Initial Management of Pediatric Acromioclavicular (AC) Joint Pain
Begin with conservative management consisting of sling immobilization for comfort followed by early functional rehabilitation with progressive physical therapy and shoulder range of motion exercises 1, 2.
First-Line Treatment Approach
Immediate Management
- Apply sling immobilization initially for symptomatic relief and protection 1, 2
- Avoid prolonged immobilization beyond what is necessary for comfort, as this can lead to stiffness and weakness 1
- Most pediatric AC joint injuries (sprains and Grade I-III separations) respond well to non-operative treatment 1, 2
Activity Modification
- Restrict activities that reproduce pain while maintaining general conditioning 3
- Complete immobilization should be avoided to prevent muscle atrophy and deconditioning 3
- Gradual return to activity as symptoms improve 1
Pain Management
- Use scheduled NSAIDs (oral or topical) for pain control during the acute phase 3
- Topical NSAIDs are preferable in pediatric patients as they eliminate gastrointestinal hemorrhage risk 3
- NSAIDs facilitate participation in physical therapy by controlling pain 3
Physical Therapy and Rehabilitation
Progressive Exercise Program
- Initiate early functional rehabilitation once acute pain subsides 1, 2
- Focus on progressive shoulder range of motion exercises 1, 2
- Implement strengthening exercises as tolerated, particularly for shoulder stabilizers 1
Treatment Duration
- Continue conservative management for at least 3-6 months before considering advanced interventions 3, 4
- Most patients achieve full recovery with appropriate conservative treatment within this timeframe 3
- Expect excellent outcomes with full return of function in the majority of cases 1, 5
Critical Diagnostic Considerations in Pediatric Patients
Age-Specific Injury Patterns
- Children under 13 years rarely sustain true AC joint dislocations 5
- In younger children, what appears as AC joint injury is typically a distal clavicle fracture with intact AC joint but ruptured coracoclavicular ligaments 5
- The periosteal sleeve remains intact in younger children, creating a "pseudo-dislocation" appearance 5
- Children 13 years and older sustain adult-type AC joint dislocations 5
Imaging Considerations
- Obtain plain radiographs to differentiate true AC dislocation from distal clavicle fracture 5
- In children under 13, the injury is often misdiagnosed as AC dislocation when it is actually a physeal injury 5
When Conservative Management Fails
Corticosteroid Injections
- Use corticosteroid injections with extreme caution in pediatric patients 3, 4
- May provide short-term pain relief but do not alter disease progression 4
- Risk of inhibiting healing, reducing tensile strength, and predisposing to spontaneous rupture in children 3
- Consider only after diagnostic local anesthetic injection confirms AC joint as pain source 4
Surgical Intervention
- Reserve surgery only for cases failing 3-6 months of conservative therapy 3, 4
- In children under 13 with distal clavicle fractures, conservative treatment typically produces excellent results 5
- Surgical options include distal clavicle resection (open or arthroscopic) for persistent symptomatic osteoarthritis 4
- For true Grade IV, V, and VI dislocations (rare in children), operative reduction and fixation may be required 1
Common Pitfalls to Avoid
- Do not misdiagnose distal clavicle fractures as AC joint dislocations in children under 13 5
- Avoid prolonged immobilization that leads to shoulder stiffness and weakness 1
- Do not rush to surgery; over 90% of pediatric AC injuries heal with conservative management 5
- Avoid early corticosteroid injections given the risks in the pediatric population 3
Expected Outcomes
- Non-operatively treated AC injuries show no significant strength deficits when properly rehabilitated 6
- Children treated conservatively achieve good to excellent results in over 90% of cases 5
- Full return to asymptomatic activity is expected with appropriate conservative management 5
- Growth disturbances are not a concern with proper non-operative treatment 5