What is the treatment for mild Acromioclavicular (AC) joint arthropathy?

Treatment of Mild AC Joint Arthropathy

For mild AC joint arthropathy, begin with conservative management including NSAIDs, activity modification, and consider corticosteroid injection for short-term pain relief, reserving surgical distal clavicle excision for cases failing 6 months of conservative treatment.

Initial Conservative Management

First-Line Pharmacologic Treatment

• Acetaminophen (up to 4g/day) is the preferred initial oral analgesic for mild to moderate pain, offering comparable pain relief to NSAIDs without gastrointestinal risks 1
• Topical NSAIDs are preferred over systemic NSAIDs for mild to moderate pain when few joints are affected 1
• Oral NSAIDs should be used at the lowest effective dose for the shortest duration if acetaminophen is inadequate 1
  • In patients with increased GI risk, use non-selective NSAIDs plus gastroprotection or COX-2 inhibitors 1
  • COX-2 inhibitors are contraindicated in patients with cardiovascular risk 1

Activity Modification

• Joint protection strategies to avoid adverse mechanical factors are essential 1
• Physical therapy plays only a minor role in AC joint arthropathy, as therapeutic exercise and range of motion have limited benefit 2

Thermal Interventions

• Local application of heat (paraffin wax, hot packs) before activity may provide symptomatic benefit 1

Corticosteroid Injection Therapy

Indications and Efficacy

• Intra-articular corticosteroid injection provides short-term pain relief (mean duration 20 days, range 2 hours to 3 months) but does not alter disease progression 3, 2
• Injection should be performed under image intensifier guidance to ensure accurate placement 4
• Injection produces significant pain reduction and partial improvement in shoulder range of motion at 2 weeks 4
• 93% of patients experience initial improvement in pain and function, but 81% fail to obtain long-term relief 3

Important Caveats

• The judicious use of corticosteroid injections remains controversial 2
• Most experts agree steroid injections do not alter natural disease progression 2
• Consider injection as a diagnostic tool: if it provides relief, it confirms AC joint as pain source 2

Surgical Management

Indications

• Surgical distal clavicle excision is indicated after minimum 6 months of unsuccessful conservative treatment 2
• Surgery should be considered for persistent, insidious pain despite conservative measures 3

Surgical Outcomes

• Both open and arthroscopic distal clavicle excision are effective with no significant difference between approaches 5
• Mean functional outcome scores average 87.8% after surgery 5
• Excision of 0.5-2 cm of distal clavicle produces good outcomes 5
• 67% of patients with persistent pain ultimately require distal clavicle excision 3

Treatment Algorithm Summary

1. Initial therapy (0-2 months):

   • Acetaminophen up to 4g/day 1
   • Activity modification 1
   • Local heat application 1

2. If inadequate response (2-6 months):

   • Add topical or oral NSAIDs 1
   • Consider image-guided corticosteroid injection for short-term relief 4, 3

3. If persistent symptoms after 6 months:

   • Refer for surgical evaluation for distal clavicle excision 2

Key Clinical Pitfalls

• Do not continue NSAID monotherapy beyond 2 months without reassessment 1
• Do not rely on corticosteroid injections as definitive treatment—they provide only temporary relief and do not modify disease 3, 2
• Do not overlook AC joint pathology when evaluating shoulder pain, as it is commonly neglected despite being a frequent pain source 2
• Physical therapy has limited utility for AC joint arthropathy compared to other shoulder conditions 2