American Journal of Physical Medicine & Rehabilitation:
Wisniewski, Steve J. MD; Smith, Jay MD
From the Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, Minnesota.
All correspondence and requests for reprints should be addressed to Steve Wisniewski, MD, Mayo Clinic Sports Medicine Center, 200 First Street SW, Rochester, MN 55905.
A 55-yr-old right hand–dominant female presented to clinic with a 1-yr history of right sternoclavicular joint (SCJ) pain. The pain was focal, dull, nonradiational, and increased with any upper-limb activity. She reported no history of trauma or other joint complaints. The pain started while the patient was working in a factory; it eventually resulted in early retirement and a switch to a nonmanual labor job. Rheumatologic work-up was unremarkable. Prior treatments had included numerous medications, extensive physical therapy, icing, and a non–image-guided intra-articular SCJ steroid injection, all without any appreciable change in symptoms.
Physical examination revealed obvious swelling over the right SCJ, where palpation produced significant tenderness reproductive of her usual pain. All other joints were normal.
Radiographs revealed mild degenerative changes at the right SCJ. Chest computed tomography revealed only minimal irregularity and narrowing of the right SCJ compared with the left, with moderate amounts of adjacent soft-tissue swelling. Prior bone scan was normal at the SCJ.
Because of the perception of synovitis on examination, we performed an ultrasound (US) examination of the right SCJ with comparison views of the left SCJ (Fig. 1). The exam revealed remarkable capsular hypertrophy, a small amount of anechoic intra-articular fluid, and a moderate amount of hyperechoic, intra-articular tissue exhibiting increased power Doppler flow, consistent with synovitis (Fig. 2). The visualized bony margins were only minimally irregular.
US-guided right intra-articular SCJ aspiration and injection were then performed. A small amount of yellowish fluid of slightly reduced viscosity was obtained. A 1-ml mixture of methylprednisolone and 1% lidocaine were then slowly injected under direct US guidance (Fig. 3). The patient tolerated the procedure well with no complications.
This case illustrates numerous advantages of using musculoskeletal US in a physiatric practice. Despite prior unremarkable radiographs, computed tomography scan, and bone scan, the use of US with Doppler confirmed SCJ synovitis and ensured accurate needle placement for aspiration and therapeutic injection. Accurate needle placement is particularly crucial when fluid must be obtained for analysis or when target structures are close to neurovascular structures. Finally, this procedure was easily accomplished in the office during a single patient visit.
1. Ferri M, Finlay K, Popowich T, et al: Sonographic examination of the acromioclavicular and sternoclavicular joints. J Clin Ultrasound 2005;33:345–55
2. Ernberg LA, Potter HG: Radiographic evaluation of the acromioclavicular and sternoclavicular joints. Clin Sports Med 2003;22:255–75
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