Manubriosternal Joint Pain
The manubriosternal joint can serve as a source of pain that often may mimic pain of cardiac origin. The manubriosternal joint is susceptible to the development of arthritis, including osteoarthritis, rheumatoid arthritis, ankylosing spondylitis, Reiter syndrome, and psoriatic arthritis. The joint is often traumatized during acceleration/deceleration injuries and blunt trauma to the chest.
With severe trauma, the joint may sublux or dislocate. Overuse or misuse can result in acute inflammation of the manubriosternal joint, which can be quite debilitating. The joint is subject to invasion by tumor from primary malignancies, including thymoma, metastatic disease, and infection.
What are the Symptoms
On physical examination, the physical deformity of joint subluxation after traumatic injury may be obvious on inspection. The patient vigorously attempts to splint the joint by keeping the shoulders stiffly in neutral position. Pain is reproduced by active protraction or retraction of the shoulder, deep inspiration, and full elevation of the arm.
Shrugging of the shoulder also may reproduce the pain. The manubriosternal joint may be tender to palpation and feel hot and swollen if acutely inflamed or infected. The patient may report a “clicking” sensation with movement of the joint.
How is it diagnosed?
Plain radiographs are indicated for all patients who present with pain thought to be emanating from the manubriosternal joint to rule out occult bony pathological processes, including tumor. Based on the patient’s clinical presentation, additional testing may be indicated, including complete blood count, prostate-specific antigen level, erythrocyte sedimentation rate, and antinuclear antibody testing.
Computed tomography (CT), ultrasound imaging, or magnetic resonance imaging (MRI) of the joint is indicated if infection, tumor, or joint instability is suspected. Injection of the manubriosternal joint with local anesthetic and steroid serves as a diagnostic maneuver and a therapeutic maneuver.
Ultrasound guidance may improve the accuracy of needle placement and decrease the incidence of needle-related complications.
As mentioned earlier, manubriosternal joint pain is often mistaken for cardiac pain.
A careful search for metastatic disease or tumor invasion of the chest wall is mandatory in all patients with manubriosternal joint pain, because this pain may coexist with pathological rib fractures or pathological fractures of the sternum itself, which can be missed on plain radiographs and may require radionucleotide bone scanning for proper identification.
Neuropathic pain involving the chest wall and sternum also may be confused or coexist with manubriosternal joint pain. Examples of such neuropathic pain include diabetic polyneuropathies and acute herpes zoster involving the thoracic nerves.
The possibility of diseases of the structures of the mediastinum is ever present, and these diseases can be sometimes difficult to diagnose. Pathological processes that inflame the pleura, such as pulmonary embolus, infection, and Bornholm disease, also may mimic the pain emanating from the manubriosternal joint.
Initial treatment of manubriosternal joint pain should include a combination of simple analgesics and nonsteroidal antiinflammatory drugs (NSAIDs) or cyclooxygenase-2 (COX-2) inhibitors. If these medications do not control the patient’s symptoms adequately, or if considerable sleep disturbance exists, a tricyclic antidepressant should be added.
Traditionally, tricyclic antidepressants have been a mainstay in the palliation of sleep disturbance associated with painful conditions. Controlled studies have shown the efficacy of amitriptyline for this indication.
Other tricyclic antidepressants, including nortriptyline and desipramine, also have been shown to be clinically useful. This class of drugs is associated with considerable anticholinergic side effects, including dry mouth, constipation, sedation, and urinary retention.
These drugs should be used with caution in patients with glaucoma, cardiac arrhythmia, and prostatism. To minimize side effects and encourage compliance, the primary care physician should start amitriptyline or nortriptyline at a 10-mg dose at bedtime. The dose can be titrated upward to 25 mg at bedtime as side effects allow. Upward titration of dosage in 25-mg increments can be done each week as side effects allow.
Even at lower doses, patients generally report a rapid improvement in sleep disturbance and begin to experience pain relief in 10 to 14 days. Selective serotonin reuptake inhibitors, such as fluoxetine, also have been used to treat the pain of diabetic neuropathy, and although better tolerated than tricyclic antidepressants, they seem to be less efficacious than the tricyclic antidepressants.
Local application of heat and cold may be beneficial to provide symptomatic relief of the pain of manubriosternal joint pain. The use of an elastic rib belt may help provide symptomatic relief.
For patients who do not respond to these treatment modalities, injection of the manubriosternal joint using local anesthetic and steroid may be a reasonable next step.
The major problem in the care of patients thought to have manubriosternal pain is the failure to identify potentially serious pathology of the thorax or upper abdomen secondary to metastatic disease or invasion of the chest wall and thorax by tumor.
Given the proximity of the pleural space, pneumothorax after injection of the manubriosternal joint is a possibility. The incidence of the complication is less than 1%, but it occurs with greater frequency in patients with chronic obstructive pulmonary disease.
Although uncommon, infection is an ever-present possibility, especially in an immunocompromised patient with cancer. Early detection of infection is crucial to avoid potentially life-threatening sequelae.
Patients with pain emanating from the manubriosternal joint often attribute their pain symptoms to a heart attack. Reassurance is required, although it should be remembered that this musculoskeletal pain syndrome and coronary artery disease can coexist.
Care must be taken to use sterile technique to avoid infection and universal precautions to avoid risk to the operator. The incidence of ecchymosis and hematoma formation can be decreased if pressure is placed on the injection site immediately after injection.
The use of physical modalities, including local heat and gentle range-of-motion exercises, should be introduced several days after the patient undergoes this injection technique for manubriosternal joint pain. Vigorous exercise should be avoided because it exacerbates the symptoms.
Simple analgesics and NSAIDs may be used concurrently with this injection technique. Laboratory evaluation for collagen-vascular disease is indicated for patients who have manubriosternal joint pain with other joints involved.