What is the treatment guideline for a 12-year-old with a low-grade Acromioclavicular (AC) joint injury?

Treatment of Low-Grade AC Joint Injury in a 12-Year-Old

Conservative management with the PRICE protocol (Protection, Rest, Ice, Compression, Elevation) followed by early functional rehabilitation is the recommended treatment for low-grade AC joint injuries in pediatric patients. 1

Initial Assessment and Classification

Low-grade AC joint injuries are typically classified as:

• Grade I: Sprain of the AC ligaments without joint instability
• Grade II: Partial rupture with mild instability but intact coracoclavicular ligaments

Key Diagnostic Considerations:

• Radiographs are generally not indicated if there is:
  • Intact range of motion
  • Minimal pain with manipulation
  • Ability to bear weight
  • No point tenderness over the malleoli, talus, or calcaneus 1

Acute Phase Treatment (First 72 Hours)

1. PRICE Protocol:

   • Protection: Use of a sling to limit movement and prevent further injury
   • Rest: Avoid activities that cause pain
   • Ice: Apply for 15-20 minutes, 3-4 times daily using ice wrapped in a damp cloth
   • Compression: Semi-rigid support or compression wrap (ensuring it doesn't compromise circulation)
   • Elevation: Keep the shoulder elevated when possible 1

2. Pain Management:

   • NSAIDs (e.g., ibuprofen, naproxen) to reduce pain and inflammation
   • Dosage should be age-appropriate for a 12-year-old 1

Rehabilitation Phase (After 72 Hours)

1. Early Mobilization:

   • Begin gentle range of motion exercises as tolerated
   • Avoid activities that cause significant pain 1, 2

2. Progressive Strengthening:

   • Start within 48-72 hours post-injury
   • Include resistance band exercises in all directions
   • Focus on rotator cuff and scapular stabilizer strengthening 1, 2

3. Proprioception Training:

   • Balance exercises
   • Closed-chain exercises for the upper extremity 1

Return to Activities Protocol

1. Light Activities:

   • When pain-free movement is achieved (typically 1-2 weeks)
   • Gradual return to daily activities 1, 2

2. Sports-Specific Activities:

   • When full range of motion and strength are restored (typically 3-4 weeks)
   • May require protective padding or taping for return to contact sports 2

3. Full Return to Sports:

   • Usually within 2-6 weeks for Grade I injuries
   • May take 6-8 weeks for Grade II injuries 2, 3

Important Considerations for Pediatric Patients

1. Growth Plate Concerns:

   • In pediatric patients, the clavicular physis is one of the last to close (around age 20)
   • Injuries that appear to be AC joint sprains may involve the growth plate 3

2. Long-term Prevention:

   • Continue strengthening exercises even after return to activities
   • Proprioceptive training reduces risk of recurrent injury 1

Common Pitfalls to Avoid

1. Excessive Immobilization:

   • Can lead to joint stiffness and muscle atrophy
   • Early functional rehabilitation is superior to prolonged immobilization 1

2. Inadequate Support:

   • Using only elastic bandages provides insufficient support
   • Semi-rigid supports are preferred 1

3. Overlooking Complete Recovery:

   • Returning to activities too soon can lead to chronic instability
   • Ensure full strength and range of motion before return to sports 2, 3

4. Missing Associated Injuries:

   • AC joint injuries may present with associated glenohumeral joint injuries
   • Monitor for signs of other shoulder pathology 2

By following this treatment protocol, most low-grade AC joint injuries in pediatric patients heal well with excellent functional outcomes and full return to previous activities.