What is the treatment for sternoclavicular hyperosteosis?

Treatment for Sternoclavicular Hyperostosis

The recommended first-line treatment for sternoclavicular hyperostosis is non-steroidal anti-inflammatory drugs (NSAIDs) or cyclooxygenase-2 inhibitors (COX-2) at maximum tolerated dosage, followed by intravenous bisphosphonates as second-line therapy for non-responders. 1

Diagnosis and Classification

Before initiating treatment, proper diagnosis is essential:

• Sternoclavicular hyperostosis is part of the chronic non-bacterial osteitis (CNO) spectrum in adults
• Diagnosis typically requires:
  • MRI or CT combined with nuclear imaging 1
  • Consideration of whole-body imaging to map clinically silent lesions
  • Exclusion of infectious causes, malignancy, and other rheumatologic conditions

Treatment Algorithm

First-line Treatment

• NSAIDs/COX-2 inhibitors at maximum tolerated dosage
  • Options include naproxen, indomethacin, ibuprofen, celecoxib, etoricoxib
  • Evaluate response after 2-4 weeks 1
  • Monitor for gastrointestinal, renal, and cardiovascular adverse effects, especially in elderly patients

Second-line Treatment

• Intravenous bisphosphonates (preferred option)

  • Ibandronate has shown prompt, dramatic pain relief and symptom resolution in treatment-refractory cases 2
  • Typical regimen: 4mg initial dose followed by 2mg every 3 months 2
  • Note: Some cases may be refractory even to bisphosphonate therapy 3

• TNF-α inhibitors (alternative option)

  • Consider especially when additional inflammatory features are present
  • Evaluate response after 3-6 months 1

Bridging Therapy

• Short courses of oral prednisolone or intra-articular glucocorticoid injections may be used for acute flares 4

Surgical Intervention

• Reserved for cases with severe functional impairment or neurological complications 4
• Not typically first-line due to the inflammatory nature of the condition

Monitoring and Follow-up

• Assess treatment success through:

  • Pain reduction and improved function
  • Radiological assessment (MRI or CT combined with nuclear imaging)
  • Laboratory monitoring of inflammatory markers if previously elevated 4

• Regular follow-up visits:

  • 3-6 months after initial diagnosis
  • Every 12-24 months after clinical stabilization 1

Special Considerations

• Consider referral to an expert center for all patients, particularly those who are difficult to treat 1
• A multidisciplinary approach is recommended, ideally led by a rheumatologist with expertise in autoinflammatory and bone-related disorders 1
• For patients with associated skin manifestations (such as pustulosis palmaris et plantaris or other dermatologic syndromes), dermatology consultation may be beneficial 5

Pitfalls and Caveats

• Avoid bone biopsy unless there is suspicion of malignancy or infectious osteomyelitis 4
• Rule out infection through appropriate cultures if fever or significantly raised inflammatory parameters are present 4
• The condition is often misdiagnosed or diagnosis is delayed due to low awareness, leading to prolonged pain and impaired quality of life 2
• Long-term NSAID use requires careful monitoring for adverse effects 4