Disorders of the sternoclavicular joint . . . . . . . e78Sprain of the acromioclavicular joint . . . . . . . . e81Disorders of the first rib . . . . . . . . . . . . . . . e81Traction fracture of the spinous process C7 or T1 . . . . . . . . . . . . . . . . . . . . . . . e81Lesion of the conoid/trapezoid ligament . . . . . . e81Neural compression . . . . . . . . . . . . . . . . . e81
Pain on active elevation and protraction e81
Painful limitation of active and passive elevation e82
Ankylosis of the acromioclavicular joint . . . . . . e82Disorders of the sternoclavicular joint . . . . . . . e82Disorders of the costocoracoid fascia . . . . . . . e83Scapular metastases . . . . . . . . . . . . . . . . e84Apical tumour of the lung . . . . . . . . . . . . . . e84
Limitation of active elevation and weakness of resisted elevation e84
Paraesthesia brought on by active and/or passive elevation e84
Crepitus during scapular elevation e84
Pain on active and passive scapular approximation e85
Pain on active and passive elevation (Fig. 1)
Disorders of the sternoclavicular joint
Disorders of this joint are usually the result of an injury; arthro-sis, hyperostosis and rheumatoid or septic arthritis are other possibilities.1 All conditions give rise to both scapular and shoulder signs and occasionally to signs on movements of
the neck. The clinical pattern closely resembles that of an acromioclavicular joint lesion but the localization of pain at the medial end of the clavicle draws attention to the sternoclavicu-lar joint. In posterior sternoclavicular syndrome, the pain is felt posteriorly at the base of the neck.
Positive signs are commonly found at three levels: neck or upper thorax, shoulder girdle and shoulder.
Neck signsAll active or resisted movements of the neck that involve the sternocleidomastoid muscles may also provoke some pain: active and resisted rotation towards the painless side and resisted side flexion towards the painful side.
Shoulder girdle signsThere is pain on full active and passive elevation of the shoul-der. The other active and passive movements are not, or are only slightly painful.
Shoulder signsPain is also found on active and passive movements of the arm because almost all arm movements have some influence on the sternoclavicular joint. Pain is most marked on elevation of the arm. When a disorder of the sternoclavicular joint is suspected, passive horizontal adduction of the arm should be performed: pain is most pronounced with this test (Fig. 2).
Sprain of the sternoclavicular joint/ligamentsThis is usually the result of an injury such as a fall on the out-stretched hand or on the shoulder. Occasionally, a sprain is the result of overuse, which mainly occurs in arthrotic joints.
Pain is felt unilaterally over the lateral manubrial angle and may radiate into the clavicular area. It can be elicited by active and passive elevation of the scapula and by all passive move-ments of the arm. Resisted movements are negative. Passive horizontal adduction – an accessory test – is the most painful movement. On palpation there is tenderness over the joint line or in the ligaments.
Both active and passive elevation of the arm is painful. Some-times it is even hard to achieve full range. All other movements of the arm are normal, except for passive horizontal adduction which is most painful. Clinical examination of the shoulder girdle is required. Pain is elicited by active and passive elevation of the shoulder. Resisted shoulder elevation is negative, which excludes the trapezius and levator scapulae muscles. No pain is found on palpation of the anterior portion of the sternocla-vicular joint.
TreatmentOne or two infiltrations of 20 mg triamcinolone into the pos-terior sternoclavicular ligament is helpful and can be done in one of two ways:
• By approaching the ligament from above and allowing the needle to progress behind the joint until ligamentous resistance is felt
• From the front, passing through the joint as for an intra-articular injection.
In both instances, the steroid must be infiltrated into the pos-terior ligament and counterpressure must be present during the whole procedure. Therefore the tip of the needle is partly withdrawn and reinserted several times, over the whole of the posterior ligament, as the product is injected. Throughout,
TreatmentWhen the onset is recent, the arm should be placed in a sling to diminish the effect of gravity. An intra-articular steroid injection is given at once.
Technique: injection of the sternoclavicular jointThe patient lies supine. The gap between the medial end of the clavicle and the sternum is palpated. A needle of 2.5 cm is introduced, penetrating the joint to a depth of about 1 cm (Fig. 3), and 1 ml of triamcinolone acetonide is injected. If excessive resistance is encountered, the needle is in the menis-cus; if this occurs, the tip of the needle should be partly with-drawn with continuous pressure on the plunger until the steroid floats in with little resistance.
Posterior sternoclavicular syndromeThis rare disorder may arise spontaneously in middle-aged people and usually causes a misleading clinical picture.
Patients complain of unilateral pain at the base of the neck. Surprisingly, the pain is felt more posteriorly and not at the sternoclavicular joint itself, which suggests a lesion of the cervi-cal spine. Nevertheless, clinical examination of the neck does not localize the problem: there is usually full range on passive movements and no pain on active and resisted movements.
Fig 1 • Shoulder girdle lesions with clavipectoral pain.
special care must be taken not to penetrate neighbouring vis-ceral structures.
The patient is reassessed after 2 weeks; if symptoms are still present a second infiltration is given. Normally two or three infiltrations suffice.
ArthrosisArthrosis of the sternoclavicular joint is common.2 It occurs mainly in postmenopausal women. The chief complaint is cos-metic: there is a visible thickening of the joint. The pain, if any, is minor 3. Elevation of the arm is limited as the result of the limitation of the shoulder girdle movement. Movements of the shoulder girdle are uncomfortable but not really painful.
Radiography shows degenerative changes (osteophytes, bone cysts, hyperostosis and diminution of the joint line), most pronounced at the inferior aspect of the clavicular head. Occa-sionally calcification is seen in the ligaments.4
For the overuse phenomenon in arthrosis an intra-articular injection of triamcinolone acetonide can be given.
Rheumatoid arthritisRheumatic conditions may also affect the sternoclavicular joint. This often occurs in ankylosing spondylitis.5 It gives rise to the same clinical pattern as in a sprain, but local swelling from synovial thickening is present. A progressive ankylosis develops with pronounced limitation of movement in the shoulder girdle. Other sites of rheumatoid arthritis should bring the disorder in mind, although the sternoclavicular joint may be the first joint affected.
TreatmentLocal infiltration of triamcinolone acetonide may be helpful.
Septic arthritisBacterial agents such as Staphylococcus aureus, Streptococcus group B and Brucella spp. have been isolated in septic arthritis of the sternoclavicular joint.6,7 Septic arthritis occurs in elderly patients with a deficient immune system, with rheumatoid arthritis and diabetes mellitus, and in drug addicts.8–10 The patient usually has fever, chills and sweating, and complains of pain and swelling in the sternoclavicular area, sometimes at the base of the neck. In about 20% a local, warm and erythematous mass is present at the joint because of abscess formation.11–13
A combination of neck signs, shoulder signs and shoulder girdle signs is found on examination:
• Passive and resisted neck movements are painful as the result of passive and active stretching of the sternocleidomastoid and scaleni muscles.
• Active and passive elevation of the arm are very limited.• Active and passive shoulder girdle movements are painful
and limited. There is warmth, swelling and exquisite tenderness over the sternoclavicular joint.
There is an elevated erythrocyte sedimentation rate and tomo-graphy or CT scan are mostly likely to show bony erosions and destructive changes at the medial end of the clavicle and the clavicular aspect of the sternum.
movements are painful. Radiography shows avulsion of the seventh cervical or first thoracic spinous process.
Lesion of the conoid/trapezoid ligament
Pain is felt in the midclavicular area and is often due to ‘smash’ movements, such as those which occur in volleyball, baseball and serving in tennis. It is increased at the extremes of all passive movements of the arm but resisted movements remain negative. Forced passive lateral rotation with the arm abducted to 90° is also painful, as are the extremes of all active and passive shoulder movements (see p. 237 and online chapter Non-mechanical disorders).
Neural compression
Shoulder elevation is considered one of the dural signs because it stretches or moves the thoracic dura mater via traction on the intercostal nerves. The same applies to the upper thoracic nerve roots.
Compression of the dura materDural mobility may be impaired as the result of compression from a space-occupying lesion in the spinal canal. In most instances it is a discodural interaction caused by a posterocen-tral thoracic disc protrusion. It gives rise to multisegmentally referred pain, which may increase on all active and passive scapular movements (see online chapter Applied anatomy of the cervical spine).
T1–T2 nerve root compressionThe mobility of the upper thoracic nerve roots is reduced when a space-occupying lesion in the lateral root recess or in the intervertebral foramen causes compression. Again the disc (a posterolateral protrusion) may be responsible in rare instances but reduction of the foraminal size may also be related to degenerative conditions. The active and passive movements of the shoulder may all have an influence on the symptoms: pain and paraesthesia at the inner aspect of the upper limb. Motor deficit is uncommon and if it occurs – possibly in the intrinsic muscles of the hand – should be regarded as a warning sign. Apical tumour of the lung is most likely (see pp. 156–157).
Pain on active elevation and protraction
Pain on active forwards movement of the shoulder does not occur in isolation. It is usually combined with pain on active elevation. This clinical picture may occur in rather uncommon situations:
• Lesion of the conoid and/or trapezoid ligament: this gives rise to pain located in the infraclavicular fossa, provoked by both arm and shoulder movements (see p. 245).
• Compression of an upper thoracic nerve root (T1/T2): a discoradicular interaction at the first or second thoracic
TreatmentInpatient treatment is required, the joint being immediately aspirated and antibiotics started. When an abscess is present, surgical drainage is necessary.14
Sprain of the acromioclavicular joint
Pain is usually confined to the area of the acromioclavicular joint. Both active and passive elevation of the scapula may be slightly painful but painless movement is not uncommon. The diagnosis becomes clear when the shoulder is examined. Local pain over the acromioclavicular joint is provoked at the end range of the three passive movements of the shoulder examina-tion: passive elevation, lateral rotation and medial rotation (for a detailed description, see p. 241).
Disorders of the first rib
The first rib can become affected in that it becomes sprained at the level of the articulation with the spine or becomes the site of a stress fracture.
Sprain of the first costotransverse jointThe patient complains of unilateral pain at the base of the neck elicited by certain movements of the arm and shoulder. On examination pain is elicited by active and passive side flexion away from the painful side and resisted flexion towards the painful side. Flexion may also be positive.
Such a pattern – in fact a contractile tissue pattern – draws attention to the scaleni muscles. In this case the lesion does not lie in the scaleni but in the structure to which the muscle is attached. Pain is also present on active and passive elevation of the arm and the scapula, resulting in a mixed pattern of neck, shoulder and shoulder girdle signs.
Stress fracture of the first ribPain occurs spontaneously and is felt unilaterally at the base of the neck and in the scapulopectoroclavicular area. The clinical picture is typical. There are neck, shoulder girdle and shoulder signs. In the neck a ‘contractile tissue pattern’ is found: pain on active and passive side flexion towards the painless side, combined with pain on resisted side flexion towards the painful side. All scapular movements are more or less painful and active elevation of the arm is impossible because of the pain: the arm stops at the horizontal. Passive elevation is full but painful. Radiography is confirmative (see also p. 237).
Traction fracture of the spinous process C7 or T1
Following intense exertion the patient feels a sudden pain at the cervicothoracic junction. Neck signs are subtle but arm signs are pronounced: the patient is hardly able to bring both arms actively above the horizontal. Passive arm elevation is painful but not limited. Active and resisted shoulder
identical clinical pattern as that of ankylosis of the acromiocla-vicular joint. However, pain – if present – is at the medial end of the clavicle (see p. 237).
Traumatic dislocationTraumatic dislocation of the sternoclavicular joint is not common. The medial portion of the clavicle may be displaced anteriorly or posteriorly.
Anterior luxation is by far the more common. It outnumbers posterior dislocations by up to 20 to 1.15 This is because the posterior capsule and ligaments are stiffer than the anterior structures, so that posterior luxation is more difficult.16 Some cranial displacement is associated because of the weight of the arm.
Symptoms and signs resemble those of a proximal fracture of the clavicle: the patient supports the painful arm, the shoul-der girdle looks ‘shortened’ and the head is held deviated towards the affected side. The active and passive movements of the shoulder girdle are all extremely painful. The luxation deformity is clearly visible.
Subluxation is usually not inconvenient to the patient.17 Some people can dislocate the medial portion of the clavicle voluntarily as a ‘party trick’. In this event, pain is not felt but an audible click is present. Anterior displacement must be distinguished from synovial swelling, which may take place in rheumatoid arthritis. The history of an injury suggests displace-ment. Radiography is of little help.
A posterior dislocation may threaten or damage mediastinal structures (Fig. 4).18–21 It may result in venous congestion of arm and head, as well as dyspnoea and swallowing disturbances.22
level gives rise to a partial articular pattern of the thoracic spine. Dural symptoms and signs should be sought, although they are not necessarily present. Any other space-occupying lesion (e.g. a tumour) is also possible and even more probable (see p. 156).
• Idiopathic contracture of the costocoracoid fascia: the clinical picture strongly resembles a sprained coracoclavicular ligament. Often arm and shoulder elevation are slightly limited.
Painful limitation of active and passive elevation
Ankylosis of the acromioclavicular joint
Limitation on active and passive elevation of the scapula may be the outcome of complete ankylosis of the acromioclavicular joint as the result of ankylosing spondylitis, arthrosis or rheu-matoid arthritis. The arm cannot actively or passively be raised above the horizontal. Examination of the glenohumeral joint reveals normal mobility. Examination of the shoulder girdle shows that scapular elevation is completely limited (see p. 237).
Disorders of the sternoclavicular joint
Ankylosis of the sternoclavicular jointAnkylosis of the sternoclavicular joint as a result of ankylosing spondylitis, arthrosis or rheumatoid arthritis gives rise to an
Fig 4 • A posterior dislocation may threaten mediastinal structures.
TreatmentLuxation of the bone often needs surgical repair23 and is nec-essary when neurovascular structures are involved.24 In sub-luxation it usually suffices to do a passive retropulsion of the shoulder girdle by immobilization,25 for example fixating it with a ‘figure-of-eight’ bandage. Intra-articular triamcinolone may occasionally be added.
Sternoclavicular hyperostosisThis is a rare condition, in which progressive ossification devel-ops in the sternoclavicular joint, the joint between the first rib and the sternum and the sternoclavicular and costoclavicular ligaments. In advanced cases the formation of a massive osseous block between sternum, clavicle and first rib can be seen. It may be associated with seronegative spondyloarthropathy26 and occasionally with pustulosis palmaris and plantaris. It is then known as SAPHO syndrome (synovitis–acne–pustulosis– hyperostosis–osteitis).27–29
Characteristically, the complaints start at a young age, with intermittent pain, local swelling and reddening over the sternum and the sternoclavicular joints. Clinical examination shows a gradual loss of mobility within the shoulder girdle, which may end in complete ankylosis.30 Active and passive elevation of the shoulder girdle then becomes impossible.
Elevation of the arm is grossly limited and shows a forward component, while the scapula remains totally immobile.
Radiology shows a progressive joint destruction in combina-tion with an increasing hyperostosis of the sternoclavicular liga-ments.31 In most cases there is an increase in the erythrocyte sedimentation rate.32
TreatmentThere is no causative treatment for this condition. Steroid infiltration in the ligaments may give some temporary relief. The results after surgery are poor.
Disorders of the costocoracoid fascia
Contracture of the costocoracoid fascia and/or the pectoralis minor may also limit active and passive shoulder elevation (Fig. 5), (See p. 237):
• An idiopathic contracture is a very uncommon cause of limited elevation of the arm.33 It comes on spontaneously and initially causes unilateral pectoroscapular pain on full elevation of the arm and on active and passive elevation of the shoulder girdle. At a later stage, the pain becomes permanent and a limitation of about 10° on active and passive elevation of arm and shoulder may set in. The
in the pectoroscapular area which may radiate down the upper limb. It may affect the normal functioning of the thoracic spine, the shoulder girdle and the shoulder. In the shoulder girdle examination, active and passive elevation of the shoulder may be painful and limited. Accompanying symptoms and signs, such as Horner’s syndrome or atrophy of the intrinsic muscles of the hand, reveal the disorder (see p. 236).
Limitation of active elevation and weakness of resisted elevation
This presentation may point towards a lesion of the nerve root C2–C4. A posterolateral herniation at these levels is extremely rare.
limitation of elevation of the arm suggests a psychogenic disorder, but repeated shoulder girdle examination showing an unfailing and isolated limitation in elevation of the shoulder girdle provides the key to the diagnosis. Forward movement of the shoulder (protraction) is painful but of full range, although backward movement (retraction) is normal. No resisted movements hurt. On examination of the neck, slight pain may be found on active flexion to the contralateral side and on resisted side flexion towards the painful side. Diagnosis is made on MRI, where thickening and irregularity in the upper–lateral part of the pectoralis minor can be seen. Surgical treatment – section of the thickened fibrous tissue – provides good and permanent results.
• Neoplasm: the previous disorder must be differentiated from an invasion of the costocoracoid fascia by a tumour. This gives rise to the same signs but is more rapid and swifter in its evolution. Other neurological signs (e.g. Horner’s syndrome) should be looked for.
• Healed apical tuberculosis: this may also limit mobility and elasticity of the costocoracoid fascia, causing the same clinical picture as in idiopathic contracture.
• After radiation therapy: similar clinical features may be encountered after radiation therapy for cancer of the lung or breast and after dissection of axillary nodes in breast surgery.34
• Haematoma between the costocoracoid fascia and the ribs with subsequent traumatic fasciitis may result from injury to the anterior chest wall. This again gives rise to a similar clinical picture: pain and limitation of both active and passive elevation of the shoulder and arm. The radiograph shows no evidence of rib fracture. The disorder undergoes spontaneous cure over about 3 months.
Scapular metastases
Warning
The type and localization of the pain, together with – in its later stage – muscular atrophy and weakness, and a poor general condition, must warn the examiner, and a radiograph must be taken at once.
Scapular metastases are accompanied by unilateral scapular pain, which is increased by all active and passive movements of the shoulder. As the result of excessive pain, active and passive elevation of the shoulder may become limited.
Apical tumour of the lung
Pancoast’s tumour is not uncommon. It grows from the upper part of the lung and may involve most structures in that area, such as the brachial plexus, the sympathetic ganglia at the base of the neck, the ribs and the vertebrae. It gives rise to pain felt
Warning
A physician who examines a patient complaining of pectoroscapular pain should always bear in mind the possibility of an apical lung tumour and look for unusual symptoms and signs.
Another cause of weakness of the trapezius is a disorder of the spinal accessory nerve (see online chapter Nerve lesions and entrapment neuropathies of the upper limb).
Paraesthesia brought on by active and/or passive elevation
If pins and needles occur in fingers or hand during active or passive elevation of the scapula, a thoracic outlet syndrome is very likely (see online chapter Nerve lesions and entrapment neuropathies of the upper limb).
Crepitus during scapular elevation
Painless crepitus is sometimes heard and felt on moving the scapula actively up and down.
A crepitating or snapping scapula stems from the disruption of normal mechanics in the scapulothoracic gliding surface.35 When the patient abducts the scapula by moving the shoulders forwards the noise may stop. This can occur unilaterally or bilaterally and implies that the posterior thoracic wall, just beyond the lateral edge of the iliocostalis muscle, has become rough.36 It is usually painless and does not require treatment. Exceptionally, scapular pain occurs after exertion or even at rest. It occurs mainly in professions where thoracic hyperky-phosis is maintained for a long period of time (e.g. computer operators and physiotherapists).
Other cases, usually associated with pain, are the result of local injury, an inflamed bursa or an inflammation of other soft tissues in this location.37 Bursitis is frequently encountered in baseball pitchers.38 True scapular ‘snapping’ is the outcome of an osseous projection on the thorax or the anterior wall of the scapula.39
This presentation draws attention to interference with the dura mater or the dural nerve root sleeve by an upper thoracic disc protrusion or a spinal tumour.
Treatment
Deep frictionIn roughening of the posterior thoracic wall, deep friction can be tried. The affected area is outlined by asking the patient to abduct the scapula progressively, meanwhile testing scapular elevation at each degree of abduction. In the position that crepitus ceases, the scapula has been brought so far laterally that it has lost contact with the roughened thorax. The lesion now lies just medial to the medial scapular border. If local tenderness is not found on palpation, the whole upper area around the medial part of the scapula must be treated.
Technique: deep friction to the posterior thoracic wallThe patient lies prone with the shoulder well abducted and the arm in full medial rotation. The therapist stands at the opposite side and gives massage with all fingers in a mediolateral direction for about 20 minutes (Fig. 6); friction is repeated on alternate days. The crepitus will not disappear but the pain usually does, although 20 sessions may be required.
SurgeryIf massage fails, the superomedial angle of the scapula can be removed.40 In some cases the whole vertebral border has been removed.41
Fig 6 • Deep friction to the posterior thoracic wall.
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