What is the recommended management for a patient with early bony hypertrophic changes at the acromioclavicular joint?

Management of Early Bony Hypertrophic Changes at the Acromioclavicular Joint

For a patient with early bony hypertrophic changes (osteoarthritis) at the acromioclavicular joint detected on radiographs, initial conservative management with activity modification, NSAIDs, and physical therapy for 6-12 months is recommended, with surgical distal clavicle resection reserved only for patients who fail conservative treatment and have persistent symptoms that limit their desired activity level. 1

Initial Conservative Management (First-Line Treatment)

The standard approach for early AC joint osteoarthritis begins with a prolonged trial of non-operative management 1:

• Activity modification: Avoid overhead activities and movements that exacerbate AC joint pain 1
• NSAIDs: Use for pain control and anti-inflammatory effect 1
• Physical therapy: Focus on shoulder strengthening and range of motion exercises for 6-12 months 1
• Corticosteroid injection: Consider for persistent symptoms during the conservative trial 2

The majority of patients respond well to conservative management and can return to their previous activity levels 1. This approach is supported across all injury severity classifications for degenerative AC joint disease 2, 3.

When to Consider Surgical Intervention

Surgical distal clavicle resection should only be considered after failure of conservative management 1:

• Indication: Persistent pain after 6-12 months of conservative treatment that prevents return to desired activity level 1
• Procedure options:
  • Arthroscopic distal clavicle resection (preferred due to faster recovery and minimal invasiveness) 1
  • Open distal clavicle excision (traditional approach, but longer recovery) 1

Arthroscopic resection offers advantages of rapid rehabilitation with excellent functional results compared to open techniques 1. The arthroscopic approach avoids violating the deltotrapezial fascia, which can weaken the shoulder with open procedures 1.

Important Clinical Considerations

This patient's radiographic finding of "mild undersurface spurring" represents early degenerative changes, not an acute injury 4. The management differs significantly from traumatic AC joint separations (Rockwood classifications), which may require acute surgical intervention for high-grade injuries 5, 4.

Key Pitfalls to Avoid:

• Do not rush to surgery: The natural history of early AC joint osteoarthritis is generally favorable with conservative management 2, 3
• Do not confuse with acute trauma: Degenerative changes require different management than acute AC joint separations 4
• Avoid premature return to aggravating activities: Patients should only resume full activity when they achieve normal shoulder motion, strength, and are asymptomatic compared to the contralateral side 5

Prognosis

Conservative treatment typically yields favorable outcomes for early AC joint osteoarthritis 1. For the minority who require surgical intervention after failed conservative management, both arthroscopic and open distal clavicle resection provide satisfactory pain relief and return to functional activities 1, 4.