What are the treatment recommendations for a patient with a grade 2 Acromioclavicular (AC) separation due to trauma to the shoulder?

Treatment Recommendations for Grade 2 AC Separation

Conservative management is the recommended treatment for grade 2 acromioclavicular (AC) joint separations, focusing on pain control, progressive rehabilitation, and gradual return to function.

Initial Management

• Pain control and inflammation reduction:

  • NSAIDs as first-line medication for pain management, tapering as tolerated 1
  • Cryotherapy in the first week to reduce pain 2
  • Avoid complete immobilization as it can lead to stiffness and muscle atrophy 1

• Temporary support:

  • Use of a sling for comfort during the acute phase (typically 1-2 weeks)
  • Adhesive taping of the AC joint for palliative support 3

Rehabilitation Protocol (3-Phase Approach)

Phase 1 (Weeks 1-2)

• Relative rest while maintaining some movement to prevent stiffness 1
• Gentle range of motion exercises within pain-free range
• Isometric quadriceps exercises for muscle reactivation (if no pain) 2
• Proper positioning education to avoid stress on the AC joint

Phase 2 (Weeks 3-6)

• Progressive ROM exercises to gradually increase range of motion
• Light strengthening exercises for rotator cuff and periscapular muscles
• Scapular stabilization exercises focusing on proper scapular mechanics 1
• Joint mobilizations to improve mobility 3

Phase 3 (Weeks 7-12)

• Progressive resistance training to increase load on rotator cuff muscles
• Advanced scapular stabilization and dynamic control
• Sport or activity-specific training
• Functional activities that mimic daily tasks 1

Follow-up Schedule

• Initial follow-up: 1-2 weeks after treatment initiation to assess response
• Clinical reassessment: 6 weeks to evaluate progress
• Rehabilitation progress evaluation: 3 months 1

Imaging

• Initial plain radiographs should include at least 3 views: anteroposterior, Grashey projection, and either axillary lateral or scapular Y view 1
• Follow-up imaging may be considered if symptoms worsen or do not improve

Indications for Surgical Referral

• Persistent pain and functional limitation despite 3 months of appropriate rehabilitation
• High-demand athletes or manual laborers with persistent symptoms
• Development of AC joint instability during rehabilitation 4

Expected Outcomes

• Most patients with grade 2 AC separations achieve excellent functional outcomes with conservative management
• Return to work and sports is typically faster with non-operative treatment compared to surgical intervention 4
• A visible "step deformity" may remain but is usually not functionally limiting 3
• Long-term follow-up (10 years) shows minimal degenerative changes and good functional outcomes with conservative management 3

Common Pitfalls to Avoid

• Prolonged immobilization leading to stiffness and muscle atrophy
• Premature return to high-impact or overhead activities
• Overuse of corticosteroid injections (limit to 3-4 per year) to avoid potential tendon weakening 1
• Neglecting scapular stabilization exercises, which are crucial for proper shoulder mechanics

The most recent evidence strongly supports non-operative management for grade 2 AC separations, with surgical intervention reserved only for cases that fail conservative treatment. This approach minimizes complications while achieving comparable functional outcomes to surgical treatment 4, 5.