CHRONIC SUPERIOR STERNAL PAIN - SOFTBALL

Abstract

HISTORY A 17-year-old, right handed high school softball outfielder presented with a long history of bilateral sternocalvicular joint pain, worse for two years. She described painful, popping sensations with activities, particularly throwing and overhead maneuvers. Her symptoms were associated with anterior protrusion of both sternocalvicular joints, although she was most symptomatic on the left. At times, she had difficulty competing. There was a remote history of right clavicular fracture, although there was no clear relation to the onset of her complaints. There was no personal or family history of rheumatic or connective tissue disease. PHYSICAL EXAMINATION A thorough joint examination revealed mildly increased laxity around her fingers and thumbs with minimal recurvatum at her elbows. No other ligamentous laxity or stigmata of connective tissue disease were present. Shoulders had full range of motion with no instability. A cromioclavicular joints were nontender. Both sternoclavicular joints were tender, left greater than right, at the level of the physis. Abduction of the arms was painful, and precipitated anterior subluxation of the sternocalvicular joints bilaterally. Pulses and neurologic examinations were normal in the upper extremities. DIFFERENTIAL DIAGNOSIS: Sternoclavicular joint subluxation Sternoclavicular joint disclocation Fracture of the epiphysis or physis of the clavicle TEST AND RESULTS: CT: Open growth plates bilaterally Left sided posterior/superior subluxation with arms at sides, with mild compression of the anterior brachiocephalic vein by the head of the left clavicle Bilateral anterior subluxation with arms abducted Mild hypertrophic changes of left sternoclavicular joint MRI: Posterior subluxation on the left with arms at sides Anterior subluxation bilaterally with arm abduction Left greater than right hypertrophic changes Synovial proliferation of left sternoclavicular joint Small joint effusion on the right FINAL/WORKING DIAGNOSIS: Bilateral chronic sternoclavicular joint subluxation TREATMENT: Observation - surgery not recommended NSAIDS as needed Activities as tolerated