Treatment of Acromioclavicular (AC) Joint Arthritis
For AC joint arthritis, begin with scheduled NSAIDs at the minimum effective dose after assessing cardiovascular, gastrointestinal, and renal risks, and if NSAIDs fail or are contraindicated, proceed directly to intra-articular corticosteroid injection, which is the most effective conservative intervention before considering surgical distal clavicle excision after 6 months of failed conservative management. 1, 2, 3
Initial Conservative Management
First-line pharmacologic therapy:
NSAIDs should be prescribed at the lowest effective dose for the shortest duration necessary, with mandatory assessment of gastrointestinal, cardiovascular, and renal risk factors before initiation 1, 4. For patients requiring prolonged NSAID therapy, co-prescribe a proton pump inhibitor for gastroprotection 4, 2.
Acetaminophen (up to 4 grams daily) is appropriate for mild to moderate pain, particularly in elderly patients or those at high risk for NSAID complications 1, 4.
Activity modification is essential to control symptoms and prevent progression 5, 3.
Physical therapy has limited utility:
- Unlike other shoulder conditions, therapeutic exercise and range of motion provide only minor benefit for AC joint arthritis 1, 3. Physical therapy should not be emphasized as a primary treatment modality for this specific condition.
Intra-articular Corticosteroid Injection
When oral medications fail or are contraindicated:
Intra-articular corticosteroid injection is the optimal next-step intervention, providing effective short-term pain relief 2, 3, 6. Joint aspiration followed by long-acting glucocorticosteroid injection is highly effective and safe for monoarticular inflammatory arthritis 2.
Injection provides approximately 50% improvement in pain levels at mean follow-up of 7.5 months 6.
Critical technical consideration: Avoid peri-tendon injections around the AC joint that could compromise rotator cuff integrity 2.
Reassess within 1-2 weeks after injection to evaluate treatment response 2.
Important caveat: While corticosteroid injections provide symptomatic relief, they do not alter the natural progression of the disease 3.
Surgical Management
Indications for surgery:
Distal clavicle excision is indicated after a minimum of 6 months of unsuccessful conservative treatment 3, 6, 7.
Surgical options include open or arthroscopic distal clavicle resection, with no significant difference in outcomes between open versus arthroscopic approaches 6.
Surgical outcomes:
Operative studies show mean functional outcomes of 87.8% with good results when 0.5 to 2 cm of clavicle is excised 6.
Patients requiring concomitant shoulder procedures have similarly good outcomes 6.
Critical Pitfalls to Avoid
Never use high-dose NSAIDs for prolonged periods in elderly patients due to increased risk of gastrointestinal, platelet, and nephrotoxic effects 1.
Do not rely on physical therapy as primary treatment for AC joint arthritis, as it has minimal efficacy compared to other shoulder pathology 1, 3.
Always assess cardiovascular, renal, and GI bleeding risk before prescribing NSAIDs, especially in patients over 65 years 2, 1.