What is the treatment approach for an AC (Acromioclavicular) joint sprain based on its grade?

AC Joint Sprain Treatment by Grade

For Grade I and II AC joint sprains, initiate the PRICE protocol for 72 hours followed immediately by supervised functional rehabilitation with semirigid bracing for 4-6 weeks, while Grade III injuries should be managed conservatively unless the patient is a professional athlete requiring rapid return to play. 1

Classification System

AC joint sprains are graded based on ligamentous injury severity 2:

• Grade I: Mild sprain with tearing of only a few fibers of the AC ligament; AC and coracoclavicular (CC) ligaments remain intact 2
• Grade II: Moderate force causing rupture of the AC joint capsule and AC ligament, but CC ligaments remain intact 2
• Grade III: Severe force rupturing both AC and CC ligaments, resulting in complete joint dislocation 2
• Grades IV-VI: Severe dislocations with posterior displacement (IV), extreme superior displacement (V), or inferior displacement (VI) requiring surgical management 2

Initial Management (First 72 Hours)

Apply the PRICE protocol immediately 1:

• Protection of the joint from further injury
• Rest from aggravating activities
• Ice application to reduce swelling and pain
• Compression with bandaging
• Elevation to minimize fluid accumulation

Pain management during acute phase 1:

• NSAIDs for short-term use (less than 14 days) effectively control pain and swelling without significant adverse events 1
• Paracetamol (acetaminophen) is equally effective if NSAIDs are contraindicated 1
• Avoid opioid analgesics as they cause significantly more side effects without superior pain relief 1

Brief sling immobilization (less than 10 days) may be used to decrease initial pain and edema, but prolonged immobilization beyond 10 days correlates with worse functional outcomes and delayed return to work 1

Functional Rehabilitation Phase (After 72 Hours)

Begin supervised exercises immediately after the initial 72-hour period 1:

1. Range of motion exercises first: Focus on restoring full shoulder mobility 1
2. Progress to strengthening: Target proprioception, strength, coordination, and functional movements 1
3. Functional support: Use semirigid braces or splints for 4-6 weeks rather than elastic bandages, as semirigid supports are more effective and cost-efficient 1

Re-examine at 3-5 days post-injury when pain and swelling have improved to better assess ligament damage severity 1

Grade-Specific Treatment Recommendations

Grades I and II

Conservative management is the standard of care 2:

• Complete the PRICE protocol and functional rehabilitation as outlined above 1
• Most patients achieve good outcomes, though 40% may have significant pain at 6 months, decreasing to 14% at final follow-up 3
• Patients symptomatic at 6 months are more likely to have persistent symptoms beyond 1 year 3

Grade III

Conservative management is recommended for most patients 2:

• Follow the same rehabilitation protocol as Grades I and II 1
• Surgery is reserved only for: Professional athletes requiring rapid return to play, or chronic symptomatic instability unresponsive to comprehensive conservative treatment 1
• Grade III injuries treated conservatively can achieve satisfactory outcomes in most cases 2

Grades IV-VI

Surgical management is recommended due to severe displacement and soft tissue disruption 2

Critical Pitfalls to Avoid

Do not use NSAIDs beyond 14 days, as prolonged use may delay natural healing since inflammation is necessary for tissue recovery 1

Avoid prolonged immobilization beyond 10 days, which leads to worse functional outcomes, delayed return to work, and increased stiffness 1

Do not underestimate the severity of Grade I and II injuries: Studies show that 27% may develop chronic AC joint pathology requiring subsequent surgery, and only 52% remain completely asymptomatic long-term 4. Radiographic changes including degenerative changes, CC ligament ossification, or distal clavicular osteolysis develop in the majority of patients 4.

Long-Term Management and Prevention

Continue functional support devices (bracing) during high-risk activities, particularly for patients with history of recurrent sprains 1

Maintain ongoing strengthening and proprioceptive exercises as part of regular training to prevent recurrent injuries 1

Educate patients on realistic recovery expectations: Patients may continue to experience adverse symptoms beyond 6 months and should be counseled that there is a positive correlation between symptoms at 6 months and persistent symptoms beyond 1 year 3

Monitor for chronic complications: At long-term follow-up (mean 6.3 years), activity-related pain occurs in approximately 29% of patients, residual anteroposterior instability in 33%, and radiographic degenerative changes in the majority 4