Sternoclavicular Joint Injury

Upper Limb

Overview

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 supine or seated; palpate the sternoclavicular joint directly by applying gentle pressure to the medial end of the clavicle and surrounding joint capsule. Assess for tenderness, swelling, or deformity.

Positive Finding

Localized tenderness, palpable swelling, or anterior/posterior prominence of the joint

Sensitivity / Specificity

Unknown / Unknown

Interpretation

Suggests acute or chronic sternoclavicular joint injury, arthritis, or osteitis. High specificity when combined with mechanism of injury and pain reproduction.

Sternoclavicular Compression Test (Crossover Adduction)

Procedure

Patient supine or seated; passively adduct the affected arm across the body toward the opposite shoulder, gently compressing the sternoclavicular joint. Alternatively, apply direct anterior-to-posterior compression across the sternum.

Positive Finding

Pain or apprehension at the sternoclavicular joint with compression or adduction movement

Sensitivity / Specificity

Unknown / Unknown

Interpretation

Indicates sternoclavicular joint dysfunction, subluxation, or intra-articular pathology. Useful for provocative testing in suspected instability or arthrosis.

Sternoclavicular Shear Test (Horizontal Abduction)

Procedure

Patient supine or seated with shoulder abducted to 90° and internally rotated; apply gentle horizontal adduction across the body or apply anteroposterior shear force to the medial clavicle.

Positive Finding

Pain reproduction at the sternoclavicular joint or sensation of instability/clunking

Sensitivity / Specificity

Unknown / Unknown

Interpretation

Suggests sternoclavicular joint strain, capsular laxity, or anterior/posterior subluxation. May reproduce symptoms in ligamentous injury or hypermobility.

Serratus Anterior Weakness Test (Scapular Dyskinesis Assessment)

Procedure

Patient performs a wall push-up or prone push-up position; observe scapular winging or protraction loss. Alternatively, have patient perform shoulder flexion to 120° against resistance while observing scapular control.

Positive Finding

Scapular winging, loss of scapular protraction, or medial scapular border prominence; weakness or loss of dynamic stability

Sensitivity / Specificity

Unknown / Unknown

Interpretation

Suggests secondary scapular dysfunction common in sternoclavicular injury or proximal upper limb pathology. Indicates need for neuromuscular rehabilitation.

Clavicle Excursion Test

Procedure

Patient seated; apply gentle longitudinal traction and compression along the clavicle axis, or perform gentle anteroposterior mobilization of the medial clavicle while assessing range and quality of motion.

Positive Finding

Restricted clavicular movement, pain with mobilization, or hypermobility compared to contralateral side

Sensitivity / Specificity

Unknown / Unknown

Interpretation

Identifies hypomobility suggesting adhesions or post-traumatic stiffness, or hypermobility suggesting ligamentous insufficiency or subluxation.

Cross-Body Adduction Test (Horizontal Adduction Maneuver)

Procedure

Patient seated or supine; actively or passively adduct the shoulder across the body to the opposite side, bringing the elbow toward the contralateral shoulder while the examiner notes pain location and severity.

Positive Finding

Pain localized to the sternoclavicular joint or anterior chest wall at end-range or mid-range adduction

Sensitivity / Specificity

Unknown / Unknown

Interpretation

Non-specific but useful as a functional provocation test; may reproduce pain in sternoclavicular pathology, acromioclavicular pathology, or referred pain from rotator cuff.

⚠ 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

Soft Tissue

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

Articulation

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

Functional

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

MET

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

Soft Tissue

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

Articulation

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.

Add-On Approaches

Chinese Medicine

TCM diagnosis typically involves Qi and Blood stagnation in the Lung and Heart meridians, with acupuncture points (LU1 Zhongfu, ST12 Quepen, REN23 Lianquan) and moxibustion used to improve local circulation and reduce inflammation. Herbal formulations addressing Qi stagnation may support tissue healing.

Chiropractic

Chiropractic management focuses on SC joint mobilisation with attention to clavicular mechanics and scapulohumeral rhythm. Adjustments to restore SC joint alignment (avoiding aggressive posterior-directed force in risk of posterior dislocation), combined with advice on avoiding provocative positions, align with osteopathic principles.

Physiotherapy

Physiotherapy emphasises progressive strengthening of scapular stabilisers (serratus anterior, lower trapezius, rhomboids), proprioceptive retraining to improve dynamic stability, and postural correction to reduce abnormal SC joint loading. Progressive resistance exercises and neuromuscular control drills support functional recovery.

Remedial Massage

Remedial massage targets pectoralis major/minor, sternocleidomastoid, and upper trapezius tension using soft tissue release, trigger point therapy, and gentle cross-fibre techniques. Addressing myofascial restrictions improves mobility and reduces guarding patterns that perpetuate SC joint dysfunction.

Rehabilitation Exercises

Pendulum Swings (Codman's Pendulum Mobilisation)

Range of MotionBeginner

Cross-Body Shoulder Stretch (Gentle, Pain-Free Range)

StretchingBeginner

Pectoralis Major Doorway Stretch

StretchingBeginner

Shoulder Shrugs and Rolls

Range of MotionBeginner

Scapular Retraction (Prone Y-Raises)

StrengtheningIntermediate

Serratus Anterior Activation (Wall Push-Ups with Scapular Protraction)

StrengtheningIntermediate

Prone Shoulder External Rotation (Sleeper Stretch Strengthening)

StrengtheningIntermediate

Postural Correction: Chin Tucks and Upper Thoracic Extension

PosturalBeginner

Thoracic Extension Mobilisation (Foam Roller or Towel Roll)

PosturalBeginner

Resistance Band Rows (Prone, Supine, and Standing Variations)

StrengtheningIntermediate

Proprioceptive Shoulder Stability (Quadruped Shoulder Taps and Holds)

BalanceIntermediate

Progressive Loaded Shoulder Flexion and Abduction (Dumbbell or Theraband)

StrengtheningAdvanced

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