What is the initial management for adolescent patients presenting with acromioclavicular (AC) joint pain?

Initial Management of AC Joint Pain in Adolescents

For adolescent patients presenting with acromioclavicular (AC) joint pain, initial management should focus on determining whether this represents traumatic injury versus inflammatory arthritis, as the treatment pathways differ dramatically—traumatic AC injuries are managed with rest, NSAIDs, and sling immobilization, while inflammatory conditions like juvenile idiopathic arthritis require disease-modifying therapy.

Differential Diagnosis Framework

The critical first step is distinguishing between:

Traumatic AC Joint Injury

• History of direct trauma (fall onto shoulder, contact sports injury) suggests ligamentous sprain or AC separation 1
• Most common in athletic adolescents from direct fall onto superior shoulder with arm adducted 1
• Physical examination findings: Point tenderness over AC joint, visible deformity in higher grade injuries, positive cross-body adduction test 1
• Imaging: Plain radiographs are the mainstay to classify injury severity using Rockwood grading system 2

Inflammatory/Overuse Conditions

• Insidious onset without trauma suggests osteolysis of distal clavicle (increasingly prevalent with weight training) or inflammatory arthritis 3
• Systemic symptoms (fever, multiple joint involvement, morning stiffness) raise concern for juvenile idiopathic arthritis 4
• Consider enthesitis-related arthritis if AC joint involvement is part of broader entheseal inflammation 5

Initial Management for Traumatic AC Joint Injury

Conservative Treatment (Rockwood Types I-II)

• Sling immobilization for comfort in acute phase 1, 3
• NSAIDs for pain control and inflammation 3
• Early functional rehabilitation once acute pain subsides 1, 3
• Excellent outcomes expected with full return of function 3

Surgical Consideration (Rockwood Types IV-VI)

• Operative reduction and fixation required for severe dislocations 3
• Type III and V injuries remain controversial—most can be managed conservatively 1

Initial Management for Inflammatory Arthritis

If clinical presentation suggests inflammatory arthritis rather than trauma:

Immediate Workup

• Laboratory studies: CBC with differential, ESR, CRP to assess inflammation 4
• Imaging: Plain radiographs and ultrasound to detect effusion and assess for other joint involvement 4
• Consider MRI if osteomyelitis or deeper pathology suspected 4

Initial Pharmacologic Treatment

• NSAIDs are strongly recommended as first-line therapy for enthesitis (which can involve AC joint region) 5
• Physical therapy is conditionally recommended for adolescents with enthesitis who have or are at risk for functional limitations 5
• Bridging oral glucocorticoids (<3 months) may be considered during initiation of therapy if high disease activity, limited mobility, or significant symptoms 5

Escalation if NSAIDs Fail

• TNF inhibitors are conditionally recommended over methotrexate or sulfasalazine for active enthesitis despite NSAIDs 5
• Methotrexate is strongly recommended against as monotherapy for enthesitis 5

Special Consideration: Distal Clavicle Osteolysis

For atraumatic, overuse-related AC joint pain (common in weight-training adolescents):

• Activity modification is the best method of controlling symptoms 3
• NSAIDs for symptomatic relief 3
• Operative excision of distal clavicle only if conservative approach fails 3

Critical Pitfalls to Avoid

• Do not dismiss insidious onset AC pain as simple overuse without ruling out inflammatory arthritis—early DMARD therapy is crucial for JIA to prevent permanent joint damage 6, 7
• Do not use prolonged oral glucocorticoids as monotherapy for inflammatory conditions—they are only for short-term bridging (<3 months) 5
• Do not assume all adolescent shoulder pain is traumatic—systemic symptoms, multiple joint involvement, or lack of trauma history warrant inflammatory workup 4
• Physical activity should not be completely restricted in JIA patients, as lower activity correlates with greater pain severity and interference 8