What is the initial treatment for sternoclavicular arthritis?

Initial Treatment for Sternoclavicular Arthritis

The initial treatment for sternoclavicular arthritis should consist of NSAIDs as first-line therapy, followed by intra-articular corticosteroid injections for symptom relief when needed, after appropriate evaluation of gastrointestinal, renal, and cardiovascular risks. 1

Diagnostic Approach

• Clinical examination is the primary method for detecting sternoclavicular joint arthritis 2, 1
• Ultrasound or MRI can confirm synovitis when clinical examination is inconclusive 1
• Assess for risk factors of persistent/erosive disease:
  • Number of swollen joints
  • Elevated acute phase reactants (ESR, CRP)
  • Presence of rheumatoid factor or ACPA
  • Imaging findings showing inflammation 2

Treatment Algorithm

First-Line Treatment

• NSAIDs for symptomatic relief:
  • Must be used at minimum effective dose
  • For shortest time possible
  • After careful evaluation of:
    • Gastrointestinal risks
    • Renal function
    • Cardiovascular status 2, 1

Second-Line/Adjunctive Treatment

• Intra-articular corticosteroid injection:
  • Highly effective for local symptom relief
  • Must be performed with strict aseptic technique
  • Dosage: 5-15 mg of triamcinolone acetonide for larger joints like the sternoclavicular joint 1, 3
  • Technical considerations:
    • Prior use of local anesthetic may be beneficial
    • Avoid injecting into surrounding tissues to prevent atrophy 3

For Persistent Disease

• If symptoms persist beyond 3 months or risk factors for persistent disease are present:
  • Initiate DMARDs, with methotrexate as the anchor drug (7.5-15mg weekly) 2, 1
  • Consider systemic glucocorticoids temporarily (<6 months) as bridging therapy 2

Monitoring and Follow-up

• Assess joint tenderness, swelling, and function at 1-3 month intervals 1
• Monitor inflammatory markers (ESR, CRP) every 4-6 weeks after treatment initiation 1
• The goal of treatment is clinical remission 2

Important Considerations and Pitfalls

• Pitfall #1: Delayed referral to rheumatology

  • Patients with arthritis should be referred to a rheumatologist within 6 weeks of symptom onset 2

• Pitfall #2: Prolonged systemic glucocorticoid use

  • Avoid using oral glucocorticoids for >6 months due to cumulative side effects 2, 1

• Pitfall #3: Failure to recognize infectious etiology

  • Septic arthritis of the sternoclavicular joint can lead to serious complications including mediastinitis and sepsis
  • Requires prompt antibiotic therapy and often surgical intervention 4

• Pitfall #4: Overlooking non-pharmacological interventions

  • Dynamic exercises and occupational therapy should complement drug treatment 2
  • Patient education about the disease and coping strategies is important 2

• Caveat: Primary osteoarthritis of the sternoclavicular joint is common in older adults (90% of people over age 60) and should be considered in the differential diagnosis of chest wall pain 5