Sternoclavicular post-traumatic joint injury and instability treatment

Ross A. Hauser, MD., Danielle Matias, PA-C

A patient will come into our Fort Myers clinic. They have already seen a number of pain specialists for a subluxing sternoclavicular (SC) joint and they usually have an MRI report that they don’t really understand but they believe it contains the information that they can share with doctors that will help explain their situation. As we will see below, they will have more faith in the MRI than their doctors do.

Before the patient comes in, they will usually communicate with us that they suffer from a lot of pain when they try to move one or both arms, regardless of whether they suffer from uni or bilateral (one of both sides) sternoclavicular dislocations or subluxations. They also will describe a bump or lump or an indent or depression, a clear anatomical deformity in their chest when the sternoclavicular joint pops out or pops in, and that they have themselves become adept at putting “things,” or the SC joint back into place.

If you are reading this article and you suffer from a subluxing sternoclavicular joint you do not need us to tell you how difficult it is to manage the painful aspect of this condition. Often times a patient will tell us that despite having an MRI report and an “explanation,” for what is wrong with them, doctors have not been able to use this information to help them beyond their eventual failed recommendations of physical therapy, cortisone injections, and various pain relief medications.

In this article, we will present the evidence for Prolotherapy, a regenerative medicine injection technique, that can help restore stability in the sternoclavicular joint and help prevent future subluxations.

Ross Hauser, MD and Danielle Matias, PA-C discuss our approach using Prolotherapy to treat sternoclavicular joint and rib instability.

In this video we are talking about chest pain the sternoclavicular joint. The sternoclavicular joint connects the clavicle to the sternum. The sternoclavicular joint is the main connector between the upper extremity and the body. The sternoclavicular joint is not a stable joint. The collar bone (the clavicle) connects to the sternum at this joint and is held in place by the ligaments, not boney structures. We often say that  joint instability, in this case sternoclavicular joint instability is a progressive and destructive disorder. Meaning if left untreated it can impact and cause instability in the shoulder at the acromioclavicular joint. When you have sternoclavicular joint instability, the clavicle can act as a see saw and create and up and down movement between the sternoclavicular joint and the acromioclavicular joint and that is what can contribute to shoulder instability and subluxations.

A sternoclavicular subluxation can be treated non-surgically and with success

A patient with Sternoclavicular subluxation. 

If you have a subluxing sternoclavicular problem, you know that “conservative care,” or non-surgical options do not work very well. Yes, they may work for some people but they did not work for you, or you would not be here looking for possible solutions. You have tried and may still be using pain medications and you may have tried the various recommendations for activity and movement modification. Yet your situation has become worse. Is there a solution? The answer may be in the ligaments that hold the sternoclavicular joint in place. For many of you, this may be the first time you have heard about your ligaments being a problem. For others, subluxing sternoclavicular ligament reconstruction surgery may have been recommended. So why have some not been told to treat the ligaments with surgery and some managed without focusing on the ligaments? Because the surgery does not work well and if you can’t treat the ligaments with surgery, some doctors think these ligaments are therefore untreatable.

Doctors talking to doctors about a subluxing sternoclavicular joint -what do you hear?

We are going to present a little research here to show you the thinking in the medical community in recommending treatment for an injured subluxing sternoclavicular joint. You may see an explanation as to why your treatments have failed and why you are here looking for other options.

First, how did you get injured and what type of injury was it?

• Did you have a severe injury with significant bone, cartilage, tissue damage? Like that of being in a high-impact accident? In the National Institutes of Health’s Clinical Pearls (1) publication, John Kiel and Kimberly Kaiser of the University of Kentucky describe this impact injury: “Sternoclavicular dislocation refers to complete rupture of all the sternoclavicular and costoclavicular ligaments. This occurs from a single, well-defined trauma most commonly a motor vehicle accident or collision sport such as rugby or American football. The force is typically indirect on the shoulder. Most commonly, this is from an anterolateral or posterolateral force vector directed at the shoulder.”

In other words, a significant one-time direct impact on the shoulder, front or backside, occurred with enough force to damage the connective tissue that holds the sternum to the clavicle. This is also commonly referred to as a GRADE III Sternoclavicular dislocation (tearing or rupturing of all ligaments).

• Anatomically, in the anterolateral injury, the end of the clavicle is pushed in front of the sternum.
• Anatomically, in the posterolateral injury, the end of the clavicle is pushed behind the sternum and into the upper chest.

This type of injury may require a surgical reconstruction if complete ligament ruptures occur or significant anatomical deformity is present and cannot be put back into place with a “closed reduction,” or “put back into place without surgery,” more commonly “popped back into place.”

Other grade  descriptions of Sternoclavicular injury are the:

• GRADE I: Sprain (ligaments intact)
• GRADE II: Subluxation (sternoclavicular ligaments damaged or torn; costoclavicular ligaments intact).

Understanding Sternoclavicular joint anatomy – a look at ligaments and tendons and understanding treatments that can work

The sternoclavicular joint has an important function: it is the only bony connection linking the bones of the upper limbs to the main part of the skeleton. The connection is made by the bone connecting bone soft connective tissue ligaments. Here is the relationship between the ligaments and the clavicle (collar bone) and the sternum, (the breast bone).

We have the:

• The anterior sternoclavicular ligament helps connect the sternum to the clavicle.
• The costoclavicular ligament connects the first rib to the clavicle.
• The interclavicular ligament helps connect the sternum to the clavicle.
• The posterior sternoclavicular ligament helps connect the sternum to the clavicle.

In our more than 27 years of experience in helping patients with sternoclavicular joint injuries, we have found a comprehensive H3 Prolotherapy treatment can strengthen the ligaments and allow proper anatomical healing of the joint. Because of the stress on the sternoclavicular joint as the only bony connection linking the bones of the arms/shoulders to the main part of the skeleton, treatment may require more frequent visits. Bracing with a figure-eight strap wraps in between treatments can assist with healing.

Sternoclavicular joint instability can contribute to Tietze syndrome, costochondritis, or rib hypermobility. It can also contribute to shoulder instability and difficulties in arm motion.

Treating chronic anterior sternoclavicular instability with physical therapy or surgery

In October 2022, doctors in the United Kingdom publishing in the journal Bone & joint open (4) assessed whether a standardized treatment algorithm chronic anterior sternoclavicular instability could successfully guide management and reduce the number needing surgery.

In this study, patients with chronic anterior sternoclavicular instability were divided into non-traumatic (offered physiotherapy) and traumatic (offered surgery) groups.

• A total of 47 patients (50 sternoclavicular subluxations, three patients suffered bilateral) responded for 75% return rate. Of these, 31 SCJs were treated with physiotherapy and 19 with surgery.
• Overall, 96% (48/50) achieved a stable sternoclavicular, with 60% (30/50) achieving unrestricted function.
• In terms of outcomes, 82% (41/50) recorded good-to-excellent  Oxford Shoulder Instability Score (84% (26/31) physiotherapy, 79% (15/19) surgery), and 76% (38/50) reported low pain visual analog scores (0 no pain to 10 unbearable pain) scores at final follow-up.
• Complications of the total surgical group included a 19% (5/27) revision rate, 11% (3/27) frozen shoulder, and 4% (1/27) scar sensitivity.

Treating sternoclavicular joint injury and instability with Prolotherapy and Platelet Rich Plasma Injections

Our friend and colleague, the late Alvin Stein MD, published his research and observations in a 21-year-old male with bilateral subluxation of the sternoclavicular joint, which seriously hampered the patient’s athletic and daily living activities. This paper was published in the Open Access Journal of Sports Medicine. (2) Here are the summarized learning points:

As described in the paper, Dr. Stein had been performing Prolotherapy for 16 years and orthopedic surgery for over 30 years before that. During this time, Dr. Stein noted that milder cases of sternoclavicular joint instability responded to Prolotherapy with successful relief of pain and return to full activity. A persistently painful postoperative case was rendered pain-free by Prolotherapy. What Dr. Stein noted in this one particular case was that: “The degree of instability experienced by this patient was so severe that its resolution by Prolotherapy (was so successful, it) warranted a write-up of the case.

• The patient was a 21-year-old college student who was active in high-impact athletics, including powerlifting, Brazilian jiu-jitsu, mixed martial arts, and a long history of freestyle bicycle motocross (BMX).
• He has no acute injury that could explain his current condition but the patient admitted to having “crashed many times while engaging in freestyle BMX. In addition, though not identifying any defining event while powerlifting, there was suspicion that heavy bench press exercises may have contributed to the problem affecting the patient’s sternoclavicular joints.”
• The patient reported a clunking sensation at the sternoclavicular joints on both sides during routine warm-ups. The sternoclavicular joints would visibly sublux and then spontaneously reduce without any discomfort.
• One day after a workout the patient went home and began playing with his dog. During this play, the patient experienced a catching sensation followed by an audible ripping sound and locking of the sternoclavicular joint as forward flexion of the right arm was attempted. The pain associated with this event was severe and persisted for several weeks. From that point on, the joints became increasingly unstable and each subluxation event became excessively painful.

Dr. Stein noted here that the patient sought medical attention but was so afraid to move his arm that the first examination could not determine the full extent of his injury. This full extent was achieved at a second examination. It was suggested that he had torn away from the anterior capsule of the sternoclavicular joint. As the initial severe pain started to subside, the splinting of the area associated with the initial injury also subsided. This allowed the full extent of the instability to be recognized clinically.

• The patient was advised by two separate competent shoulder surgeons that surgical intervention for atraumatic anterior sternoclavicular joint instability was not recommended and carried a large risk of complications. Unhappy over the prospect of being unable to get relief of symptoms and the problem, the patient actively researched other options for treatment. This led to articles about Prolotherapy and, eventually, to a Prolotherapist.

How Prolotherapy worked for this patient.

Dr. Stein noted that at the patient’s first visit, approximately 4 months after the painful subluxation-dislocation episode, examination revealed extreme instability in the sternoclavicular joint, especially on the right side.

Micro perforation Prolotherapy (many injections) was used for the ligament laxity, degeneration, and disruption of the damage this was causing in the sternoclavicular joint.

Aggressive Prolotherapy Treatment vs. More conservative Prolotherapy treatment

After the initial treatments, the patient had a very mild tightness in the sternoclavicular joint area and did not have any severe pain. After 5–6 weeks, he felt some reduction in the popping and could realize more freedom of movement without the anxiety associated with the subluxations.

The patient was a student, whose combined travel and treatment time in the clinic encompassed a full day away from school. As a matter of convenience, he had three treatment sessions with each of two different prolotherapists closer to his school who used a more traditional form of prolotherapy treatment. The patient did not feel that he made an acceptable amount of progress with those six treatments.

This lack of progress made the patient realize that the more aggressive treatment yielded a better outcome and he returned to the clinic 4 1/2 months later for reevaluation. The right side was still hypermobile but was not popping. The left side was popping. Both sides were still painful.

Introduction of Platelet-rich plasma therapy.

Platelet-rich plasma injection using the same micro-perforation technique was employed at this time.

In 2009, Ross Hauser, MD wrote in the Journal of Prolotherapy (3):

“In basic terms, PRP involves the application of concentrated platelets (taken from your blood), which release growth factors to stimulate recovery in non-healing injuries. PRP causes a mass influx of growth factors, such as platelet-derived growth factor, transforming growth factor, and others, which exert their effects on fibroblasts (new collagen > cartilage producers) causing proliferation and thereby accelerating the regeneration of injured tissues. Specifically, PRP enhances the fibroblastic events involved in tissue healing including chemotaxis (getting cells that repair to the site of injury), proliferation of cells, proteosynthesis (using proteins to heal), reparation, extra-cellular matrix deposition (in simplest terms patching cartilage holes see the Caring Medical article on Extra Cellular Matrix), and the remodeling of tissues. The bottom line here is that PRP helps the healing process.”

From every point of view, the shoulder and the sternoclavicular joints are completely normal with no clinical evidence of a problem having existed

Returning to Dr. Stein’s paper:

(After the introduction of Platelet Rich Plasma therapy given in the same manner as Prolotherapy (multiple injections) Progressive improvement was observed at each subsequent visit with increasingly greater levels of stability observed over the intervening weeks. Several additional sessions of the micro-perforation Prolotherapy treatment were administered.

The sixth Prolotherapy treatment was given 13 months after the initial injection session. The patient had much more stability and experienced no popping. When the patient was lying down, he felt that the joints separated more than normal. This was confirmed on examination. Close examination showed some tenderness at the posterior part of the SCJ on palpation of that area. As a result, another Prolotherapy treatment was given. A 4-month hiatus of treatment was recommended to allow the tissues to continue to heal without further stimulation.

The patient was last examined in February 2011, 20 months after he first presented in the clinic. At this visit, he had complete stability of both sternoclavicular joints with no evidence whatsoever of the tendency to subluxation and no weakness of the shoulder girdle or apprehension of upper extremity movement. He was content with the treatment and was pleased that he had not suffered any surgical incisions or complications from a surgical procedure. From every point of view, the shoulder and the SCJs are completely normal with no clinical evidence of a problem has existed.

In Prolotherapy treatments, attention is given to the laxity or weakness of the anterior sternoclavicular ligament and Costoclavicular ligament.

Summary

The sternoclavicular joint attaches the clavicle, or collarbone, to the sternum. It is an underappreciated joint that allows us more upper extremity movement. We frequently see weightlifters, wrestlers, or other athletes who have chronic subluxation and weakness of this joint. They complain of a constant “pop, pop, pop” sound every time they do upper body work. In others, they can physically see and feel the joint subluxing. Again, we see how joint instability, even in this smaller joint, causes a good deal of pain and weakness during and after workouts. Often when an athlete hears the word “weakness” he or she thinks they just need to work out harder. Let us assure you that is not the case with sternoclavicular joint injuries. Muscles are not typically the problem. If you have been doing physical therapy, exercising the surrounding muscles, massage, and the popping is still happening, you have to consider that the joint instability is not being addressed. While some athletes do have to take more care to use good form during their workouts, most sternoclavicular joint problems are best dealt with using Prolotherapy. The ligament attachments of the sternoclavicular joint typically need a few Prolotherapy treatments, and once the sternoclavicular joint is more stable, an athlete gets back to the gym without restriction. Ultimately, this is what our patients are after.

If you have a question about sternoclavicular subluxation, you can get help and information from our Caring Medical staff.

1 Kiel J, Kaiser K. Sternoclavicular Joint Injury. [Updated 2019 Mar 26]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2019 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK507894/ [Google Scholar]
2. Stein A, McAleer S, Hinz M. Microperforation prolotherapy: a novel method for successful nonsurgical treatment of atraumatic spontaneous anterior sternoclavicular subluxation, with an illustrative case. Open access journal of sports medicine. 2011;2:47. [Google Scholar]
3. Hauser R, Hauser M. Platelet rich plasma (PRP) injection technique. Journal of Prolotherapy. 2009;1(3):184. [Google Scholar]
4 Athanatos L, Kulkarni K, Tunnicliffe H, Samaras M, Singh HP, Armstrong AL. Midterm results of chronic anterior instability of the sternoclavicular joint managed using a standardized treatment algorithm. Bone & joint open. 2022 Oct;3(10):815-25. [Google Scholar]

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• Surgery
• NSAIDs
• Cortisone Shots
• R.I.C.E.