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Hi, my name's Jo Gibson and I'm a clinical physiotherapy specialist working at the Liverpool Upper Limb Unit, in Liverpool, in the UK. And I'm also a consultant in private practice. Now you may well have seen that with Clinical Edge, we've launched some free videos about shoulder diagnosis. Really looking at that non-traumatic group in terms of causes of acute onset shoulder pain. If you've not had an opportunity to see those yet, then you can go to www.clinicaledge.co/shoulder where those free webinars are still available. There's three and they really look at the common causes of shoulder pain.

Now the feedback we've had to those videos has been so fantastic, we thought we'd continue the series and do some more Facebook lives on a Monday at seven o'clock just to really kind of look at some other potential causes of shoulder pain. Now we're going to maybe look at some more weird and wonderful things, some slightly less common causes of shoulder pain, but also hopefully get to answer some of your questions after we've talked about the subject and then importantly, get to questions that might matter to you.

So, what I thought we talk about tonight is the sternoclavicular joint. It's a relatively rare cause of shoulder pain. Certainly, when you compare it to other parts of the body, it's very, very rare. If you look at something like trauma and dislocation, it probably accounts for only 1% of all shoulder dislocations. Interestingly, if we look at patterns of referral of pain from the sternoclavicular joint, there's a couple of nice studies looking at injecting hypertonic saline into the sternoclavicular joint and looking at patterns of referral. And those studies showed very nicely that the sternoclavicular joint essentially can refer up into the anterior part of a trapezius and the sternocleidomastoid and the lateral aspect of the cervical spine and can actually refer into the jaw and the front of the ear. It also will refer along the clavicle into this fold or this triangle here. So, not dissimilar actually to the acromioclavicular joint, so an important thing, but again, usually associated with a localised pain and tenderness on palpation.

So, if we have a 55-year-old lady who's post-menopausal, comes into the clinic and tells us that she's got an insidious onset of localised pain on the medial end of a clavicle with radiation as we've just described, but also some associated swelling, what are the pathologies that we need to consider?

She tells you that her pain is made worse by flexion and abduction, and particularly by cross adduction or protraction. And she says herself, it's very tender to palpate and she's very concerned about this swelling. What are the things that need to go through our head? She also tells us that with sudden movement she can feel a little bit of crepiness there in the joints.

Now, if you were going to have a bet with all those things, there's absolutely no doubt that particularly in that older post-menopausal female age group, the most common cause of pathology in the sternoclavicular joint is actually the osteoarthritis, by far the most common by a country mile.

But the problem is, and the reason that we're talking about the sternoclavicular joint tonight is it's also the kind of center of some really weird and wonderful pathologies that we must consider in terms of our differential diagnosis. When we've talked about these different conditions, you'll understand why an X-Ray is an essential part of actually ruling out nasty pathology and ruling in osteoarthritis in somebody who presents to you with that presentation.

Now, one of the first things that's been described in terms of causing this medial clavicle pain is condensing osteitis. It's a relatively rare condition and essentially, it's just sclerosis of that medial end of the clavicle.

The thing that's really unique and why your X-ray is so important is that essentially your X-ray will show that the pathology is just located to the medial clavicle. It doesn't actually involve the sternoclavicular joint itself and that immediately distinguishes it from osteoarthritis.

The other thing that will distinguish it is actually it tends to be a little younger population and not as common in that post-menopausal group, so it's definitely most common in women, but generally between the ages of 20 and 40. You'll still get swelling, there won't be any redness, it will still be unilateral, but as I say, the pathology itself is located more to that medial clavicle than the sternoclavicular joint itself.

Another condition that's very similar to condensing osteitis is a condition known as Friedrich's disease, which is actually avascular necrosis of the medial end of the clavicle. Now again, very, very rare. As ever we have to ask ourselves, does it really matter if we can differentiate these groups?

Well, it definitely does in terms of prognosis because osteoarthritis, generally, patients will get an episode of pain and swelling. It could last three to six months, but generally it resolves on its own or with some supportive rehabilitation. And in some cases, very rare cases, it may need an injection to help it on its way.

Conditions like condensing osteitis and Friedrich's can actually take 12 to 18 months to resolve. So, in terms of setting patients' expectations, getting that diagnosis can be very, very important. In terms of Friedrich's disease, then actually that can affect any age. It tends to be a spontaneous onset of pain. Actually, pain is not as severe as that generally reported associated with osteoarthritis or with condensing osteitis. So those pain descriptors can be very important, but they definitely have that localised swelling. Again, if you do bloods and stuff, the important things will be essentially normal.

So, we've got our osteoarthritis, which is probably our most common diagnosis. We've got condensing osteitis, which this lady's probably a little bit too old for, particularly she's post-menopausal and we've also got Friedrich's disease, which in terms of the fact she's had a gradual increase in pain and development of swelling rather than a more spontaneous onset, then at the moment in terms of betting, we're still kind of thinking in that osteoarthritis group.

Now, another condition that we must consider but again has some very distinct features is a condition called SAPHO. Now, SAPHO stands for synovitis acne pustulosis hyperostosis and osteitis. So, five key things, synovitis, acne, pustulosis, hyperostosis and osteitis. What does that mean? Well, synovitis is the thickening and swelling at the local joint that we see at the sternoclavicular joint. The acne can be over the skin here and so again, it tends to be associated with dermatological problems. Similarly, this pustulosis is actually the pustules that can actually form on the palm of the hand or on the soles of the feet. And I remember the first time I saw this, it was really weird. This lady had bilateral SC joint pain with swelling, we were waiting for investigations, and in the weeks while we were waiting for this and trying to get the results back, she developed these little pustules on her hand. It was really weird.

Now there's thought to be some genetic links, immunological links and also some infective links, but the answer is we don't really know. We think it comes within that seronegative spondyloarthropathy group, but there's still a lot we don't understand about the condition.

Now again, in terms of diagnosis, your imaging is absolutely invaluable. If we look at imaging, then we're looking to see that very typical hyperostosis or expansion of the bone and some very distinct features specific to this condition. You're going to see that periosteal reaction because again, this is a reactive process.

Now, the other thing, how do we differentiate this? Okay, so if we have no skin involvement at all, that's clearly going to be very helpful in our decision making, but let's say that somebody's just got a skin condition anyway. What are the other things that might help you?

Well in SAPHO, it tends not to be just located in the sternoclavicular joint, it tends to involve some of the sternocostal joints and actually involved in the manubrium as well. So, you have a more widespread involvement in terms of local tenderness. It's not uncommon to have bilateral involvement in this particular condition, in fact, it's less common to be unilateral.

The other thing is it generally affects the axial skeleton rather than peripheral joints, and it can involve the SI joint, the hips, the knees, but essentially, again, it's that association with the skin that is an important thing. Now, it's probably also important at this point to mention psoriatic arthritis. So again, people who have psoriasis and have other generalised joint pain, actually sternoclavicular joint pathology is a feature of 50% of patients with psoriatic arthritis and it actually can be the initial presentation. So questioning people about dermatological stuff when they've got SC joint pain and swelling is massively, massively important. So, SAPHO’s just one to work for.

So far, we've got our localised osteoarthritis, which remember is the most common, but we've got to investigate to be sure that's what it is, because of this relative instance of other things that aren't so nice. We've got our condensing osteitis, which is localised, but just involves the medial end of the clavicle rather than the SC joint itself. We've got Friedrich's disease, which is this spontaneous avascular necrosis, so your onset will be slightly different. And then we've got SAPHO, which is typically related to other weird skin complaints as well. But just remember sometimes with SAPHO, they can get the sternoclavicular joint signs and then develop the skin involvement later down the line. So just important things to bear in mind.

So, what are the conditions that we need to consider? Well, it's interesting you remember I said at the beginning that that pain referral tends to be into this region here. If you have radiation down into the front of the chest here, there's a couple of other things that we need to consider. There's a condition called Tietze syndrome, which essentially is inflammation of the costochondral joints and genuinely relates when people have had flu, or a cough, or done some strenuous exercise that they haven't done for a long period of time. The key thing with this is, it tends to be in people under the age of 40. There's generally a mechanism onset and it's very localised to the second and third and not often more than that, but occasionally the fourth costochondral joints. Important, they will have swelling more over the costochondral junctions than they will over the sternoclavicular joint itself. Again, tends to be unilateral.

Now there's one other condition that can mimic Tietze's, which is actually far more common than Tietze syndrome and that's just costochondritis. Again, that tends to be your older population, so over the age of 40, not that I think that's very old anymore. Again, very local, but they will have swelling over this region here, but it will be several of those, usually five typically in terms of involving those costochondral joints. So, it doesn't seem to be any clear mechanism, seems to be in older populations, always exacerbated by physical activity and doesn't tend to be a problem at rest apart from deep breaths. But again, the key differential really, between costochondritis and Tietze syndrome is how many of those joints are involved and the age range if you like. But Tietze is really is very relatively rare.

Now, why am I mentioning all these things? Well, the key thing with the sternoclavicular joint is it has a relatively higher instance of nasty malignancy in terms of neoplasm. Ewing sarcoma, Non-Hodgkin's Lymphoma can actually cause lesions in this area.

I never forget having a young guy, it was a nightmare because he was the boyfriend of a very good friend of mine and she asked me to look at his shoulder and it all sounded fairly straightforward, until when I was listening to his story, I thought, well, there isn't really a clear mechanical picture to this and there's also no real reason for onset. He was a young guy, sternoclavicular joint pathology in somebody who's young fit well with no other risk factors is actually pretty rare. And he said that he did get some issues when he was repeatedly using his arm. But again, other than that there was no consistency in terms of flexion, abduction, protraction in terms of exacerbating his pain and something just didn't ring true. And I think as a clinician, that's the one thing you can never ignore. So, I said to this guy, I thought there were things I could treat, but I really wasn't happy to treat him until he had an X-Ray.

So, he went along to have an X-Ray and it turns out he had Non-Hodgkin's lymphoma and he had a big lesion involving two of his ribs here and that's all this swelling down here. He thinks I saved his life, I was just absolutely mortified that he was my friend's boyfriend and God, I'm just so glad that I trusted my instincts and didn't ignore it. But the guys I work with in clinic, the orthopods that I work with are absolutely adamant in this group that you've got to X-ray them as a first line screen and if anything doesn't fit, then we need to be looking at things like CT and MRI to look at patients further.

There are two other things that we need to consider. Well, maybe three actually. One is infection, so again, the sternoclavicular joint is a very common site of infection. If we look, there's usually risk factors and there's no doubt your immuno-depressed population and more vulnerable. So, if we look at drug abuse, we look at alcoholism, we look at people who are on renal dialysis, we look at people who've got Type 1 diabetes. What else? HIV, anybody who's immunocompromised are at big risk or much higher risk of developing a septic arthritis in the sternoclavicular joints.

In the literature, it's well reported again, that young guys, particularly, if they've got acne, if they have a fall and they have an open wound or just a scrape that's actually bled, that again seems to be a risk factor for developing a secondary septic arthritis in the sternoclavicular joint. If we look at young guys with ankylosing spondylitis, again, if we look at things like Reiter's, which is a reactive arthritis, so Reiter's syndrome. Commonly people think that just relates to sexually transmitted diseases, but actually it's very linked to Salmonella and Campylobacter, so food poisoning and again, the sternoclavicular joint can be a real common site of that, when you compare it relatively to other joints.

It's also a site of gout, but again, if you look at your infective groups, obviously that can affect any age. If you look at gout, it tends to be men over the age of 40 with a lot of the lifestyle factors that you would associate. And the other group that you need to look at is guys, as I say, with ankylosing spondylitis, with that reactive and certainly younger guys who again seem to have this increased prevalence.

So, we go back to our 55-year-old lady that we talked about at the beginning, who presented with pain, referred into a clavicle up into the side of her neck. Insidious onset, no mechanism of trauma and very localised pain and swelling, tenderness over that sternoclavicular joint, pain reproduced with the movement she would expect, flexion, abduction, protraction, and cross adduction. Then as I say, if you're going to put a bet, you would say, this is going to be osteoarthritis, but as I say, that X-ray is absolutely clear. If the X-ray's clear, great. If it's not, if it shows typical signs of osteoarthritis, then fantastic, but as soon as we start to see any erosive or reactive changes on that X-ray, then clearly, we need to get more information.

Similarly, if there's redness, there's heat and the patient's got a temperature, then again, these are all things that we would pick up as clinicians. But really the reason I wanted to talk about the sternoclavicular joint is I think it's one joint where our imaging is actually essential in terms of confirming our diagnosis, but also importantly, being able to set realistic expectations. As I say, osteoarthritis, the very typical picture in that post-menopausal age group that present with this localised swelling, is that it remains painful and comfortable for three to six months and then it resolves. It's quite unusual for it to persist longer than that.

The thing that's important is just to tell your patients if that group genuinely will get better, but one other thing that's important to say to your patients is they can be left with a thickening here. A lot of ladies get quite distressed because they get some very specific thickening around the medial end of the joints and unfortunately that's just because of that thickening is part of that osteoarthritic process. We get this kind of acute phase where we get the swelling, it gets uncomfortable, and then it kind of burns itself out. Once we've got that thickening around the joints' edges, and then it was asymptomatic, but as I say, it's worth kind of counseling patients that that's likely to happen, but the good news is it won't hurt and they'll be able to do what they need to do.

Very occasionally, docs will put an injection in if they're really struggling to progress. But in terms of our rehab, it's really about making sure we get the cuff, the scapula, the shoulder muscles rehabilitated to do their job as best they can and improve their capacity.

So, our 55-year-old lady, we've talked about some other diagnosis we might want to consider. By the very nature of her age, she's far more likely to have osteoarthritis or she may fit into that SAPHO group, particularly if she's got some associated skin findings.

Again, we might want to think about that Friedrich's disease, but in terms of things like that condensing osteitis, she's probably too old to consider that. So, these very simple things just show us how we can actually use the evidence to help rule in and rule out diagnosis. So, I hope that's been useful to you. I've had one question that I can see at the bottom here that's actually about, I think it's something to do with lumbar spondylosis. So, I have to confess, I'm probably not the right person to speak to about that. Anything that's shoulder related, very, very happy to talk and take your questions. But really what I wanted to do was continue our journey through the diagnosis of non-traumatic shoulder pathology and shoulder pain.

So, your key take homes about the sternoclavicular joints. It's a relatively higher site of not very nice pathology, both in terms of neoplasm, malignancy, metastasis and infection and also weird things like gout, but as I say, gout tends to be guys over 40, your infections tends to be your immuno-compressed patients or those who've had trauma, but again, you saw how age is a really useful thing as well in terms of ruling in and ruling out and the literature really kind of underpins that.

But again, remember if you look at those SC joint studies and you look at following patients up, there is if they have that clear picture in terms of flexion, abduction, protraction, cross adduction, pain with local palpable tenderness and any referral into this area here, the key thing you want to understand then is essentially what the mechanism of onset was and if there's any worrying signs.

Oh Carl, let's have a look what it... Oh, thank you. When would you choose MRI over CT?

So, MRI is much more sensitive in terms of picking up infection, whereas obviously CT is much better at looking at bony change. In our unit, it tends to be that we do CT first just because of all those things we've talked about in terms of erosive pathology, in terms of your condensing osteitis and your Friedrich's disease. But also, we often may do both, particularly if there's any worry about malignancy.

So, infection, MRI would be the first line, bony erosion, looking at those bony conditions, CT would be the first one. But if we find anything that we don't like, it wouldn't be uncommon to do both of those investigations.

Now, a question from Lee, would SC joint symptoms like you describe ever be evident in a 35-year-old yet with wider reaching symptoms to the costochondral?

So, if you have involvement of the costochondral joints, it's less likely to be the SC joint on its own unless they've got specific stiffness or they've had trauma. Like any sign over your joints, if they've had trauma or they've had a longstanding injury, whether it developed stiffness, then of course you can transfer load to the adjacent joints and that may be a role. But what I'd be most interested in is actually what their mechanism of onset was.

In a 35-year-old, again, if you look at the literature, osteoarthritic findings in the sternoclavicular joint do happen quite early. And the two biggest groups that we'll see with that in our clinics are the post-menopausal group that I've already talked about, but also manual laborers. So younger guys doing heavy loaded jobs can also present with a similar localised pain. But again, if you've got that costochondral involvement, if there's no skin involvement, fantastic. But again, I would just be asking myself, is it more that they're coming into that costochondritis or Tietze syndrome group rather than the true SC joint pathology. But I'd want to know a little bit more about the history, the mechanism of onset and their clinical.

Oh, here we go. Oh, sorry. It's a lady. I'm so sorry. Insidious onset. So again, if you remember what we said in terms of that condensing osteitis group, that tends to be that 20 to 40 age group, but that tends to just be located to that medial end of clavicle. However, like all these things, if it goes on for long enough, there's no reason that they couldn't develop associated symptoms. What I want to know is the behavior of that pain. If there's any worrying signs in terms of night pain, any systemic markers or whatever. But as I said at the beginning, if somebody got SC joint symptoms, doing an X-Ray as an initial screen is really, really important. So, I hope that answers that Lee. As I say, I can't underpin enough how important it is to just get that routine X-ray to be sure because of that relative incidence.

It's a little bit like frozen shoulder and the relative increase instance of malignancy that gets diagnosed as frozen shoulder, in the sternoclavicular joint, it's even higher in terms of weird stuff that goes on.

So, from Darren, do you address think the vagus nerve has any interaction with SC joint pathologies? Oh, that's a great question. And I'm not sure I know the answer to that. I'd have to reflect on that. That's a really great question. You can maybe post what the basis of the question is.

I think what I would say is when you look at nerve involvement and not necessarily the vagus nerve, but certainly when you look at the spinal accessory nerve and the fact that we have some cranial nerves that go off that, we can get some really weird symptomology in terms of numbness and symptoms around the jaw, around the ear and in front...

Oh, and Lee's got vagus. This is fantastic guys, I'm loving all these questions. Lee that's brilliant. It's been sent from investigations, has nights where... You're doing all the right things. Definitely get her investigated because that's clearly, it's something we need to know what's going on there, so you're doing all the right things. Fantastic.

Darren, in terms of the vagus nerve, I'm going to just say, I don't actually know. That's a great question. I'm going to look into that and I will post something on the page when I've done a little bit of research. If I'm honest, I think that SC joint pathology is relatively rare, I don't see a lot of it. The majority that I see is either the osteoarthritis located to that medial end of the clavicle. I've seen three patients with SAPHO. I've seen a couple of patients with Friedrich's disease, that spontaneous avascular necrosis. Unfortunately, I've seen several people with infection and malignancy and I'm trying to think what else I've seen. And then the other most common thing I see is atraumatic instability. So young, stretchy people whose joint subluxes, who generally do pretty well with rehabilitation.

So, in terms of those more weird things, certainly in terms of nerve involvement and sympathetic stuff, I tend to see more associated with trauma and particularly with clavicular fractures, if there's been a particular malunion or something that's impacting the thoracic outlet. But in terms of the vagus nerve particularly, I'm going to have to do a little bit of research about that. So, watch this space. I'm just seeing if there's any more questions. It'd be great to hear how Lee goes on with his patients and what the outcome is.

But guys, I'm going to be here every Monday. I think in a couple of weeks. I'm actually lecturing to rugby club so it'll be either this Sunday or Tuesday instead, but we'll let you know in plenty of time and all these videos will be available on the Clinical Edge Facebook page for you to peruse again. But also, if you're not able to join us actually at the time, because I realised depending on which country you are, it's not always necessarily that convenient.

So, really this is just part of continuing our journey through diagnosis of non-traumatic shoulder problems. I hope that's given you a little bit of a taste of some of the common pathologies we see in the sternoclavicular joint. As I say, you can still access those free webinars, there's three webinars about the diagnosis of acute shoulder pain, so acute onset shoulder pain and how it may influence your decision making and whether we actually need a diagnosis. You can still access those at www.clinicaledge.co/shoulder.

But I really hope you've enjoyed that. Thank you for the nice comments. It's really lovely to see that people are finding it useful. I'm not sure what the sad faces are. I'm hoping that's not negative, but thank you very much for the thumbs up and all the positive stuff that people have posted. It's really just about sharing knowledge and really helping to kind of make sure patients get the best care and just really some things. I'm lucky to work in a shoulder unit where we see all sorts of weird and wonderful things and it's just great to kind of share some of that knowledge.

And maybe time for one last question. Eleni, thank you very much. CT quite perhaps, but any advice for clavicle fracture patients treated with ORIF to prevent stiff shoulder?

The great thing with ORIF is you can generally get patients going, the key thing to remember, I think the interesting thing about the sternoclavicular joint is it's actually quite mobile. We think of it as this massively stable joint, but as a saddle joint, actually only about 50% of the bony surfaces are actually in contact at any time and it's the discs and the ligaments that give it its stability. You get about 30 degrees of AP in superior-inferior movements and about 45 degrees of rotation. So, it's a really mobile joint. For me as ever, the key thing is really in exaggerating if you like, the scapula component to anything you do. So, I still do my usual cuff rehab. I make sure the cuff's got capacity, but it's a time when I'll really exaggerate that scapular component.

So, you can do stuff with a band around the bat, you could do it standing against the wall with a ball behind you to really encourage that scapular upward rotation movement.

You can also do stuff just with your arm out to the side, doing shrugs, which really gets your upper traps, which is really important in terms of, again, facilitating that rotation. So, for me it would just be about what are the restrictions imposed by the surgeon? How much do I need to support the weight of the arm to actually allow them to get the movement?

But what I want is everything I can do to push that clavicle around. Remember, clavicular rotation is secondary to the scapula movement, so the scapular pushes that clavicle around through its ligaments’ attachments. So, the more you can get movements, the better.

The issue is, that a lot of our clavicle rotation doesn't really start until we get to 80 degrees or below. So, it's really knowing the limitations of the surgical procedure and working within that. If your surgeon wants to kind of hang off and make sure you've got good fixation, then anything you can do to target traps and make sure your cuffs got its capacity is going to be your friend and doing things that are lower degree exaggerating your serratus, again will be really helpful. So, some really quick tips and tricks, but I hope that will help.

So, guys, I've got two minutes left. Thank you, Monica for your lovely comments and Rena, thank you very much. I'm glad you're enjoying the course. That's awesome. I have a question about frozen shoulder. When will you think about the need of arthroscopic release? Great question.

Essentially if a patient continues to struggle and it's had a significant impact on their life. Generally, there are some patients where stiffness-wise they just hit an absolute plateau. Hydrotherapy doesn't work, hydrodilatation hasn't worked and you'll often find, it's certainly ladies with younger onset with hormone issues, associated hormone issues, people in that diabetic group, they are the ones that tend to be more likely to go on to need an arthroscopic release to get the best results. Similarly, some postoperative groups.

But for me it's all about the patients and what is causing them functional restriction. If we can't help them cope, or pain and stiffness persist, then it remains an option. And you know, they do report good outcomes as they do with MUA. But again, we would kind of, I would say operate on a relatively small percentage of that group because we've probably got a better idea of our other rehabilitation options. So, I hope that answers that for you too.

Guys, half an hour has gone already. Thank you so much for joining us. Thank you so much for the lovely comments. Just always happy to talk about shoulders. If you have any key things you'd like me to talk about, then don't hesitate to post on the Clinical Edge Facebook page and we can look at including that in the future. I've got some plans about what I would think I think will be useful and particularly in response to the people who answered the survey about the diagnosing videos that we've already released at the very beginning, but don't be afraid to let us know if there's particular things you'd like me to talk about.

Thanks so much for joining us. Don't forget you can still access the other three free webinars at www.clinicaledge.co/shoulder, but if you still want some more shoulder information and another subject, watch this space. We'll be letting you know what it is in Facebook over the next week and I look forward to seeing you next Monday.

Thanks so much for joining us. Thanks so much for those of you who have posted comments and I look forward to seeing you next week. Thanks a million.