What is the optimal treatment approach for patients with acromioclavicular joint injuries, according to the Journal of Shoulder and Elbow Surgery?

Optimal Treatment for Acromioclavicular Joint Injuries According to the Journal of Shoulder and Elbow Surgery

The optimal treatment for acromioclavicular (AC) joint injuries should be based on the classification of injury severity, with types I-II managed non-operatively and types IV-VI requiring surgical intervention, while type III injuries remain controversial and should be decided based on patient-specific factors.

Classification and Injury Assessment

• AC joint injuries are among the most common shoulder girdle injuries in athletes, typically resulting from a direct force to the acromion with the arm in an adducted position 1
• Proper assessment requires upright radiographs as they better demonstrate the true degree of displacement compared to supine radiographs 2, 3
• The Rockwood classification system is used to categorize AC joint injuries based on severity:
  • Type I: Sprain of AC ligaments with intact joint
  • Type II: Disruption of AC ligaments with intact coracoclavicular ligaments
  • Type III: Disruption of both AC and coracoclavicular ligaments with 25-100% superior displacement
  • Type IV: Complete displacement with posterior displacement into trapezius
  • Type V: Complete displacement with 100-300% superior displacement
  • Type VI: Inferior displacement beneath coracoid process 1, 4

Non-Operative Management (Types I and II)

• Type I and II injuries should be treated non-operatively with excellent outcomes 1, 4
• Initial treatment includes:
  • Sling immobilization (preferred over figure-of-eight bandage) 2, 3
  • Ice application for pain and swelling control 5
  • Early shoulder motion exercises as tolerated 1, 6
  • Progressive physical therapy focusing on range of motion and strengthening 1, 7
• Return to activity criteria:
  • Normal shoulder motion and strength compared to contralateral side 1
  • Resolution of pain with activity 1, 6
  • Typical recovery time: 2-3 weeks for type I, 4-6 weeks for type II 4

Controversial Management (Type III)

• Treatment of type III injuries remains controversial and should be individualized based on:
  • Patient's age and activity level 1
  • Occupational demands (overhead work, heavy labor) 1, 4
  • Athletic participation, especially in overhead sports 1
  • Degree of displacement and associated symptoms 4
• Non-operative treatment can result in successful return to previous level of function in many cases 1, 4
• Surgical consideration is warranted for:
  • High-demand athletes, especially those in overhead sports 1
  • Manual laborers requiring overhead work 4
  • Patients with persistent symptoms after non-operative management 4

Surgical Management (Types IV-VI and Selected Type III)

• Surgical intervention is clearly indicated for high-grade injuries (types IV-VI) 1, 4
• Goals of surgical treatment include:
  • Anatomic reduction of the AC joint 1
  • Reconstruction of the coracoclavicular ligaments 1, 4
  • Repair of the deltotrapezial fascia 1
• Surgical techniques with favorable outcomes include:
  • Coracoclavicular ligament reconstruction 1, 4
  • Coracoacromial ligament transfer 1, 4
  • Anatomic AC joint reconstruction (biomechanically superior for persistent instability) 4
• Outcomes after surgical reconstruction have been satisfactory regarding pain relief and return to function 1

Potential Complications

• Non-operative treatment of high-grade injuries may result in:
  • Persistent pain and instability 1, 4
  • Decreased shoulder strength and function 3
  • Cosmetic deformity 3
• Surgical complications may include:
  • Loss of reduction and construct failure with cyclic loading 1
  • Need for hardware removal 3
  • Infection and wound complications 4

Rehabilitation Protocol

• Post-operative or post-injury rehabilitation should focus on:
  • Progressive range of motion exercises 1, 6
  • Strengthening of shoulder girdle muscles, particularly trapezius and deltoid 5, 6
  • Gradual return to sport-specific activities 1
• Return to full activities typically occurs:
  • 6-8 weeks for non-operatively treated type I-II injuries 4, 6
  • 3-6 months following surgical reconstruction 1, 4

Associated Injuries

• AC joint injuries may present with associated glenohumeral joint injuries, including an increased incidence of superior labrum anterior posterior (SLAP) tears 1
• Comprehensive evaluation for concomitant injuries is essential for optimal treatment planning 1