Treatment of Degenerative Acromioclavicular (AC) Joint Changes
Conservative management should be the first-line treatment for degenerative AC joint changes, with surgical intervention (distal clavicle excision) reserved only for patients who fail 6-12 months of non-operative treatment. 1, 2, 3
Initial Conservative Management (First 6-12 Months)
The following stepwise approach should be implemented before considering surgery:
First-Line Pharmacologic Treatment
- Start with oral NSAIDs (ibuprofen 1.2-2.4 g daily) as the most appropriate initial pharmacologic intervention, prescribed at low doses for short periods with monitoring for side effects 4
- Topical NSAIDs can be considered as a safer alternative, particularly for older adults (>75 years) with localized joint involvement 4
- Paracetamol up to 4 g daily may be added if NSAIDs alone provide inadequate relief 4
Activity Modification and Physical Therapy
- Avoid activities that exacerbate symptoms, particularly overhead movements and cross-body adduction 2, 3
- Physical therapy plays a limited role in AC joint osteoarthritis compared to other shoulder pathology, as therapeutic exercise and range of motion have minimal impact on this specific condition 3
- Patient education should be ongoing and include information about the condition, management options, and ergonomic principles 4
Corticosteroid Injections
- Diagnostic local anesthetic injection into the AC joint is essential to confirm the joint as the pain source before proceeding with treatment 3
- If diagnostic injection provides relief, corticosteroid injections may offer short-term pain relief (mean 50% improvement at 7.5 months follow-up) 5
- Important caveat: Steroid injections do not alter disease progression and should be used judiciously 3
Surgical Management (After Failed Conservative Treatment)
Indications for Surgery
Surgery should be considered only after:
- Minimum 6-12 months of unsuccessful conservative treatment 2, 5, 3
- Radiographic evidence of AC joint osteoarthritis 4
- Marked disability and reduced quality of life 4
- Positive response to diagnostic local anesthetic injection confirming AC joint as pain source 3
Surgical Technique
- Both open and arthroscopic distal clavicle excision (DCE) are equally effective with no significant difference in outcomes 5
- Arthroscopic approach offers advantages of minimal invasiveness and rapid rehabilitation 2
- Excision of 0.5-2 cm of distal clavicle produces good outcomes (mean functional outcome score 87.8%) 5
Special Considerations
- Patients with coexisting rotator cuff pathology may have less favorable outcomes if only the AC joint is addressed 1
- Concomitant shoulder procedures can be performed with similarly good outcomes 5
- Manual laborers and overhead athletes should still receive initial conservative treatment despite high shoulder demands, as there is no evidence supporting early surgical intervention for these populations 6
Common Pitfalls to Avoid
- Do not overlook the AC joint when evaluating shoulder pain, as it is frequently neglected despite being a common pain source 3
- Do not proceed to surgery without a positive diagnostic injection, as this confirms the AC joint as the primary pain generator 3
- Do not rush to surgery in athletes or manual laborers, as conservative management is equally appropriate regardless of occupation 6
- Plain radiographs should be obtained to document degenerative changes, though MRI may be needed to evaluate associated soft tissue structures in complex cases 7