What is the treatment for Acromioclavicular (AC) separation?

Treatment of Acromioclavicular (AC) Joint Separation

Treatment of AC separation is determined primarily by injury grade: Grades I-II and most Grade III injuries should be managed conservatively with physical therapy and NSAIDs, while Grades IV-VI require surgical reconstruction. 1

Initial Assessment

• Obtain upright anteroposterior (AP) shoulder radiographs in internal and external rotation, plus an axillary or scapula-Y view to confirm diagnosis and grade the injury 2, 1
• Upright positioning is critical as malalignment can be underrepresented on supine imaging 1
• Grade the injury using the Rockwood classification, though be aware that inter-rater reliability is poor to fair (kappa 0.08-0.35), and intra-rater reliability is only moderate to good (kappa 0.6-0.63) 3

Treatment Algorithm by Grade

Grades I-II (Low-Grade Separations)

• Initiate conservative management with physical therapy, NSAIDs, and activity modification 4, 5
• Use acetaminophen as first-line oral analgesic due to favorable safety profile 4
• If inadequate relief, use NSAIDs at the lowest effective dose for the shortest duration 4
• Begin range of motion and strengthening exercises focusing on rotator cuff and posterior shoulder girdle muscles 4
• Expect rapid and full return to play with rehabilitation 5

Grade III (Controversial - Most Treated Conservatively)

Current evidence strongly favors initial conservative management for Grade III injuries, with surgery reserved only for patients who remain symptomatic after adequate conservative treatment. 3, 5

Conservative Management (Preferred Initial Approach)

• Treat initially with figure-of-8 brace or sling 6
• Begin wrist, hand, and elbow strengthening at 3-4 weeks postinjury 6
• Start shoulder range of motion and periscapular strengthening at 6 weeks 6
• Initiate formal physical therapy with interval throwing program (for overhead athletes) at 8-12 weeks if pain-free with full ROM 6

Evidence Supporting Conservative Management

• Functional outcomes (Constant, QuickDASH, ASES, UCLA scores) are identical between operative and non-operative treatment at minimum 1-year follow-up 3
• Return to work and sports is significantly faster with non-operative treatment 3
• No complications occur with conservative treatment, while 9 of operated patients in one series suffered complications 3
• None of the conservatively treated patients required secondary stabilizing surgery 3

Indications for Surgery in Grade III

• AC joint pain >7/10 on VAS at 7 days post-injury with no functional improvement 3
• Persistent painful instability after adequate conservative trial 5
• Some surgeons support early intervention in overhead athletes, though this remains controversial 5

Grades IV, V, and VI (High-Grade Separations)

Surgical reconstruction is typically required for Grades IV-VI injuries, as they represent severe injuries with significant displacement that rarely achieve adequate stability with conservative management. 1

• Operative intervention is recommended for acute types IV, V, and VI 5
• Goal is to create stiff and strong repair/reconstruction of coracoclavicular ligaments while providing stability in all planes 5

Surgical Techniques

• Reconstruction of coracoclavicular ligaments with augmented coracoacromial ligament transfer (modified Weaver-Dunn procedure) 7, 5
• Tendon graft reconstructions using semitendinosus graft through bone tunnels in distal clavicle and coracoid 7
• Anatomic reconstruction of ligaments provides the most function and stability based on biomechanical research 5

Common Pitfalls to Avoid

• Failing to obtain proper upright radiographic views, which can underestimate the degree of separation 1
• Rushing to surgery for Grade III injuries without adequate conservative trial, given equivalent long-term outcomes and faster return to activity with non-operative management 3
• Not counseling young athletic patients that surgical management results in longer time to return to work and sports despite potential cosmetic improvement 3
• Relying solely on Rockwood classification without clinical correlation, given its poor inter-rater reliability 3