Treatment of Fibrosis Lesion of the Sternoclavicular Joint
The primary treatment approach for fibrosis lesions of the sternoclavicular joint should begin with conservative management including activity modification, physical therapy, NSAIDs, and potentially corticosteroid injections, reserving surgical intervention only for cases with persistent pain and functional impairment that fail conservative therapy. 1
Initial Conservative Management
Conservative treatment is the cornerstone of initial management and should be attempted for at least 3-6 months before considering surgical options 1, 2:
- Activity modification to avoid provocative movements and reduce mechanical stress on the joint 1
- Physical therapy focusing on scapular stabilization, postural correction, and gradual range-of-motion exercises 2
- Oral NSAIDs for pain control and anti-inflammatory effects 1
- Corticosteroid injections into the sternoclavicular joint for persistent symptoms unresponsive to oral medications 1
Diagnostic Workup to Guide Treatment
Before initiating treatment, proper imaging is essential to characterize the lesion and exclude other pathology:
- Plain radiographs as initial imaging to evaluate for structural abnormalities, though sensitivity is limited 3
- CT chest provides superior characterization of osseous involvement, cortical erosion, and extent of disease 3
- MRI is preferred for detecting bone marrow edema and soft tissue involvement, particularly useful for inflammatory conditions 3
- Bone scintigraphy may be considered if inflammatory conditions like chronic non-bacterial osteitis (CNO) or SAPHO syndrome are suspected, as it has 100% sensitivity for detecting sternoclavicular joint inflammation 3
Differential Diagnosis Considerations
The treatment approach must account for the underlying etiology of the fibrosis lesion 3:
- Chronic non-bacterial osteitis (CNO) or SAPHO syndrome—consider if there is bone marrow edema on MRI with sternoclavicular involvement 3
- Degenerative osteoarthritis—more common in older patients with subchondral sclerosis and osteophytes 3, 4
- Post-traumatic fibrosis—history of prior injury or instability 1, 5
- Inflammatory arthropathies (psoriatic arthritis, axial spondyloarthritis)—look for associated features like psoriasis, inflammatory back pain, or HLA-B27 positivity 3, 6
Surgical Intervention
Surgery is indicated only when conservative treatment fails to manage symptoms after an adequate trial (typically 3-6 months) 1, 4:
- Resection arthroplasty of the medial clavicle is the primary surgical option for symptomatic fibrosis with degenerative changes 4
- Ligament reconstruction with figure-of-8 graft technique may be added if there is associated instability, though this carries risk of neurovascular injury 1, 4
- Arthroscopic resection is an alternative to open surgery that may decrease operating time and recovery while reducing iatrogenic injury risk 4
Special Considerations for Inflammatory Conditions
If the fibrosis lesion is associated with CNO or SAPHO syndrome 3:
- Initial surveillance may be appropriate as first-line management rather than immediate intervention 3
- NSAIDs remain first-line pharmacologic therapy 3
- Systemic therapies (such as bisphosphonates or biologics) may be considered for progressive symptomatic disease after multidisciplinary discussion 3
- Radiotherapy is generally not recommended for benign inflammatory conditions due to concerns about late toxicity in young patients 3
Common Pitfalls to Avoid
- Do not perform routine bone biopsy unless there is concern for infection or malignancy that cannot be excluded by imaging 3
- Avoid premature surgical intervention before adequate conservative trial, as most cases respond to non-operative management 1, 5
- Do not overlook systemic inflammatory conditions that may require disease-modifying treatment rather than local intervention alone 3, 6
- Be cautious with figure-of-8 reconstruction due to proximity to vital mediastinal structures 1, 4