides information on inflammation, soft-tissue masses or osteonecrosis. Although MRI offers comprehensive evaluation, CT is preferred in acute settings because of speed, availability and the ability to differentiate soft tissue from bone, especially in acute injuries [12]. Laboratory tests may help confirm or exclude specific diagnoses where inflammatory or infectious disease is suspected (e.g., RA, septic arthritis, osteomyelitis).

Radiologic assessment of SCJ dislocations includes a standard anteroposterior chest radiograph, which may indicate SCJ injury [10]. This projection is not always optimal to visualise the joint; the serendipity view (bilateral projection) is more reliable for diagnosis.

Clinical Examination

Palpation of surface anatomy:The SCJ is easily palpated by identifying the jugular notch and then moving laterally to the joint surface. The sternal angle (angle of Louis) is felt where the sternum is most prominent and is often used to locate the second costal attachment. With optimal shoulder positioning, the scapula is upwardly rotated. The distance between the medial and lateral ends of the clavicle approximates the width of two upright fingers (“two-finger rule”). The slope of the clavicle indicates scapular upward rotation posterior to the clavicle [11].

Muscle assessment — Subclavius:

Lies just deep to pectoralis major; originates from the first costochondral junction and inserts into the undersurface of the clavicle. Referred pain pattern to the arm in a C5/6 distribution has been described [20].

• Patient side-lying; shoulder protracted and pectoralis major relaxed

• Palpate subclavius from the medial to mid-clavicle

• Apply gentle pressure and enquire about pain; C5/6 pain suggests an active trigger point

• Digital ischaemic compression may be used therapeuticallyClinical tip: To avoid palpating pectoralis major, ask the patient to contract and relax before palpating subclavius [11]

Serratus anterior:

• Patient elevates the arm to 130° flexion

• Palpate the inferior angle and apply downward pressure while the patient resists

• Observe whether the scapula or arm moves first

• Downward rotation preceding arm movement suggests weakness in upward rotation

Scalenes:

• Rotate the head and side-bend to the same side; bring the chin into the supraclavicular fossa

• Hold 30 seconds

• Positive if cramping occurs [23]

Assessment of joint play and mobility (compare with asymptomatic side):

• Distraction: Patient sitting; stabilise the manubrium and apply gentle distraction to the clavicle

• Posterior glide: Supine; palpate the SCJ; ask the patient to elevate both arms and protract the shoulders; assess for posterior clavicular rotation

• Inferior glide: Supine; ask the patient to shrug; observe inferior translation of the joint

• Posterior rotation: More challenging to assess; palpate posterosuperiorly while the patient elevates the arms; approximately 30° should be available; ligaments limit motion beyond ~45°; the costoclavicular ligament is the main restraint

First rib assessment:

• Elevation compression test: Patient seated; stand behind and feel for first-rib elevation during deep inspiration; compare sides

• Rotation–side-bending test: Rotate the head to one side and side-bend towards the shoulder; passively side-bend the head; compare sides; an elevated first rib may restrict motion

Thoracic spine assessment:

• Combined elevation test: Prone with arms outstretched; lift arms as high as possible while keeping the head down; measure wrist-to-table distance; active vs passive helps differentiate insufficiency vs tightness

• Seated rotation: Patient seated with a ball between knees to stabilise the pelvis; rotate the trunk; use a dowel for reference; digital inclinometers or apps may be used; validated using an iPhone at C7/T1 with hands behind the head

Further examination:

• Cervical spine screening

• Active and passive motion of the shoulder, ACJ and SCJ

• Observation and palpation

• Resisted testing

• Functional tests

Physiotherapy Management

Considerations in SCJ Dysfunction

Joint:

• Hypermobile (lax joint)

• Hypomobile (stiff joint; common without trauma)

• First-rib position

Myofascial:

• Subclavius (reduced extensibility)

• Sternocleidomastoid (overactive / reduced extensibility)

• Scalenes

Evidence for optimal management of SCJ dysfunction is limited; interventions should be based on individual findings and response. Extensive physiotherapy is often unnecessary.

Initial Physiotherapy Interventions

• Mobility exercises: AROM, AAROM, PROM for the shoulder

• Strength training

• Motor control training

• Scapular stabilisation

• Manual therapy directed to the SCJ, glenohumeral joint and ACJ

Acute and Post-Operative Care

In severe traumatic dislocations, reduction may be required. Posterior dislocations are a medical emergency given the proximity of major vessels, nerves, trachea, oesophagus and lungs. The clavicle must be reduced prior to physiotherapy [29].

Anterior dislocation — closed reduction first: 

Local anaesthesia, sedation or general anaesthesia may be used.

• Supine, arm supinated, bolster between shoulders

• Shoulder abducted to 90°, extended 10–15° and traction applied while pressing over the sternal end of the clavicle [29]

Posterior dislocation — reduction under general anaesthesia:

• Supine, injured shoulder near the table edge, bolster between scapulae

• Abduction and extension with lateral traction on the arm

• The clavicle may be lifted manually or with forceps if needed

• Always maintain sterility; joint is usually stable after reduction [29]

Surgery

Rarely indicated due to complication risk (e.g., infection); considered only if conservative care fails [29].

Aftercare

• Unstable SCJ: Sling for several weeks until symptoms settle, then gradual mobility and strengthening (deltoid and trapezius as dynamic stabilisers) [29]

• Immobilisation in retracted shoulder posture depending on stability. If stable: figure-of-eight brace for 6 weeks [30][29]

• Day 2: Gentle pendulums (avoid active flexion/abduction >90°) [31][32]

• Day 4: Passive glenohumeral motion including internal/external rotation [33]

• Week 3: If stable, commence elbow exercises and shoulder rotations (active flexion, extension, abduction, rotations, isometrics). Keep the hand in view to avoid re-dislocation [29]

• First 6 weeks: Avoid abduction and large SCJ motions

• After 6 weeks: Progress ROM including overhead elevation and cautious strengthening [33]

• Weeks 8–12: Stretching and strengthening programme [31][32]

Non-Surgical Management — Selected Techniques

First-rib treatment (MET): Useful when first-rib elevation and thoracic outlet symptoms are present; often uncomfortable.

• Patient seated, relaxed, leaning towards the affected side

• Finger over the flat bony portion of the first rib; side-bend the spine while applying rib depression

• Instruct a deep breath and hold ~5 seconds while gently pressing the ear into the therapist’s hand (~25% effort)

• On exhalation, the rib should drop slightly

• Repeat 2–3 times until motion improves; reassess side-bending/rotation [34]

Scalene MET:

• Patient seated holding the chair; look towards the affected shoulder

• Side-bend away and take a deep breath in

• Hold, exhale and increase side-bending

• Repeat 3–4 times; suitable as home exercise

Scalene release test:

• Patient places the hand on the forehead and lifts the elbow overhead

• This manoeuvre opens the brachial plexus/scalene region

Sternocleidomastoid:

• Depress the shoulder girdle, rotate the head away from the symptomatic side, side-bend and retract; hold the position

• Important: Assess breathing mechanics (apical patterns are common)

Manual Therapy — SCJ and Thoracic Spine

Improve inferior glide:

• Palpate the medial clavicular joint line and mobilise while passively elevating the shoulder

• Use a soft pad under the fingers for comfort

• If pain occurs at ~110° elevation, stop there and apply inferior glide

• Alternative: MET — patient presses shoulders down against resistance; reassess glide after elevation [37]

Improve posterior glide:

• Supine; palpate medial clavicle• Patient places hand on therapist’s shoulder and retracts the scapula (30% effort, hold 4 s)

• Relax and protract; repeat 3–4 times

Improve posterior rotation:

• Side-lying; palpate posterosuperior clavicle

• Ask the patient to elevate the arm while you facilitate posterior rotation

• Alternative: Mobilise the clavicle via the ACJ with gentle pressure through the scapula

Thoracic manual therapy:

• Supine on foam roller; self-mobilisation/SNAGs

• Seated with external shoulder rotation and gentle extension using a towel around the thorax

• Overhead squat with band to train thoracic rotation (Howe & Read, 2015)

Improve thoracic rotation:

• PNF pattern: side-lying, knees together, trunk rotation

Exercise Therapy — Key Muscles and Kinetic Chain

Serratus anterior exercises

• Protraction with band: Band wrapped around the back to load protraction through the kinetic chain

• Dynamic punches: Incorporate trunk rotation to emphasise the serratus as a protractor

• Push-up plus: Targets serratus anterior during protraction

EMG study (Castelein & Ann Cools) [39] compared serratus anterior and pectoralis minor activity in the serratus punch, floor push-up and wall push-up:

• Serratus punch produced 63% pectoralis minor activity relative to serratus anterior

• Floor push-up: 93% pectoralis minor relative to serratus anterior

• Wall push-up: 97% pectoralis minor relative to serratus anterior

Note: Overactive pectoralis minor drives downward rotation, internal rotation and anterior tilt of the scapula — the opposite of what is desired during elevation.

Exercises for scapular upward rotation

• Cue the sensation of the scapula moving around and up overhead

• Modified Cuban press on Swiss ball: Posterior tilt and elevation combined with external rotation

• Modified upright row: Emphasises posterior tilt and upward rotation

• Upward-rotation on foam roller with band: Prone; support the arm on the roller, position the scapula in upward rotation and elevate the arm

Lower trapezius

• May lack the capacity to create sufficient posterior tilt

• Train prone with arm raises off the plinth, focusing on posterior tilt

• Progress with resistance (e.g., bands)

• Key cue: Teach posterior tilt — not pure retraction

• If excessive retraction occurs, address rhomboid dominance (downward rotators)

Kinetic-chain drills

• Press a Swiss ball against a wall while elevating the arms, maintaining scapular upward rotation

• Add a power band anchored above the shoulder and around the foot for resistance

• Evaluate levator scapulae if excessive shoulder hiking is observed

Subacromial spaceBdaiwi et al. [41] examined strategies to maintain the subacromial space by stimulating lower trapezius, serratus anterior and both combined. Lower trapezius alone increased the space, but the greatest increase occurred when both muscles were activated — important for exercise selection.

Outcome Measures

There are no SCJ-specific instruments; upper-limb tools are often applicable:

• DASH

• QuickDASH

• Penn Shoulder Score

Summary / Prognosis

SCJ disorders are uncommon but clinically important due to proximity to critical mediastinal structures. Anterior dislocations predominate; posterior dislocations constitute emergencies. Atraumatic disorders span degenerative, inflammatory, infectious and mechanical causes. Management relies on careful assessment of joint mechanics, first-rib and thoracic contributions, and targeted rehabilitation of scapular control (particularly serratus anterior and lower trapezius). Prognosis is generally good with accurate diagnosis, appropriate reduction when needed, and progressive, function-oriented physiotherapy.

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