What is the initial management for a patient with a low-grade AC joint injury presenting with minimal elevation of the distal clavicle with respect to the acromion?

Initial Management of Low-Grade AC Joint Injury

For a patient with a low-grade AC joint injury (Type I-II) presenting with minimal elevation of the distal clavicle, initial management should be conservative with sling immobilization for comfort (typically less than 1-2 weeks), followed by early range of motion exercises and progressive rehabilitation. 1, 2

Conservative Management Protocol

Immediate Phase (First 1-2 Weeks)

• Sling immobilization for comfort only, not for strict immobilization, as prolonged sling use can lead to stiffness 1, 2
• Pain control with NSAIDs and ice application to reduce inflammation 2
• Avoid overhead activities and cross-body movements that stress the AC joint during the acute phase 2

Early Rehabilitation Phase (Weeks 2-6)

• Begin gentle range of motion exercises once acute pain subsides, focusing initially on pendulum exercises and passive motion 2
• Progress to active-assisted range of motion in all planes, avoiding painful arcs 2
• Initiate periscapular and rotator cuff strengthening once pain-free motion is achieved 3, 2
• Avoid the cross-arm maneuver during examination and rehabilitation, as this stresses the AC joint and can exacerbate symptoms 4

Progressive Strengthening Phase (Weeks 6-12)

• Advance to resistive exercises for the rotator cuff, deltoid, and scapular stabilizers 2
• Incorporate sport-specific or occupation-specific movements gradually as strength improves 2
• Return to full activity is typically achieved by 6-12 weeks for Type I injuries and 6-16 weeks for Type II injuries 2

Key Clinical Considerations

Imaging Requirements

• Standard three-view radiographs (anteroposterior in internal and external rotation, plus axillary or scapular-Y view) are sufficient for initial evaluation 3
• Stress radiographs are typically normal in Type I injuries and may show minimal widening in Type II injuries 4
• Advanced imaging (MRI) is not routinely indicated for low-grade AC joint injuries unless there is concern for concomitant rotator cuff pathology or failure of conservative management 3

Expected Outcomes

• Type I and II injuries respond well to conservative management in the vast majority of cases, with patients returning to full activity without deficits 1, 2
• Anatomic reduction is not necessary for good functional outcomes; there is no correlation between radiographic reduction and improvement in pain, strength, or motion 1
• Long-term symptoms are manageable without surgical intervention, though some patients may develop degenerative changes requiring steroid injection or distal clavicle excision years later 1

Common Pitfalls to Avoid

• Prolonged immobilization beyond 1-2 weeks leads to unnecessary stiffness and delayed recovery 2
• Premature return to overhead or contact activities before adequate strength restoration can result in persistent pain 2
• Rushing to surgery for Type III injuries is not supported by evidence; even overhead athletes and manual laborers should initially be treated conservatively 1
• Underestimating the importance of rehabilitation is a common error; emphasis on progressive strengthening is critical for optimal outcomes 1, 2

When to Consider Alternative Management

• Failure of conservative management after 3-6 months of appropriate rehabilitation may warrant consideration of distal clavicle excision 1, 5
• Persistent pain with activities of daily living despite adequate conservative treatment may benefit from corticosteroid injection into the AC joint 1
• Development of symptomatic AC joint arthritis can be managed with arthroscopic or open distal clavicle resection 5