What is the treatment for Acromioclavicular (AC) joint separation?

Treatment for AC Joint Separation

Conservative management is the recommended treatment for grade I-III acromioclavicular (AC) joint separations, while surgical intervention is typically reserved for grades IV-VI. 1

Initial Assessment and Classification

• Standard radiographic evaluation should include:

  • Anteroposterior (AP) views in internal and external rotation
  • Axillary or scapula-Y view (critical for proper assessment) 2
  • Upright positioning (malalignment can be underrepresented on supine radiography) 2

• Rockwood classification determines treatment approach:

  • Grade I: Mild sprain of AC ligaments
  • Grade II: Disruption of AC ligaments with intact coracoclavicular ligaments
  • Grade III: Disruption of both AC and coracoclavicular ligaments
  • Grades IV-VI: Severe dislocations with displacement

Treatment Algorithm

Grade I-III AC Joint Separations:

1. Immediate Management (0-7 days):

   • Ice/cryotherapy for pain and swelling control 1
   • Simple sling for comfort (typically 1-2 weeks) 1, 3
   • Pain management with oral analgesics as needed
   • Weight bearing as tolerated with proper mechanics

2. Early Rehabilitation Phase (1-3 weeks):

   • Progress from isometric to gentle active range of motion exercises
   • Begin pendulum exercises and passive range of motion
   • Continue ice for pain control
   • Maintain sling use during painful activities or sleep

3. Intermediate Phase (3-6 weeks):

   • Progressive strengthening of rotator cuff and scapular stabilizers
   • Advance to active-assisted and active range of motion exercises
   • Begin light resistance training when pain allows

4. Advanced Phase (6+ weeks):

   • Progressive resistance training
   • Sport or occupation-specific exercises
   • Return to full activities when:
     • Pain-free full range of motion is achieved
     • Normal strength compared to unaffected side
     • Able to perform sport/work-specific movements without pain

Grade IV-VI AC Joint Separations:

• Surgical intervention is typically recommended 1, 3
• Surgical options include:
  • Hook plate fixation (requires later removal) 4
  • Tight-rope system (no removal required) 4
  • Other techniques involving ligament reconstruction

Special Considerations

• Recent evidence suggests even some grade III injuries may be managed non-operatively with good functional outcomes 5
• Return to work and sports is typically faster with non-operative treatment 5
• Surgery should be considered for patients whose AC joint remains painful (VAS>7) after 7 days of conservative treatment with no functional improvement 5
• Surgical complications are more common than complications from conservative management 5

Rehabilitation Pearls

• Focus on restoring scapular control and rotator cuff strength
• Address any compensatory movement patterns
• Gradually increase load on the AC joint as healing progresses
• For athletes, sport-specific training should be incorporated before full return to play
• Maintenance of proper posture is essential throughout rehabilitation

The treatment approach should prioritize functional outcomes and quality of life, with the understanding that conservative management often yields excellent results for lower-grade separations while avoiding surgical complications.