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Sports Medicine > Shoulder
Acromioclavicular Joint Injury
Article Last Updated: Oct 27, 2008
AUTHOR AND EDITOR INFORMATION
Section 1 of 11  
Author: L. Edward Seade, MD, Chief of Shoulder Service, Orthopaedic Specialists of Austin
Coauthor(s):
Reed L Bartz, MD, Consulting Staff, Division of Sports Medicine, Nebraska Orthopaedic and Sports Medicine PC;
Robert Josey, MD, Consulting Staff, Department of Orthopedic Surgery, Orthopaedic Specialists of Austin
Editors: David T Bernhardt, MD, Director of Adolescent and Sports Medicine Fellowship, Associate Professor, Department of Pediatrics, University of Wisconsin; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Russell D White, MD, Professor of Medicine, Department of Community and Family Medicine, University of Missouri-Kansas City School of Medicine, Truman Medical Center Lakewood; Jon B Whitehurst, MD, Clinical Instructor of Surgery, University of Illinois College of Medicine; Partner and Executive Board Member, Rockford Orthopedic Associates; Orthopedic Chairman, Rockford Memorial Hospital; Craig C Young, MD, Professor, Departments of Orthopedic Surgery and Community and Family Medicine, Medical Director of Sports Medicine, Sports Medicine Fellowship Director, Medical College of Wisconsin
Author and Editor Disclosure
Synonyms and related keywords:
acromioclavicular joint injury, shoulder pain, shoulder injury, shoulder dislocation, shoulder separation, acromioclavicular joint separations, dislocated shoulder, AC joint injury, AC separation, AC joint disruption, acromioclavicular disruption, shoulder joint
Injuries in and around the shoulder are common in today's athletic society. Proper knowledge of the different problems and treatment options for shoulder disorders is necessary to get patients back to their preinjury state.
Background
Acromioclavicular (AC) joint injuries are common and often seen after bicycle wrecks, contact sports, and car accidents. The acromioclavicular joint is located at the top of the shoulder where the acromion process and the clavicle meet to form a joint. Several ligaments surround this joint, and depending on the severity of the injury, a person may tear one or all of the ligaments. Torn ligaments lead to acromioclavicular joint sprains and separations.1
The distal clavicle and acromion process can also be fractured. Injury to the acromioclavicular joint may injure the cartilage within the joint and can later cause arthritis of the acromioclavicular joint.
This article discusses the anatomy of the acromioclavicular joint, the diagnosis of disorders of this joint, and the different treatment options.
For excellent patient education resources, see eMedicine's Breaks, Fractures, and Dislocations Center. Also, see eMedicine's article on Shoulder Dislocation.
Related eMedicine topics:
Acromioclavicular Injury [in the Emergency Medicine section]
Acromioclavicular Joint Separations [in the Orthopedic Surgery section]
Dislocation, Shoulder [in the Emergency Medicine section]
Shoulder Dislocation [in the Orthopedic Surgery section]
Related Medscape topics:
Resource Center Exercise and Sports Medicine
Resource Center Joint Disorders
Resource Center Trauma
Specialty Site Orthopaedics
CME/CE Management of Chronic Shoulder Disorders Reviewed
Variations in Corticosteroid/Anesthetic Injections for Painful Shoulder Conditions: Comparisons Among Orthopaedic Surgeons, Rheumatologists, and Physical Medicine and Primary-Care Physicians
Frequency
United States
Injuries to the acromioclavicular joint are the most common reason that athletes seek medical attention following an acute shoulder injury. Glenohumeral dislocations (see Shoulder Dislocation) are the second most common injuries seen. Men in their second through fourth decades of life have the greatest frequency of acromioclavicular joint injuries, which are most often incomplete tears of the ligaments.1
Functional Anatomy
The normal width of the acromioclavicula joint is 1-3 mm in younger individuals; it narrows to 0.5 mm or less in individuals older than 60 years.
The acromioclavicular joint is made up of 2 bones (the clavicle and the acromion), 4 ligaments, and a meniscus inside the joint.
- The acromioclavicular joint is surrounded by a thin joint capsule and 4 small ligaments. These ligaments mostly give joint stability to anterior and posterior translation, as well as provide horizontal stability to the joint.
- Another set of ligaments also provides vertical stability to the acromioclavicular joint. These ligaments are called the coracoclavicular ligaments, which are found medial to the acromioclavicular joint and go from the coracoid process on the scapula to the clavicle.
- Different injuries result in different tears of the 2 coracoclavicular ligaments (the conoid and the trapezoid). Torn acromioclavicular joint ligaments and/or torn coracoclavicular ligaments are seen in acromioclavicular joint sprains. The meniscus that lies in the joint may also be injured during sprains or fractures around the acromioclavicular joint.
- The acromioclavicular capsular ligaments provide most of the joint stability in the anteroposterior (AP) direction. The conoid and trapezoid ligaments aid in providing superior-inferior stability to the joint. Compression of the joint is restrained mainly by the trapezoid ligament.
Sport-Specific Biomechanics
When a person falls onto their shoulder, the force pushes the tip of the shoulder down. The clavicle is usually kept in its anatomic position, whereas the shoulder is driven down, which injures the different ligaments or causes a fracture. When the ligaments are injured they are either sprained or, in more severe cases, torn.
Acromioclavicular joint sprains have been classified according to their severity. In a type I sprain, a mild force applied to these ligaments does not tear them. The injury simply results in a sprain, which hurts, but the shoulder does not show any gross evidence of an acromioclavicular joint dislocation. Type II sprains are seen when a heavier force is applied to the shoulder, disrupting the acromioclavicular ligaments but leaving the coracoclavicular ligaments intact. When these injuries occur, the lateral clavicle becomes a little more prominent.
In type III sprains, the force completely disrupts the acromioclavicular and coracoclavicular ligaments. This leads to complete separation of the clavicle and obvious changes in appearance. The lateral clavicle is very prominent. A few more types of acromioclavicular joint sprains have been classified, but types I–III are the most common.
Classification of acromioclavicular joint injuries.
An acromioclavicular joint sprain is more common than a fracture after an injury. However, fractures of the distal clavicle and the acromion process may occur, so the healthcare provider must be aware of such injuries and ready to diagnose and treat them as well (see Clavicular Injuries).
History
An acromioclavicular joint injury should be considered in any patient complaining of pain over the superior part of the shoulder. Injuries to this part of the body are painful.
- The most common mechanism for an acromioclavicular joint injury is a fall directly onto the acromion, with the arm adducted up against the body. Multiple indirect forces can result in an acromioclavicular joint injury. A fall onto an outstretched hand (FOOSH injury) and a downward force on the upper extremity have been implicated in acromioclavicular joint injuries.1, 2, 3
- In the immediate setting, the patient may initially experience generalized shoulder tenderness and swelling; however, as the diffuse pain resolves, specific point tenderness over the acromioclavicular joint is usually noted. The athlete may note a significant abrasion or prominence of the distal clavicle.
- Athletes involved in weight training typically experience pain with specific exercises such as with use of the bench press and dips.
- Many individuals experience nocturnal pain and awakening when rolling onto the involved shoulder, which puts pressure on the acromioclavicular joint.
- Rarely, the patient may report popping or catching in the region of the acromioclavicular joint.
Physical
- Patients have pain over the acromioclavicular joint. Swelling, bruising, and a prominent clavicle may be evident, depending on the type of sprain that the patient has sustained. In types I and II sprains, deformity is usually minimal. In type III, the distal clavicle is abnormally prominent. Of note, clavicle fractures, without acromioclavicular joint sprains, can also cause the clavicle to be prominent.
- The patient has poor shoulder range of motion and moderate pain when trying to raise up the arm.
- In the acute situation, the examiner may have difficulty ruling out a concomitant rotator cuff tear, as active and passive shoulder abduction maneuvers are difficult to perform in the face of an acromioclavicular joint separation.
- The most reliable physical examination test for acromioclavicular joint pathology is the cross-body adduction test. The test is performed by elevating the arm on the affected side 90º, while the examiner grasps the elbow and adducts the involved arm across the body. Although reproduction of pain with this maneuver may occur in patients with posterior capsule tightness or subacromial impingement, pain is suggestive of acromioclavicular joint pathology. Restriction of range of motion, which is rarely associated with acromioclavicular joint pathology, more likely suggests adhesive capsulitis or glenohumeral arthritis.
Causes
See History.
Clavicular Injuries
Rotator Cuff Injury
Shoulder Dislocation
Shoulder Impingement Syndrome
Superior Labrum Lesions
Other Problems to Be Considered
Glenoid labrum tear
Imaging Studies
- Radiographs
- As with all skeletal injuries, a minimum of 2 radiographic views is necessary to evaluate the individual injury in cases of suspected acromioclavicular joint injury.
- AP and lateral views are the minimum needed to evaluate an acromioclavicular joint injury. The AP view should be taken with the arms at the side, and both acromioclavicular joints should be imaged for comparison. If a true AP view is obtained, the acromioclavicular joint can be seen superimposed on the spine of the scapula; hence, some authorities have recommended the Zanca view, in which 10-15° of cephalic tilt of the radiographic beam provides a clearer image of the acromioclavicular joint.
- An axillary lateral view is also needed in suspected acromioclavicular joint injuries to account for any anterior or posterior displacement of the distal clavicle.
Type III acromioclavicular joint separation.
- If an unstable acromioclavicular joint injury is suspected, yet not confirmed on routine AP and lateral views, stress views may be indicated.
- Ten to 15 lb of weight should be attached to the wrist of the affected side, and an AP view can be taken. This stress tests the integrity of the coracoclavicular ligament, and, if the ligament has been disrupted completely, the test will demonstrate the complete dislocation.
- Routine use of stress radiographs is not recommended in the emergency department setting because of the painful nature of the test. Weighted stress tests may be valuable in follow-up care if the clinician has any doubt about the instability of the acromioclavicular joint. Even with conservative care of types III-VI acromioclavicular disruptions, this test may be helpful for determining a timetable for return to conditioning and sporting activities.
- Athletes with a previous history of acromioclavicular injury or a history of heavy weight lifting may present with relatively acute shoulder pain over the distal clavicle, and they may have classic radiographic findings of distal clavicle osteolysis or acromioclavicular osteoarthritis (ie, joint narrowing, distal clavicle or acromial spurring). When these radiographic findings are present, the clinician may expect that seemingly little trauma may result in significant pain.
- Magnetic resonance imaging (MRI)
- MRI is not routinely ordered in the management of straightforward acromioclavicular disruptions. Detailed knowledge of acromioclavicular and coracoclavicular ligamentous injury is not needed for conservative or, in rare cases, surgical care.
- In middle-aged and older patients who continue to have disabling shoulder pain after the acute pain of an acromioclavicular disruption abates, one may consider an MRI to evaluate for a possible rotator cuff tear.
- Very rarely, athletes with persistent pain over the acromioclavicular joint merit an MRI to determine whether or not the cartilaginous disk has been damaged irreversibly and to determine whether or not the process of distal clavicle osteolysis or early osteoarthritis has begun.
Acute Phase
Rehabilitation Program
Physical Therapy
Acromioclavicular joint injuries are painful and the patient often lacks full range of motion after the injury. Physical therapy plays a role in the treatment of these patients. The author routinely starts therapy within the first couple of weeks in acromioclavicular joint sprains.
For fractures of the acromioclavicular joint, wait until evidence of healing is apparent either clinically or radiographically before starting formal therapy. Therapy for degenerative joint disease of the acromioclavicular joint has not been proven to be successful.
Surgical Intervention
Acromioclavicular joint sprains do well with conservative management. Type I and II injuries never necessitate surgical care to reconstruct the injured ligaments. These injuries may need further care if the acromioclavicular joint becomes arthritic from the injury (see image).
Surgical intervention may be an option in type III acromioclavicular joint sprains, but only after the patient's condition has failed a good trial of conservative treatment with physical therapy and medication. The procedure for these patients is reconstruction of the torn coracoclavicular ligaments with either local tissue or an allograft. In the past, surgeons have used screws, sutures, suture tape, synthetic grafts, and Kirschner (K)-wires to try to repair the defect. These have all fallen out of favor, and the current criterion standard is to reconstruct the torn ligaments as mentioned above.
Postoperative coracoclavicular ligament reconstruction. The clavicle is back to its normal position. The anchor in the clavicle keeps the allograft tendon from coming off of the clavicle. Also note the distal clavicle has been excised, because it had traumatic arthritis from the injury.
Fractures in and around the acromioclavicular joint are mostly treated conservatively in a sling. The few times surgery needs to be considered are when there is a moderate amount of displacement of the fracture fragments. Surgery is indicated for open fractures, neurovascular injury, and for those cases in which the skin is compromised and may rupture from the pressure of the prominent bone.
Injuries that lead to arthritis of the acromioclavicular joint are also treated with conservative measures first. Anti-inflammatory medication and intra-articular steroid injections work well for degenerative changes in the acromioclavicular joint. In cases that have failed conservative therapy, excision of the distal clavicle can be performed with a minimally invasive arthroscopic procedure.
Consultations
If the athlete has sustained concomitant rib fractures with shortness of breath, good quality chest radiographs are indicated. A consult from a pulmonary physician or cardiovascular chest surgeon may be necessary.
The initial treatment of degenerative arthritis of the acromioclavicular joint may include the use of nonsteroidal anti-inflammatory drugs (NSAIDs), along with occasional corticosteroid injections.
Related Medscape topics:
Resource Center Pain Management: Advanced Approaches to Chronic Pain Management
Resource Center Pain Management: Pharmacologic Approaches
Drug Category: Nonsteroidal Anti-inflammatory Drugs (NSAIDs)
NSAIDs have analgesic, anti-inflammatory, and antipyretic activities. The mechanism of action of these agents is not known, but they may inhibit cyclooxygenase activity and prostaglandin synthesis. Other mechanisms may exist as well; these may include inhibition of leukotriene synthesis, lysosomal enzyme release, lipoxygenase activity, neutrophil aggregation, and various cell-membrane functions.
Related eMedicine topic:
Toxicity, Nonsteroidal Anti-inflammatory Agents
| Drug Name | Ibuprofen (Motrin, Ibuprin, Advil) |
|---|
| Description | DOC for patients with mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis. |
|---|
| Adult Dose | 200-400 mg PO q4-6h while symptoms persist; not to exceed 3.2 g/d |
|---|
| Pediatric Dose | <6 months: Not established
6 months to 12 years: 4-10 mg/kg/dose PO tid/qid
>12 years: Administer as in adults. |
|---|
| Contraindications | Documented hypersensitivity; peptic ulcer disease, recent GI bleeding or perforation, renal insufficiency, or high risk of bleeding |
|---|
| Interactions | Coadministration with aspirin increases the risk of inducing serious NSAID-related side effects; probenecid may increase the concentrations and, possibly, the toxicity of NSAIDs; may decrease the effect of hydralazine, captopril, and beta-blockers; may decrease the diuretic effects of furosemide and thiazides; may increase PT duration when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase the risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently |
|---|
| Pregnancy | B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
|
|---|
| Precautions | Caution in the presence of congestive heart failure, hypertension, and decreased renal and hepatic function; caution in the presence of coagulation abnormalities or during anticoagulant therapy |
|---|
| Drug Name | Ketoprofen (Oruvail, Actron, Orudis) |
|---|
| Description | For relief of mild to moderate pain and inflammation. Small dosages are initially indicated in small and elderly patients and in those with renal or liver disease.
Doses exceeding 75 mg do not increase the therapeutic effects. Administer high doses with caution, and closely observe patient for response. |
|---|
| Adult Dose | 25-50 mg PO q6-8h prn; not to exceed 300 mg/d |
|---|
| Pediatric Dose | <3 months: Not established
3 months to 12 years: 0.1-1 mg/kg PO q6-8h
>12 years: Administer as in adults. |
|---|
| Contraindications | Documented hypersensitivity |
|---|
| Interactions | Coadministration with aspirin increases the risk of inducing serious NSAID-related side effects; probenecid may increase the concentrations and, possibly, the toxicity of NSAIDs; may decrease the effect of hydralazine, captopril, and beta-blockers; may decrease the diuretic effects of furosemide and thiazides; may increase PT duration when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase the risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently |
|---|
| Pregnancy | C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
|
|---|
| Precautions | Caution in the presence of congestive heart failure, hypertension, and decreased renal and hepatic function; caution in the presence of coagulation abnormalities or during anticoagulant therapy |
|---|
| Drug Name | Naproxen (Naprelan, Anaprox, Naprosyn) |
|---|
| Description | For relief of mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing the activity of cyclooxygenase, which results in a decrease of prostaglandin synthesis. |
|---|
| Adult Dose | 500 mg PO followed by 250 mg q6-8h; not to exceed 1.25 g/d |
|---|
| Pediatric Dose | <2 years: Not established
>2 years: 2.5 mg/kg/dose PO; not to exceed 10 mg/kg/d |
|---|
| Contraindications | Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency |
|---|
| Interactions | Coadministration with aspirin increases the risk of inducing serious NSAID-related side effects; probenecid may increase the concentrations and, possibly, the toxicity of NSAIDs; may decrease the effect of hydralazine, captopril, and beta-blockers; may decrease the diuretic effects of furosemide and thiazides; may increase PT duration when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase the risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently |
|---|
| Pregnancy | C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
|
|---|
| Precautions | Acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with preexisting renal disease or compromised renal perfusion risk acute renal failure; leukopenia occurs rarely, is transient, and usually returns to normal during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrants further evaluation and may require discontinuation of the drug. |
|---|
| Drug Name | Indomethacin (Indocin, Indochron ER) |
|---|
| Description | Rapidly absorbed. Metabolism occurs in the liver by demethylation, deacetylation, and glucuronide conjugation. Inhibits prostaglandin synthesis. |
|---|
| Adult Dose | 25-50 mg PO bid/tid
75 mg SR PO bid; not to exceed 200 mg/d |
|---|
| Pediatric Dose | 1-2 mg/kg/d divided PO bid/qid; not to exceed 4 mg/kg/d or 150-200 mg/d |
|---|
| Contraindications | Documented hypersensitivity; GI bleeding or renal insufficiency |
|---|
| Interactions | Coadministration with aspirin increases the risk of inducing serious NSAID-related side effects; probenecid may increase the concentrations and, possibly, the toxicity of NSAIDs; may decrease the effect of hydralazine, captopril, and beta-blockers; may decrease the diuretic effects of furosemide and thiazides; may increase PT duration when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase the risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently |
|---|
| Pregnancy | C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
|
|---|
| Precautions | Acute renal insufficiency, hyperkalemia, hyponatremia, interstitial nephritis, and renal papillary necrosis may occur; increases the risk of acute renal failure in patients with preexisting renal disease or compromised renal perfusion; reversible leukopenia may occur; discontinue if persistent leukopenia, granulocytopenia, or thrombocytopenia occurs |
|---|
| Drug Name | Diclofenac (Voltaren, Cataflam) |
|---|
| Description | Inhibits prostaglandin synthesis by decreasing the activity of the enzyme cyclooxygenase, which in turn decreases the formation of prostaglandin precursors. |
|---|
| Adult Dose | Persistent night pain or morning stiffness: Up to 100 mg hs may help to relieve pain; not to exceed total daily dose of 200 mg |
|---|
| Pediatric Dose | >12 years: Administer as in adults.
<12 years: Not established |
|---|
| Contraindications | Documented hypersensitivity; do not administer into the CNS; do not give to patients with peptic ulcer disease, recent GI bleeding or perforation, or renal insufficiency; do not administer to those at high risk of bleeding. |
|---|
| Interactions | Coadministration with aspirin increases the risk of inducing serious NSAID-related side effects; probenecid may increase the concentrations and, possibly, the toxicity of NSAIDs; may decrease the effect of hydralazine, captopril, and beta-blockers; may decrease the diuretic effects of furosemide and thiazides; may increase PT duration when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase the risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently |
|---|
| Pregnancy | C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
|
|---|
| Precautions | Acute renal insufficiency, hyperkalemia, hyponatremia, interstitial nephritis, and renal papillary necrosis may occur; increases the risk of acute renal failure in patients with preexisting renal disease or compromised renal perfusion; low white blood cell counts occur rarely and usually return to normal in ongoing therapy; discontinuation of therapy may be necessary if persistent leukopenia, granulocytopenia, or thrombocytopenia occurs |
|---|
| Drug Name | Sulindac (Clinoril) |
|---|
| Description | Decreases the activity of cyclooxygenase and in turn inhibits prostaglandin synthesis. Results in a decreased formation of inflammatory mediators. |
|---|
| Adult Dose | 150-200 mg PO bid or 300-400 qd; not to exceed 400 mg/d |
|---|
| Pediatric Dose | Not established |
|---|
| Contraindications | Documented hypersensitivity; patients in whom aspirin, iodides, or other NSAIDS induce hypersensitivity; gastrointestinal (GI) bleed; renal insufficiency |
|---|
| Interactions | Coadministration with aspirin increases the risk of inducing serious NSAID-related side effects; probenecid may increase the concentrations and, possibly, the toxicity of NSAIDs; may decrease the effect of hydralazine, captopril, and beta-blockers; may decrease the diuretic effects of furosemide and thiazides; may increase PT duration when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase the risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently |
|---|
| Pregnancy | C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
|
|---|
| Precautions | Acute renal insufficiency, hyperkalemia, hyponatremia, interstitial nephritis, and renal papillary necrosis may occur; increases the risk of acute renal failure in preexisting renal disease or compromised renal perfusion; low white blood cell counts occur rarely and usually return to normal in ongoing therapy; discontinuation of therapy may be necessary if persistent leukopenia, granulocytopenia, or thrombocytopenia occurs; caution in persons with anticoagulation defects or in those receiving anticoagulant therapy |
|---|
Drug Category: Corticosteroids
Corticosteroids have anti-inflammatory properties and cause profound and varied metabolic effects. These agents modify the body's immune response to diverse stimuli.
| Drug Name | Hydrocortisone (Solu-Cortef, Hydrocortone phosphate) |
|---|
| Description | Decreases inflammation by suppressing the migration of polymorphonuclear leukocytes and reversing increased capillary permeability. |
|---|
| Adult Dose | Small joints: 10-25 mg intralesional
Large joints: 25 mg intralesional |
|---|
| Pediatric Dose | Not established |
|---|
| Contraindications | Documented hypersensitivity; viral, fungal, or tubercular skin infections |
|---|
| Interactions | Corticosteroid clearance may decrease with estrogens; may increase digitalis toxicity secondary to hypokalemia |
|---|
| Pregnancy | C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
|
|---|
| Precautions | Caution in the presence of hyperthyroidism, osteoporosis, peptic ulcer, cirrhosis, nonspecific ulcerative colitis, diabetes, and myasthenia gravis; abrupt discontinuation of glucocorticoids may cause adrenal crisis. |
|---|
| Drug Name | Triamcinolone (Aristospan Intra-Articular, Aristocort Forte, Kenaject-40) |
|---|
| Description | For inflammatory dermatosis responsive to steroids. Decreases inflammation by suppressing the migration of polymorphonuclear leukocytes and reversing capillary permeability. |
|---|
| Adult Dose | 2-20 mg intra-articularly q3-4wk |
|---|
| Pediatric Dose | Not established |
|---|
| Contraindications | Documented hypersensitivity; fungal, viral, and bacterial skin infections |
|---|
| Interactions | Coadministration with barbiturates, phenytoin, and rifampin decreases the effects of triamcinolone. |
|---|
| Pregnancy | C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
|
|---|
| Precautions | Multiple complications (eg, severe infections, hyperglycemia, edema, osteonecrosis, myopathy, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, myasthenia gravis, growth suppression) may occur; the abrupt discontinuation of glucocorticoids may cause adrenal crisis. |
|---|
Return to Play
The author has the following strict return-to-sports criteria that he addresses with patients who have acromioclavicular joint injuries and with physical therapists:
- No swelling/pain with functional activity
- Isokinetic strength that is 80% of the opposite rotator cuff
- Full active and passive range of motion
- Scapula is stable through full range of motion and has normal scapulohumeral rhythm
- Pain-free activities of daily living (ADLs)
Postoperative rehabilitation.
Complications
Just like any other joint in the body, once the acromioclavicular joint has been injured, it has a tendency for arthritis and pain. The most common problem after these injuries is pain in the acromioclavicular joint. In type III sprains, the most common setback is also instability in the clavicle from the torn ligaments. Postoperative complications may also arise. The most common complication is mild residual instability after ligament reconstruction. This complication was more common when screws, sutures, suture tape, and K-wires were being used to repair coracoclavicular ligament tears. Infections may also occur, but these are rare, occurring less than 1% of the time.
When a patient is dealing with an arthritic acromioclavicular joint, the most common problem is inadequate resection of the clavicle during surgery. This causes continued acromioclavicular joint pain in these patients, but it is easily fixed with proper arthroscopic resection of the fragment.
Prevention
Prevention of significant acromioclavicular joint degenerative pathology simply consists of early diagnosis of the problem and avoidance of causative maneuvers, if possible.
Prognosis
Although the literature does not contain studies investigating the natural history of acromioclavicular joint degenerative disease, some studies report that athletes with distal clavicle osteolysis often experience resolution of symptoms with avoidance of provocative activities.4, 5 Published studies of patients undergoing both arthroscopic and open resection have reported good or excellent results in approximately 60-100% of cases of acromioclavicular joint injuries. No prospective comparisons of open versus arthroscopic treatment have been published; however, retrospective studies have shown similar long-term results. Patients undergoing arthroscopic treatment are likely to return to activity more quickly than other patients.7
Medical/Legal Pitfalls
- Failure to diagnose and treat a concomitant pathologic condition may be a medicolegal pitfall.
Related Medscape topic:
Resource Center Medical Malpractice and Legal Issues
| Media file 1:
Classification of acromioclavicular joint injuries. |
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Media type: Illustration
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| Media file 2:
Type III acromioclavicular joint separation. |
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Media type: Radiograph
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| Media file 3:
Type III acromioclavicular joint separation. |
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Media type: Radiograph
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| Media file 4:
Postoperative coracoclavicular ligament reconstruction. The clavicle is back to its normal position. The anchor in the clavicle keeps the allograft tendon from coming off of the clavicle. Also note the distal clavicle has been excised, because it had traumatic arthritis from the injury. |
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Media type: Radiograph
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- Rockwood CA, Green DP, eds. Injuries to the acromioclavicular joint. Fractures in Adults. Philadelphia, Pa: JB Lippincott; 1984:860-91.
- Macdonald PB, Lapointe P. Acromioclavicular and sternoclavicular joint injuries. Orthop Clin North Am. Oct 2008;39(4):535-45. [Medline].
- Shaffer BS. Painful conditions of the acromioclavicular joint. J Am Acad Orthop Surg. May-Jun 1999;7(3):176-88. [Medline].
- Slawski DP, Cahill BR. Atraumatic osteolysis of the distal clavicle. Results of open surgical excision. Am J Sports Med. Mar-Apr 1994;22(2):267-71. [Medline].
- Cahill BR. Osteolysis of the distal part of the clavicle in male athletes. J Bone Joint Surg Am. Sep 1982;64(7):1053-8. [Medline]. [Full Text].
- Murphy OB, Bellamy R, Wheeler W, Brower TD. Post-traumatic osteolysis of the distal clavicle. Clin Orthop Relat Res. 1975;109:108-14. [Medline].
- Flatow EL, Duralde XA, Nicholson GP, Pollock RG, Bigliani LU. Arthroscopic resection of the distal clavicle with a superior approach. J Shoulder Elbow Surg. Jan-Feb 1995;4(1 pt 1):41-50. [Medline].
- Allman FL Jr. Fractures and ligamentous injuries of the clavicle and its articulation. J Bone Joint Surg Am. Jun 1967;49(4):774-84. [Medline]. [Full Text].
- Fukuda K, Craig EV, An KN, Cofield RH, Chao EY. Biomechanical study of the ligamentous system of the acromioclavicular joint. J Bone Joint Surg Am. Mar 1986;68(3):434-40. [Medline]. [Full Text].
- Le Corroller T, Cohen M, Aswad R, Pauly V, Champsaur P. Sonography of the painful shoulder: role of the operator's experience. Skeletal Radiol. Nov 2008;37(11):979-86. [Medline].
- Lee SJ, Keefer EP, McHugh MP, Kremenic IJ, et al. Cyclical loading of coracoclavicular ligament reconstructions: a comparative biomechanical study. Am J Sports Med. Oct 2008;36(10):1990-7. [Medline].
- Rolf O, Hann von Weyhern A, et al. Acromioclavicular dislocation Rockwood III-V: results of early versus delayed surgical treatment. Arch Orthop Trauma Surg. Oct 2008;128(10):1153-7. [Medline].
- Seade LE. Coracoclavicular ligament reconstruction with semitendinosus allograft for AC joint separations, 2-5 year follow-up. Presented at: Annual Meeting of Texas Orthopaedic Association; May 14, 2004; Austin, Texas.
- Seade LE. Coracoclavicular ligament reconstruction with semitendinosus allograft for AC joint separations, 2-5 year follow-up. Presented at: Western Orthopaedic Association; October 13, 2006; Santa Fe, New Mexico.
- Urist MR. Complete dislocation of the acromioclavicular joint: the nature of the traumatic lesion and effective methods of treatment with analysis of 41 cases. J Bone Joint Surg Am. 1946;28A:813-37. [Full Text].
- Zanca P. Shoulder pain: involvement of the acromioclavicular joint. (Analysis of 1,000 cases). Am J Roentgenol Radium Ther Nucl Med. Jul 1971;112(3):493-506. [Medline].
Acromioclavicular Joint Injury excerpt Article Last Updated: Oct 27, 2008
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