What is the appropriate management for an older adult patient with hypertrophic degenerative arthritic changes at the acromioclavicular joint, presenting with shoulder pain?

Management of Acromioclavicular Joint Osteoarthritis

Begin with conservative non-operative treatment including NSAIDs or acetaminophen, physical therapy focused on rotator cuff strengthening, and activity modification, reserving surgical intervention only after at least 6 months of failed conservative management. 1, 2, 3, 4

Initial Conservative Management (First-Line Treatment)

Pharmacologic Options:

• Start with acetaminophen (up to 4 grams daily) as the safest first-line analgesic, particularly in older adults, as it provides pain relief comparable to NSAIDs without gastrointestinal toxicity 5
• If acetaminophen fails, trial NSAIDs (OTC or prescription), but use cautiously in elderly patients due to high risk of GI bleeding, platelet dysfunction, nephrotoxicity, and drug-drug interactions with common comorbidities like heart failure and hypertension 5
• Consider COX-2 selective inhibitors (celecoxib) for patients with history of gastroduodenal ulcers or GI bleeding, though monitor for fluid retention and cardiovascular risk 5
• Topical analgesics (methyl salicylate, capsaicin cream, menthol) may provide benefit for mild-to-moderate pain 5

Intra-articular Injections:

• Corticosteroid injections (triamcinolone hexacetonide) may provide short-term pain relief for acute exacerbations, especially with inflammation and effusion, though they do not alter disease progression 5, 4
• The evidence for corticosteroid efficacy in AC joint arthritis is limited and controversial—use judiciously 4
• Viscosupplementation (hyaluronic acid) is an option with Grade C evidence, typically given as three weekly injections, showing pain and function improvements at 1,3, and 6 months 5, 1, 2

Physical Therapy and Exercise:

• Exercise-based therapy is foundational, focusing on rotator cuff strengthening, periscapular muscles, and core musculature to protect the joint 1, 2
• However, therapeutic exercise and range of motion play only a minor role specifically for AC joint arthritis compared to glenohumeral pathology 4
• Include static stretching daily when pain is minimal, holding terminal stretch positions for 10-30 seconds 5
• Modify exercises to avoid pain or when the joint is inflamed 5

Activity Modification:

• Avoid overhead activities and direct pressure on the AC joint 3, 4

Critical Diagnostic Consideration Before Treatment

Screen for coexisting shoulder pathology before finalizing treatment plans:

• 98% of patients with symptomatic AC joint degeneration have coexisting shoulder pathology: rotator cuff disease (81%), labral tears (33%), glenohumeral arthritis (14%), and biceps tendon disease (22%) 6
• In patients under 50 years, expect labral tears in 42% and rotator cuff disease in 65% (mostly partial tears) 6
• In patients 50 years and older, only 14% have an intact rotator cuff, with 49% having full-thickness tears 6
• This is critical because treating only the AC joint while missing a rotator cuff tear will result in persistent pain and treatment failure 6

Surgical Intervention (After Minimum 6 Months Conservative Failure)

Indications for Surgery:

• Persistent symptoms after appropriate 6-month trial of conservative treatment 4
• Significant functional debilitation despite non-operative management 7, 3

Surgical Options:

• Open or arthroscopic distal clavicle resection (Mumford procedure) 3, 4
• Perform shoulder arthroscopy at the time of AC joint surgery to address coexisting pathology in 98% of cases 6

Surgical Outcomes:

• High success rates when indicated, but overall higher complication rates compared to non-operative treatment 7
• Favorable outcomes for pain relief and return to functional activities when appropriate patient selection occurs 3

Common Pitfalls to Avoid

• Do not treat AC joint arthritis in isolation without evaluating for coexisting rotator cuff tears, labral tears, or glenohumeral arthritis—these are present in 98% of symptomatic cases 6
• Do not use NSAIDs in high doses for prolonged periods in elderly patients due to increased risk of adverse events (GI bleeding, renal dysfunction, cardiovascular complications) 5
• Do not rely solely on corticosteroid injections, as they provide only short-term relief and do not alter disease progression 4
• Do not confuse AC joint arthritis with glenohumeral osteoarthritis—the treatment algorithms differ significantly, and AC joint arthritis has limited benefit from physical therapy compared to glenohumeral pathology 1, 4
• Do not proceed to surgery before completing at least 6 months of conservative treatment 4