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

Management of Mild Acromioclavicular Joint Hypertrophy with Right Shoulder Pain

Begin with conservative management consisting of physical therapy focused on rotator cuff strengthening, NSAIDs for pain control, and activity modification before considering any invasive interventions. 1, 2

Initial Conservative Management (First-Line Treatment)

Physical Therapy

• Start structured exercise therapy immediately, focusing on range of motion and strengthening exercises that target the rotator cuff and posterior shoulder girdle muscles to improve shoulder mechanics and reduce any associated impingement 1
• Gradually increase active range of motion while restoring shoulder girdle alignment and strengthening weak muscles, with specific emphasis on external rotation and abduction 1, 2
• Address scapular dyskinesis if present, as this can contribute to impingement symptoms and is a common pitfall if neglected 1
• Evaluate and treat contributing factors such as poor posture or muscle imbalances 1

Pain Management

• Start with acetaminophen as first-line oral analgesic due to its favorable safety profile 1
• If inadequate relief, use NSAIDs (such as ibuprofen) at the lowest effective dose for the shortest duration possible 1, 2

Activity Modification

• Modify daily activities to reduce stress on the shoulder joint, particularly avoiding repetitive overhead activities that may exacerbate AC joint symptoms 1, 3

Second-Line Interventions (If Conservative Management Fails After 8-12 Weeks)

Diagnostic and Therapeutic Injections

• Consider a diagnostic local anesthetic injection into the acromioclavicular joint to confirm that the AC joint is the primary pain generator, as this can help distinguish AC joint pathology from rotator cuff disease 3, 4
• If the diagnostic injection provides relief, subacromial or AC joint corticosteroid injections may provide short-term pain relief, though they do not alter disease progression 1, 3
• Ultrasound guidance can improve accuracy of AC joint or subacromial bursa injections 4

Advanced Imaging

• Obtain MRI shoulder without contrast or ultrasound (depending on local expertise) to evaluate for rotator cuff pathology, labral tears, and other soft tissue abnormalities if symptoms persist despite 8-12 weeks of conservative management 5, 1, 2
• MRI and ultrasound are equally appropriate for evaluating the rotator cuff and biceps tendon 5

Surgical Considerations (After Minimum 6 Months of Failed Conservative Treatment)

Indications for Surgical Referral

• Persistent pain and functional limitation despite adequate conservative management for at least 6 months 1, 3
• AC joint arthritis confirmed as a significant contributor to symptoms through diagnostic injection 1

Surgical Options

• Distal clavicle resection (open or arthroscopic) is the definitive surgical treatment for symptomatic AC joint osteoarthritis refractory to conservative management 3, 6
• AC joint resection may be considered if AC joint arthritis is the primary pain generator 1

Important Clinical Considerations and Common Pitfalls

• Do not overlook the AC joint: While most shoulder pain originates from the subacromial region and glenohumeral joint, AC joint osteoarthritis is a common but often neglected source of shoulder pain 3
• Distinguish AC joint pain from rotator cuff pathology: The clinical picture may not always allow for clear differentiation; diagnostic injections are invaluable in these cases 3, 4
• Physical therapy has limited role for isolated AC joint arthritis: Unlike rotator cuff pathology, therapeutic exercise and range of motion play only a minor role in treating AC joint osteoarthritis itself, though they remain important for overall shoulder function 3
• Imaging findings may not correlate with symptoms: AC joint osteoarthritis is frequently seen on imaging, especially in elderly patients, but may have poor correlation with the clinical picture 4
• Proper radiographic views are essential: Ensure AP views in internal and external rotation plus an axillary or scapular-Y view were obtained, as AC joint pathology can be missed on AP views alone 1, 2