What is the recommended treatment for a chronic grade 3 Acromioclavicular (AC) separation of the right shoulder?

Management of Chronic Grade III Acromioclavicular (AC) Joint Separation

Conservative management is the recommended first-line treatment for chronic grade III AC joint separations, as it provides satisfactory functional outcomes with fewer complications and faster return to work and sports compared to surgical intervention. 1

Initial Assessment and Conservative Management

• Conservative treatment protocol:

  • Short-term immobilization (approximately 2-3 weeks) 2
  • Early range of motion exercises once pain allows
  • Progressive rehabilitation program

• Rehabilitation phases: 3

  1. Phase 1 (Weeks 1-2):

     • Pain control measures
     • Gentle ROM exercises
     • Proper positioning education

  2. Phase 2 (Weeks 3-6):

     • Progressive ROM exercises
     • Light strengthening
     • Scapular stabilization exercises

  3. Phase 3 (Weeks 7-12):

     • Progressive resistance training
     • Advanced scapular stabilization
     • Sport or activity-specific training

Pain Management

• First-line options: 3

  • NSAIDs for pain management
  • Ice application for acute pain and inflammation

• Second-line options: 3

  • Injectable hyaluronate preparations may provide relief for associated osteoarthritic symptoms
  • Typically administered as weekly injections for 3 weeks

Monitoring and Follow-up

• Initial follow-up at 1-2 weeks to assess response to treatment 3
• Clinical reassessment at 6 weeks
• Evaluation of rehabilitation progress at 3 months
• Most patients (80%) resume normal activity within six months 4

Imaging Considerations

• Plain radiographs (Zanca AP and lateral axillary views) to assess joint position 3
• MRI or MR arthrography may be considered if soft tissue injuries are suspected 3

Surgical Considerations

While conservative treatment is first-line, surgical referral may be considered in specific circumstances:

• Persistent severe pain (VAS>7) after 7 days of conservative treatment 1
• No functional improvement despite appropriate rehabilitation
• Young, high-demand athletes with specific occupational or sporting requirements 1

Expected Outcomes

• Research shows no significant difference in functional scores between surgically and non-surgically treated patients at 1+ year follow-up 1
• Non-operative management demonstrates: 1, 4
  • Faster return to work (0.8 months vs. 2.6 months for surgical)
  • Faster return to sports (3.5 months vs. 6.4 months for surgical)
  • No complications (compared to potential complications with surgery)
  • Satisfactory long-term functional outcomes

Important Considerations

• Strength deficits: Grade III injuries treated non-operatively typically show no significant strength deficits 5
• Patient satisfaction: Most conservatively treated patients (>90%) report being satisfied or very satisfied with outcomes 4
• Scapular dyskinesis: Present in some patients but not statistically related to worse outcomes 4

Caution

• The most recent evidence shows that surgical treatment carries higher risks of complications with similar functional outcomes to conservative management 1
• Careful patient counseling regarding expected cosmetic outcome (persistent bump) is important for setting realistic expectations