What is the best treatment approach for degenerative changes to the acromioclavicular (AC) joint?

Treatment Approach for Degenerative Changes to the Acromioclavicular (AC) Joint

Conservative management should be the first-line treatment for degenerative changes to the AC joint, with surgical intervention reserved for patients who fail to respond to non-operative measures. 1

Initial Conservative Management

• Begin with non-steroidal anti-inflammatory drugs (NSAIDs) to reduce pain and inflammation associated with AC joint degeneration 2
• Physical therapy focusing on strengthening exercises, range of motion, and maintaining joint mobility should be implemented 3
• Activity modification to avoid exacerbating movements (especially overhead activities and weight training) is recommended 4
• Corticosteroid injections into the AC joint can be both diagnostic and therapeutic for persistent symptoms 2
• A diagnostic injection of local anesthetic (bupivacaine) can help confirm the AC joint as the source of pain 5

When to Consider Surgical Intervention

Surgical management should be considered when:

• Patient has failed at least 6 months of appropriate conservative management 2
• Pain significantly limits daily activities and quality of life 5
• Diagnostic injections provide temporary but significant relief, confirming the AC joint as the pain source 5, 2

Surgical Options

Distal Clavicle Excision

This is the primary surgical treatment for AC joint osteoarthritis and can be performed through several approaches:

• Arthroscopic techniques (preferred):

  • Direct approach: Accesses the AC joint without entering the subacromial space 5
  • Indirect/bursal approach: Allows assessment of both the subacromial space and AC joint, beneficial when impingement pathology coexists 5
  • Requires less bone resection (4-8mm) compared to open procedures 5
  • Preserves superior AC ligaments for better stability 5
  • Advantages: Outpatient procedure, less disruption of musculotendinous structures, shorter rehabilitation, and quicker return to activities 5

• Open distal clavicle excision:

  • Traditional approach with reliable results 2
  • May require more extensive bone resection 5
  • Greater disruption of surrounding soft tissues 5

Potential Complications

• Residual pain from inadequate bone resection 5
• Instability, particularly in patients with previous AC joint injuries 5
• Infection (though relatively infrequent) 5
• Development of heterotopic ossification 5
• Damage to AC ligaments leading to instability 2

Outcomes and Prognosis

• Most patients with mild to moderate AC joint degeneration respond well to conservative management 4, 3
• Long-term follow-up (up to 10 years) shows that even with residual radiographic abnormalities, patients can maintain good function with conservative care 3
• Arthroscopic distal clavicle excision has shown excellent clinical results with quicker return to activities compared to open procedures 5
• Patients with coexisting rotator cuff pathology may have less favorable outcomes if only the AC joint is addressed 1

Special Considerations

• Weight lifters and athletes who perform repetitive overhead activities are at higher risk for developing AC joint degeneration and osteolysis of the distal clavicle 4
• In cases with associated subacromial impingement, addressing both pathologies simultaneously may be necessary for optimal outcomes 5
• The amount of bone resection during surgery is critical—too little may not relieve symptoms, while excessive resection may lead to instability 5, 2