What is the recommended treatment for a 64-year-old male patient with mild undersurface bony spurring at the acromioclavicular joint?

Management of Mild Undersurface Bony Spurring at the Acromioclavicular Joint

Conservative management is the recommended first-line treatment for a 64-year-old male patient with mild undersurface bony spurring at the acromioclavicular joint, focusing on pain management and physical therapy.

Initial Assessment and Diagnosis

The x-ray findings indicate:

• Intact and well-mineralized bones
• Adequate humeral head rotation
• Maintained acromioclavicular and coracoclavicular distances
• Mild undersurface spurring of the distal clavicle at the AC joint
• Normal glenohumeral joint spacing

These findings are consistent with early acromioclavicular joint osteoarthritis, which is a common source of shoulder pain that is sometimes overlooked in clinical practice 1.

Treatment Algorithm

First-Line Treatment

1. Non-pharmacological approaches:

   • Physical therapy with supervised exercise programs rather than passive modalities 2
   • Focus on strengthening exercises for the rotator cuff and scapular stabilizers
   • Range of motion exercises to maintain shoulder mobility

2. Pharmacological management:

   • NSAIDs (oral) for pain control and anti-inflammatory effects
   • No specific NSAID is recommended over others 2
   • Consider continuous rather than on-demand NSAID treatment if symptoms persist 2

Second-Line Treatment

If first-line treatments fail to provide adequate relief after 4-6 weeks:

1. Local corticosteroid injection:
   • Injection into the AC joint can provide short-term pain relief 1
   • Note that steroid injections do not alter the natural progression of the disease 1
   • Should be performed with image guidance for accuracy

Third-Line Treatment

For persistent symptoms despite 6+ months of conservative management:

1. Surgical intervention:
   • Arthroscopic distal clavicle resection is preferred over open techniques 3
   • Involves resection of 4-7 mm of distal clavicle in an en bloc fashion 3
   • Critical to resect evenly from superior to inferior without small bony remnants 3
   • Preservation of the capsule and acromioclavicular ligament is important 3

Evidence-Based Considerations

The presence of mild AC joint spurring without significant joint space narrowing suggests early osteoarthritis. Recent evidence indicates that bony edema on MRI combined with positive clinical examination findings (tenderness at the AC joint, pain with cross-body adduction) are the strongest predictors for needing surgical intervention 4. In the absence of these findings, conservative management is appropriate.

Studies have shown that arthroscopic distal clavicle excision, when indicated, provides good long-term outcomes with significant improvement in function. In one study, the UCLA shoulder rating score improved from 13.7 preoperatively to 33.4 postoperatively with a mean follow-up of over 6 years 3.

Important Caveats

• AC joint osteoarthritis is often overlooked as a source of shoulder pain, with clinicians focusing more on rotator cuff pathology or glenohumeral issues 1
• Physical therapy has limited effectiveness for isolated AC joint pathology compared to its role in other shoulder conditions 1
• Corticosteroid injections should be used judiciously due to potential side effects with repeated use
• The decision to proceed with surgery should be based on persistent symptoms despite adequate conservative management, not solely on radiographic findings 4
• In this 64-year-old patient with only mild spurring, conservative management should be exhausted before considering surgical options