What is the recommended treatment plan for a 36-year-old male patient with chronic left shoulder pain and a history of AC (acromioclavicular) separation, who is scheduled for an MRI (Magnetic Resonance Imaging) of the left shoulder without IV (intravenous) contrast?

Treatment Plan for Type 5 AC Separation with Chronic Shoulder Pain

For this 36-year-old male with a Type 5 AC separation and chronic left shoulder pain, proceed with the scheduled MRI without IV contrast to fully evaluate soft tissue pathology, then initiate structured conservative management with physical therapy focusing on rotator cuff strengthening and scapular stabilization, while recognizing that surgical intervention may ultimately be required for this severe injury grade. 1

Imaging Strategy

MRI Without Contrast is Appropriate

• The scheduled MRI shoulder without IV contrast is the correct imaging choice for evaluating rotator cuff tears, labral pathology, and other soft tissue injuries that commonly accompany AC separations 1
• MRI without contrast is optimal because any post-traumatic joint effusion or hemarthrosis (even from a prior injury) provides sufficient visualization of soft tissue structures without requiring injected contrast 1
• This modality will demonstrate bone marrow edema from trauma and identify associated rotator cuff or labral tears that may be contributing to chronic pain 1

What the MRI Will Assess

• Rotator cuff integrity (tears are common with shoulder trauma and a frequent source of chronic pain) 2
• Labral injuries and glenohumeral ligament damage 1
• Cartilage damage and early osteoarthritis 3
• Occult fractures or bone contusions 1

Understanding Type 5 AC Separation Severity

This is a Severe Injury

• Type 5 AC separations represent complete disruption of both AC and coracoclavicular ligaments with significant superior displacement of the clavicle 4
• Horizontal instability is often present and frequently underdiagnosed, which can lead to poor outcomes if not addressed 5
• The chronic nature of this patient's pain suggests either inadequate initial treatment or development of secondary pathology 4

Initial Conservative Management Approach

First-Line Physical Therapy Protocol

• Initiate a structured rehabilitation program focusing on rotator cuff strengthening and scapular stabilization exercises as the foundation of treatment 3
• Include range of motion exercises to prevent adhesive capsulitis, which can develop secondary to shoulder injuries 3
• Address postural correction, particularly forward head and rounded shoulder posture that exacerbates AC joint stress 3
• Progress resistance and complexity of exercises as tolerated over 4-6 week intervals 3

Pain Management

• Use NSAIDs for short-term pain management (2-4 weeks) to reduce inflammation 3
• Acetaminophen serves as an alternative if NSAIDs are contraindicated 3

Timeline for Conservative Management

• Reassess at 4-6 week intervals to monitor progress 3
• If no improvement after 3 months of appropriate conservative management, refer to orthopedic or sports medicine specialist 3

Surgical Considerations for Type 5 Injuries

When Surgery Should Be Considered

• For Type 5 AC separations specifically, surgical stabilization is often ultimately required despite initial conservative attempts, particularly in young, active patients 4
• Surgery should be strongly considered if pain remains severe (VAS >7) at 7 days post-injury or if function has not improved with conservative management 4
• Horizontal instability, which is common in severe AC separations, often requires surgical correction for optimal outcomes 5

Important Surgical Timing Considerations

• Recent evidence shows that functional outcomes at 1+ year may be similar between operative and non-operative management for Type 3 injuries, but Type 5 injuries are more severe 4
• Return to work and sports is actually longer with surgical management (compared to non-operative for Type 3), but Type 5 injuries may not respond adequately to conservative treatment alone 4
• Surgical complications occur in a significant percentage of cases, so the decision must weigh severity of symptoms against surgical risks 4

Second-Line Interventions if Conservative Management Fails

Diagnostic and Therapeutic Injections

• Subacromial corticosteroid injection can be both diagnostic and therapeutic for persistent pain 3
• Ultrasound-guided injections allow for precise placement in the subacromial space 3

Advanced Imaging if Needed

• MR arthrography should be considered if subtle labral pathology is suspected but not visible on standard MRI 3
• Ultrasound with dynamic assessment may reveal impingement not visible on static MRI 3

Critical Pitfalls to Avoid

Do Not Overrely on Initial MRI Results

• Normal or near-normal MRI does not rule out clinically significant pathology such as functional impingement syndrome or early tendinopathy 3
• Dynamic narrowing of the subacromial space during movement may cause pain despite normal static imaging 3

Address Biomechanical Factors

• Scapular dyskinesis and muscle imbalances must be identified and corrected during physical therapy 3
• Neglecting these factors will hinder treatment progress regardless of other interventions 3

Consider Referred Pain Sources

• Cervical spine pathology can manifest as shoulder pain and should be evaluated if shoulder-directed treatment fails 3

Avoid Premature Surgical Intervention

• Exhaust conservative management before considering surgery, but recognize that Type 5 injuries have higher surgical rates than lower-grade separations 3, 4

Specific Treatment Algorithm Based on MRI Results

If MRI Shows Rotator Cuff Pathology

• Focus on eccentric strengthening exercises for tendinopathy 3
• Consider subacromial injection if conservative management fails after 6-8 weeks 3

If MRI Shows Labral Pathology

• Implement proprioceptive and stabilization exercises 3
• Consider MR arthrography if symptoms persist and initial MRI is equivocal 3

If MRI Shows Functional Impingement

• Prioritize scapular stabilization and rotator cuff strengthening 3
• Address posture and ergonomic factors aggressively 3

Follow-Up Schedule

• Reassess at 4-6 week intervals to monitor progress and adjust treatment 3
• At 3 months, if no significant improvement with appropriate conservative management, refer to orthopedic or sports medicine specialist for surgical evaluation 3
• Given the Type 5 classification, maintain lower threshold for specialist referral compared to lower-grade AC separations 4