Sternoclavicular Joint Injury
Upper LimbOverview
Sternoclavicular (SC) joint injury encompasses acute traumatic injuries and chronic degenerative conditions affecting the articulation between the clavicle and sternum, representing 3-5% of all shoulder girdle injuries. The SC joint is the primary articulation connecting the upper limb to the axial skeleton and is critical for shoulder and arm function. Injuries range from ligamentous sprains and intra-articular disc displacement to fracture-dislocations, with anterior dislocations being more common than posterior dislocations.
Pathophysiology
The SC joint is a saddle joint with inherent laxity, stabilised primarily by ligaments (anterior and posterior capsular, interclavicular, and costoclavicular ligaments) rather than bony anatomy. Traumatic injury typically occurs from high-velocity mechanisms or direct anteroposterior force applied to the shoulder, disrupting ligamentous support and causing hypermobility, inflammation, and joint irritation. Chronic SC joint dysfunction may develop from repetitive microtrauma, postural dysfunction, or osteoarthritis affecting the articulating cartilage, leading to intra-articular inflammation and referred pain patterns. Anterior dislocations cause prominence visible at the sternal notch, while posterior dislocations risk compression of mediastinal structures (trachea, oesophagus, great vessels) due to anatomical proximity.
Patient Education
SC joint injuries require careful monitoring for swelling and deformity changes; while most anterior dislocations are managed conservatively with progressive rehabilitation, persistent instability or posterior displacement requires urgent medical imaging and possible specialist referral.
Typical Presentation
Site
Anterior chest at the medial clavicle and sternal notch; pain may radiate medially to the sternum, superiorly to the neck, or laterally across the anterior shoulder
Quality
Sharp, stabbing pain with acute injury; aching, grinding, or clicking sensations with chronic dysfunction; clicking or clunking may accompany arm movement
Intensity
Acute injuries: 6-8/10 immediately post-injury, reducing over days; chronic: 3-5/10 with activity, may spike with specific movements
Aggravating
Cross-body adduction (opposite arm across chest), horizontal adduction, arm elevation overhead, loaded pushing activities, certain sleeping positions (pressure on medial clavicle), prolonged desk work, deep inspiration if joint is inflamed
Relieving
Rest and immobilisation in acute phase, arm sling support, heat application, anti-inflammatory measures, keeping arm at side, gentle pendulum motions once acute pain subsides
Associated
Visible deformity or prominence at sternal notch (anterior dislocation), swelling and bruising over medial clavicle, restricted shoulder range of motion (especially cross-body adduction and elevation), referred pain to anterior neck or upper thorax, clicking or clunking with arm movement, postural changes with forward shoulder posture, chest wall discomfort, rarely dysphagia or dyspnoea if posterior dislocation compresses mediastinal structures
Orthopaedic Tests
Sternoclavicular Joint Palpation
Procedure
Patient seated or supine. Inspect both sternoclavicular joints for swelling or asymmetry, then palpate the medial end of each clavicle.
Positive Finding
Tenderness, swelling or a step at the joint compared with the other side.
Interpretation
Supports a sternoclavicular joint injury. A medial clavicle that feels displaced backwards (a hollow rather than a bump), or any difficulty breathing or swallowing, hoarse voice or arm swelling, suggests a posterior dislocation, which can compress the great vessels or airway and needs emergency referral. Imaging (CT) confirms the direction of displacement. This injury is diagnosed by imaging; these provocation/palpation signs have no validated diagnostic accuracy.
Sternoclavicular Compression Test (Crossover Adduction)
Procedure
Once a posterior dislocation has been excluded: with the patient seated, bring the arm across the body towards the opposite shoulder, or press gently along the clavicle towards the sternum.
Positive Finding
Reproduction of the familiar pain at the sternoclavicular joint.
Interpretation
Loads the joint and supports it as the pain source. Cross-body adduction also loads the acromioclavicular joint, so note exactly where the pain is felt.
Sternoclavicular Shear Test (Horizontal Abduction)
Procedure
Once a posterior dislocation has been excluded: stabilise the sternum with one hand and gently glide the medial clavicle forwards and backwards with the other, comparing sides.
Positive Finding
Reproduction of the familiar pain, or more movement than on the other side.
Interpretation
Suggests sternoclavicular sprain or laxity. Not a validated test; judging joint movement by hand is unreliable, so use it to locate pain rather than to grade instability.
Serratus Anterior Weakness Test (Scapular Dyskinesis Assessment)
Procedure
Observe from behind while the patient does a slow wall push-up and raises and lowers both arms.
Positive Finding
Winging of the medial border of the scapula, or poor control of scapular movement.
Interpretation
Describes scapular control to guide rehabilitation after the injury. Marked winging at rest or with a wall push-up suggests long thoracic nerve involvement and needs further assessment.
Clavicle Excursion Test
Procedure
Observe and palpate the medial clavicle while the patient shrugs, protracts and retracts the shoulders, comparing sides.
Positive Finding
Pain, clicking or visibly abnormal movement at the sternoclavicular joint during shoulder movement.
Interpretation
Not a recognised named test. Useful to find which shoulder-girdle movements provoke pain, for treatment and monitoring.
Cross-Body Adduction Test (Horizontal Adduction Maneuver)
Procedure
Patient seated. Raise the arm to 90° of flexion and bring it across the body towards the opposite shoulder, adding gentle overpressure.
Positive Finding
Pain at the sternoclavicular joint, or at the acromioclavicular joint.
Interpretation
Loads both ends of the clavicle. Ask the patient to point to the pain: pain at the top of the shoulder suggests the acromioclavicular joint; pain at the base of the neck the sternoclavicular joint.
⚠ Red Flags
- •Posterior SC dislocation with signs of vascular compromise (pale, cold arm; absent radial pulse)
- •Posterior dislocation with respiratory distress, dysphagia, or stridor (mediastinal compression)
- •Acute severe trauma with signs of underlying rib fracture, pneumothorax, or chest wall trauma
- •Severe uncontrolled swelling suggesting haemarthrosis requiring aspiration
- •Signs of concurrent brachial plexus injury (neurological symptoms in arm distribution)
- •Progressive neurological deficit or vascular compromise
- •High-velocity trauma with suspicion of fracture-dislocation on presentation
⚡ Yellow Flags
- •Frequent recurrent dislocations suggesting chronic instability and possible secondary psychological distress
- •Excessive reassurance-seeking or fear-avoidance behaviour regarding mediastinal complications
- •Chronic anxiety about posterior dislocation risk limiting normal shoulder use
- •Occupational stress from inability to perform overhead or pushing work activities
- •Prolonged disability disproportionate to clinical findings suggesting illness perception issues
- •History of hypermobility-related conditions with potential generalised ligamentous laxity
- •Avoidance of rehabilitation due to fear of re-injury or dislocation
Osteopathic Techniques
Region
Sternoclavicular joint and surrounding ligaments
Technique
Rationale
Soft tissue mobilisation to the anterior and posterior capsule, interclavicular ligament, and pectoralis major and minor attachments reduces muscle guarding, improves local blood flow for ligamentous healing, and addresses myofascial restrictions limiting SC joint gliding. Particularly valuable in acute phases when joint mobilisation is contraindicated.
Region
Sternoclavicular joint
Technique
Rationale
Gentle articulation techniques (grades I-II mobilisation) restore physiological gliding patterns of the SC joint, reduce pain through mechanoreceptor stimulation, and prevent adhesion formation during healing phases. Superior-inferior and anteroposterior gliding mobilisations are particularly effective for restoring normal arthrokinematics without aggressive force.
Region
Medial clavicle, first costochondral joint, and upper sternum
Technique
Rationale
Functional technique positions the SC joint in its position of ease to reduce ligamentous tension and pain, allowing neuromuscular re-education. This respects tissue healing phases and is valuable for chronic dysfunction where traditional mobilisation may be poorly tolerated.
Region
Pectoralis major and minor, sternocleidomastoid, anterior scalene
Technique
Rationale
Muscle energy techniques address postural muscles contributing to SC joint dysfunction. PIR stretching of pectoralis major/minor and scalene muscles reduces anterior chest tightness, improves postural alignment, and decreases abnormal SC joint loading from forward shoulder posture.
Region
Upper thoracic spine (T1-T4), manubrium, and first/second ribs
Technique
Rationale
Treatment of upper thoracic and rib cage muscles (rhomboid major, serratus anterior origin, upper trapezius, intercostal muscles) reduces compensatory tension and restores optimal scapulothoracic mechanics, which directly influences SC joint loads and positioning.
Region
Cervical spine and shoulder girdle (integrated approach)
Technique
Rationale
Gentle cervicothoracic articulation improves segmental mobility that influences SC joint positioning and pain referral patterns. Addressing upper cervical and first rib mechanics optimises the biomechanical chain supporting SC joint stability.
Rehabilitation Exercises
Pendulum Swings (Codman's Pendulum Mobilisation)
Cross-Body Shoulder Stretch (Gentle, Pain-Free Range)
Pectoralis Major Doorway Stretch
Shoulder Shrugs and Rolls
Scapular Retraction (Prone Y-Raises)
Serratus Anterior Activation (Wall Push-Ups with Scapular Protraction)
Prone Shoulder External Rotation (Sleeper Stretch Strengthening)
Postural Correction: Chin Tucks and Upper Thoracic Extension
Thoracic Extension Mobilisation (Foam Roller or Towel Roll)
Resistance Band Rows (Prone, Supine, and Standing Variations)
Proprioceptive Shoulder Stability (Quadruped Shoulder Taps and Holds)
Progressive Loaded Shoulder Flexion and Abduction (Dumbbell or Theraband)
Referral Criteria
- •Acute posterior SC dislocation or suspicion thereof (medical emergency for imaging and reduction)
- •Anterior dislocation with signs of vascular compromise or mediastinal compression
- •Fracture-dislocation confirmed on imaging requiring specialist orthopaedic assessment
- •Recurrent dislocation (more than 2 episodes) requiring surgical evaluation for reconstruction
- •Persistent severe pain or dysfunction unresponsive to conservative care after 6-8 weeks
- •Signs of intra-articular loose body or mechanical block preventing movement (MRI or ultrasound indicated)
- •Development of complex regional pain syndrome characteristics (excessive swelling, colour changes, temperature changes)
- •Concurrent injuries requiring orthopaedic input (rib fractures, clavicular shaft fractures, brachial plexus injury)
- •Haemarthrosis requiring aspiration for symptom relief and diagnosis
- •Chronic SC joint osteoarthritis with progressive instability or pain affecting occupational function
- •Underlying hypermobility syndrome (EDS, Marfan syndrome) requiring specialist medical management
- •Symptoms persisting beyond expected healing timelines with imaging showing retained intra-articular displacement