What is the appropriate management for acromioclavicular joint osteoarthritis?

Management of Acromioclavicular Joint Osteoarthritis

Begin with conservative management including oral NSAIDs or acetaminophen, activity modification, and diagnostic/therapeutic corticosteroid injection into the AC joint; if symptoms persist after 6 months of conservative treatment, proceed to arthroscopic or open distal clavicle excision. 1, 2, 3

Initial Conservative Management (First 6 Months)

Pharmacological Treatment

• Start with oral NSAIDs at the lowest effective dose for the shortest duration, considering cardiovascular and gastrointestinal risks 4, 1
• Acetaminophen (up to 3,000-4,000 mg/day) serves as an alternative when NSAIDs are contraindicated 5, 1
• Add gastroprotection with a proton pump inhibitor if the patient has high gastrointestinal risk 6

Activity Modification

• Avoid overhead activities and movements that provoke AC joint pain (cross-body adduction, reaching across the body) 1
• Modify work and recreational activities that load the AC joint 1

Diagnostic and Therapeutic Injection

• Perform a diagnostic local anesthetic injection into the AC joint to confirm the pain source 1, 2
• If diagnostic injection provides relief, proceed with corticosteroid injection for short-term pain relief (typically lasting weeks to months) 1, 2
• Limit corticosteroid injections to 3-4 per year 5
• Important caveat: Corticosteroid injections do not alter disease progression and provide only temporary symptom relief 1

Physical Therapy Limitations

• Physical therapy plays only a minor role in AC joint osteoarthritis, unlike other shoulder pathology 1
• Therapeutic exercise and range of motion have limited benefit for isolated AC joint arthritis 1
• One study comparing physiotherapy versus surgery showed surgery was more effective 3

Surgical Management (After 6 Months of Failed Conservative Treatment)

Indications for Surgery

• Persistent pain and disability after minimum 6 months of conservative treatment 1, 2, 3
• Failed response to NSAIDs, activity modification, and corticosteroid injections 1, 2

Surgical Options

• Both arthroscopic and open distal clavicle excision (DCE) are equally effective with no significant difference in patient satisfaction or complication rates 2, 7, 3
• Resect 0.5 to 2 cm of distal clavicle for optimal outcomes 3
• Arthroscopic DCE can be performed via direct or indirect (subacromial) approach 2, 7

Surgical Outcomes

• Mean functional outcome scores average 87.8% after DCE 3
• Mean follow-up in surgical studies is 28.5 months 3
• Patients with concomitant rotator cuff tears can undergo simultaneous repair with DCE without compromising outcomes 8, 3

Critical Surgical Considerations

• Avoid excessive clavicular resection to prevent instability 2
• Preserve AC ligaments when possible to maintain joint stability 2
• Use fluoroscopic guidance with Kirschner wire placement to prevent under- or over-resection during arthroscopic procedures 7

Concomitant Rotator Cuff Pathology

• If rotator cuff tear coexists with AC joint arthritis, the decision to perform DCR versus conservative AC joint management depends on symptom severity 8
• Recent evidence shows arthroscopic rotator cuff repair with subacromial decompression alone (conservative AC joint management) is as effective as combined DCR in the short term, with lower cost and fewer potential complications 8
• Consider isolated rotator cuff repair first if AC joint symptoms are mild, reserving DCR for persistent AC joint pain after rotator cuff healing 8

Common Pitfalls

• Do not overlook AC joint pathology when evaluating shoulder pain, as it is frequently neglected in favor of subacromial and glenohumeral sources 1
• Do not rely on radiographs alone; AC joint arthritis is common radiographically but may not be symptomatic—diagnostic injection is essential to confirm clinical relevance 1, 2
• Do not proceed to surgery without adequate conservative trial of at least 6 months 1, 2, 3
• Avoid prolonged oral NSAID use due to cardiovascular and gastrointestinal toxicity 4