What is the recommended management for a patient with mild hypertrophic changes at the acromioclavicular joint and shoulder pain?

Management of Mild Acromioclavicular Joint Osteoarthritis with Shoulder Pain

Initial conservative management with NSAIDs, activity modification, and early functional rehabilitation should be implemented first, with progression to corticosteroid injection if symptoms persist beyond 2-3 weeks, reserving surgical distal clavicle resection only after minimum 6 months of failed conservative treatment. 1, 2

Initial Conservative Management (First 2-3 Weeks)

• Start NSAIDs (specifically ibuprofen before bedtime) as first-line pharmacologic treatment to control pain and inflammation, as this is superior to acetaminophen for shoulder-related pain 3
• Implement strict activity modification by avoiding overhead activities, cross-body adduction movements, and weight training exercises that load the AC joint, as these aggravate AC joint pathology 4, 1
• Apply ice before exercise sessions for symptomatic relief and pain reduction 3
• Begin gentle range of motion exercises immediately, focusing on external rotation and abduction to prevent secondary adhesive capsulitis, but avoid overhead pulleys which encourage uncontrolled abduction 5, 3

The evidence strongly supports activity modification as the cornerstone of AC joint osteoarthritis management, with weight training being a particularly common aggravating factor in atraumatic AC joint pathology 4.

Physical Examination Priorities

• Assess pain location precisely: superior shoulder pain specifically implicates AC joint disease, distinguishing it from anterior pain (rotator cuff/biceps) or scapular pain (referred cervical or rotator cuff pathology) 5
• Perform cross-body adduction test to reproduce AC joint pain, which is the most specific physical finding for AC joint pathology 1, 2
• Palpate directly over the AC joint for focal tenderness and assess for hypertrophic changes, which correlate with the radiographic findings 1, 2

Diagnostic Confirmation

• Plain radiographs are already obtained (as shown in your case), which appropriately demonstrate the mild hypertrophic changes without need for additional imaging initially 5, 6
• Perform diagnostic local anesthetic injection into the AC joint if the diagnosis remains uncertain or to confirm AC joint as pain source before proceeding to corticosteroid injection 1, 2

Escalation to Corticosteroid Injection (If Conservative Measures Fail at 2-3 Weeks)

• Administer intra-articular corticosteroid injection (triamcinolone) directly into the AC joint when pain persists despite NSAIDs and activity modification 3, 1
• Corticosteroid injections provide short-term pain relief (typically weeks to months) but do not alter disease progression, so expectations should be set appropriately 1
• The role of repeated steroid injections remains controversial, with most experts recommending judicious use rather than serial injections 1

Physical therapy has limited utility for AC joint osteoarthritis specifically, as therapeutic exercise and range of motion play only a minor role compared to other shoulder pathologies 1. This distinguishes AC joint management from rotator cuff pathology where strengthening is central.

Surgical Referral Criteria (After Minimum 6 Months Conservative Treatment)

• Refer for distal clavicle resection (open or arthroscopic) only after documented failure of at least 6 months of appropriate conservative management including NSAIDs, activity modification, and corticosteroid injection 1, 2
• Persistent symptoms with functional limitations despite conservative treatment are the primary indication for surgery 7

Critical Pitfalls to Avoid

• Do not overlook coexisting rotator cuff pathology, as the majority of shoulder pain originates in the subacromial region and glenohumeral joint, and AC joint pathology may coexist with or be overshadowed by rotator cuff disease 1
• Do not delay early mobilization beyond 1 week, as this significantly increases risk of secondary adhesive capsulitis, even though the primary pathology is AC joint 3
• Do not assume AC joint is the sole pain generator without performing diagnostic injection, as patients often present with nonspecific complaints of neck, shoulder, and arm pain 2
• Avoid aggressive overhead strengthening exercises that load the AC joint during the acute phase, as these worsen symptoms 5, 4

Age-Specific Context

• In patients over 35-40 years (as appears to be your case based on degenerative changes), AC joint osteoarthritis is extremely common and often represents primary degenerative disease rather than post-traumatic arthritis 1, 2
• Screen for history of previous AC joint injury or repetitive overhead activities/weight training, as these are common etiologies for secondary AC joint arthritis 4

The evidence base for AC joint osteoarthritis management remains limited, with no high-quality randomized controlled trials directly comparing conservative versus surgical management 8. However, the consistent recommendation across all guidelines is initial conservative management with escalation only after documented failure.