Background
Acromioclavicular (AC) joint injuries are common and often seen after bicycle wrecks, contact sports, and car accidents. The AC joint is located at the top of the shoulder where the acromion process and the clavicle meet to form a joint. Several ligaments surround this joint and depending on the severity of the injury, a person may tear one or all of the ligaments. Torn ligaments lead to AC joint sprains and separations. The distal clavicle and acromion process can also be fractured. Injury to the AC joint may injure the cartilage within the joint and can later cause arthritis of the AC joint. This article discusses the anatomy of the joint, the diagnosis of this condition, and the different treatment options.
Frequency
United States
Injuries to the AC joint are the most common reason that athletes seek medical attention following an acute shoulder injury. Glenohumeral dislocations are the second most common injuries seen. Men in their second through fourth decades of life have the greatest frequency of AC joint injuries. These injuries are most often incomplete tears of the ligaments.
Functional Anatomy
The AC joint is made up of 2 bones (the clavicle and the acromion), 4 ligaments, and a meniscus inside the joint.
- The AC joint is surrounded by a thin joint capsule and 4 small ligaments. These ligaments mostly give joint stability to anterior and posterior translation. They provide the horizontal stability to the joint.
- Another set of ligaments also provides vertical stability to the AC joint. These ligaments are called the coracoclavicular (CC) ligaments. The CC ligaments are found medial to the AC joint and go from the coracoid process on the scapula to the clavicle.
- Different injuries result in different tears of the 2 CC ligaments (the conoid and the trapezoid). Torn AC joint ligaments and/or torn CC ligaments are seen in AC joint sprains. The meniscus that lies in the joint may also be injured during sprains or fractures around the AC joint.
Sport Specific Biomechanics
When a person falls onto their shoulder, the force pushes the tip of the shoulder down. The clavicle is usually kept in its anatomic position while the shoulder is driven down, which injures the different ligaments or causes a fracture. When the ligaments are injured they are either sprained or, in more severe cases, torn.
AC joint sprains have been classified according to their severity. In a type I sprain, a mild force applied to these ligaments does not tear them. The injury simply results in a sprain, which hurts, but the shoulder does not show any gross evidence of an AC joint dislocation. Type II sprains are seen when a heavier force is applied to the shoulder, disrupting the AC ligaments but leaving the CC ligaments intact. When these injuries occur, the lateral clavicle becomes a little more prominent. In type III sprains, the force completely disrupts the AC and CC ligaments. This leads to complete separation of the clavicle and obvious changes in appearance. The lateral clavicle is very prominent. A few more types of AC joint sprains have been classified, but types I - III are the most common.
Treatment
Acromioclavicular (AC) joint injuries are painful and the patient often lacks full range of motion after the injury. Physical therapy plays a role in the treatment of these patients. The author routinely starts therapy within the first couple of weeks in AC joint sprains. For fractures, wait until evidence of healing is apparent either clinically or on radiograph before starting formal therapy. Therapy for degenerative joint disease of the AC joint has not been proven successful. AC joint sprains do well with conservative management. Type I and II injuries never necessitate surgical care to reconstruct the injured ligaments. These injuries may need further care if the AC joint gets arthritic from the injury. Surgical intervention may be an option in type III AC joint sprains, but only after the patient has failed a good trial of conservative treatment with physical therapy and medication. The procedure for these patients is reconstruction of the torn coracoclavicular (CC) ligaments with either local tissue or an allograft. In the past, surgeons have used screws, sutures, suture-tape, synthetic grafts, and K-wires to try to repair the defect. These have all fallen out of favor and the criterion standard is to reconstruct the torn ligaments as mentioned above.Acute Phase
Rehabilitation Program
Physical Therapy
Surgical Intervention
Postoperative CC ligament reconstruction. The clavicle is back to its normal position. The anchor in the clavicle keeps the allograft tendon from coming off of the clavicle. Also note the distal clavicle has been excised because it had traumatic arthritis from the injury.
Fractures in and around the AC joint are mostly treated conservatively in a sling. The few times surgery needs to be considered is for a moderate amount of displacement of the fracture fragments. Surgery is indicated for open fractures, neurovascular injury, and for those in which the skin is compromised and may rupture from the pressure of the prominent bone.
If the athlete has sustained concomitant rib fractures with shortness of breath, good quality chest radiographs are indicated. A consult from a pulmonary physician or cardiovascular chest surgeon may be necessary.Injuries that lead to arthritis of the AC joint are also treated with conservative measures first. Anti-inflammatory medication and intra-articular steroid injections work well for degenerative changes in the AC joint. In patients who failed conservative therapy, excision of the distal clavicle can be performed with a minimally invasive arthroscopic procedure.
Consultations
Medication
Initial treatment of degenerative arthritis of the acromioclavicular (AC) joint may include the use of nonsteroidal anti-inflammatory drugs (NSAIDs) along with occasional corticosteroid injections.
Drug Category: NSAIDs
Have analgesic, anti-inflammatory, and antipyretic activities. Their mechanism of action is not known, but they may inhibit cyclo-oxygenase activity and prostaglandin synthesis. Other mechanisms may exist as well, such as inhibition of leukotriene synthesis, lysosomal enzyme release, lipoxygenase activity, neutrophil aggregation, and various cell membrane functions.
| Drug Name | Ibuprofen (Motrin, Ibuprin, Advil) |
|---|---|
| Description | DOC for patients with mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis. |
| Adult Dose | 200-400 mg PO q4-6h while symptoms persist; not to exceed 3.2 g/d |
| Pediatric Dose | 6 months to 12 years: 4-10 mg/kg/dose PO tid/qid >12 years: Administer as in adults |
| Contraindications | Documented hypersensitivity; peptic ulcer disease, recent GI bleeding or perforation, renal insufficiency, or high risk of bleeding |
| Interactions | Coadministration with aspirin increases risk of inducing serious NSAID-related side effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently |
| Pregnancy | B - Usually safe but benefits must outweigh the risks. |
| Precautions | Category D in third trimester of pregnancy; caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in coagulation abnormalities or during anticoagulant therapy |
| Drug Name | Ketoprofen (Oruvail, Actron, Orudis) |
|---|---|
| Description | For relief of mild to moderate pain and inflammation. Small dosages initially are indicated in small and elderly patients and in those with renal or liver disease. Doses exceeding 75 mg do not increase therapeutic effects. Administer high doses with caution, and closely observe patient for response. |
| Adult Dose | 25-50 mg PO q6-8h prn; not to exceed 300 mg/d |
| Pediatric Dose | 3 months to 12 years: 0.1-1 mg/kg PO q6-8h >12 years: Administer as in adults |
| Contraindications | Documented hypersensitivity |
| Interactions | Coadministration with aspirin increases risk of inducing serious NSAID-related side effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently |
| Pregnancy | B - Usually safe but benefits must outweigh the risks. |
| Precautions | Category D in third trimester of pregnancy; caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in coagulation abnormalities or during anticoagulant therapy |
| Drug Name | Naproxen (Naprelan, Anaprox, Naprosyn) |
|---|---|
| Description | For relief of mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing activity of cyclo-oxygenase, which results in a decrease of prostaglandin synthesis. |
| Adult Dose | 500 mg PO followed by 250 mg q6-8h; not to exceed 1.25 g/d |
| Pediatric Dose | <2>2 years: 2.5 mg/kg/dose PO; not to exceed 10 mg/kg/d |
| Contraindications | Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency |
| Interactions | Coadministration with aspirin increases risk of inducing serious NSAID-related side effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently |
| Pregnancy | B - Usually safe but benefits must outweigh the risks. |
| Precautions | Category D in third trimester of pregnancy; acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with preexisting renal disease or compromised renal perfusion risk acute renal failure; leukopenia occurs rarely, is transient, and usually returns to normal during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrants further evaluation and may require discontinuation of the drug |
| Drug Name | Indomethacin (Indocin, Indochron ER) |
|---|---|
| Description | Rapidly absorbed. Metabolism occurs in liver by demethylation, deacetylation, and glucuronide conjugation. Inhibits prostaglandin synthesis. |
| Adult Dose | 25-50 mg PO bid/tid 75 mg SR PO bid; not to exceed 200 mg/d |
| Pediatric Dose | 1-2 mg/kg/d divided PO bid/qid; not to exceed 4 mg/kg/d or 150-200 mg/d |
| Contraindications | Documented hypersensitivity; GI bleeding or renal insufficiency |
| Interactions | Coadministration with aspirin increases risk of inducing serious NSAID-related side effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently |
| Pregnancy | B - Usually safe but benefits must outweigh the risks. |
| Precautions | Category D in third trimester of pregnancy; acute renal insufficiency, hyperkalemia, hyponatremia, interstitial nephritis, and renal papillary necrosis may occur; increases risk of acute renal failure in patients with preexisting renal disease or compromised renal perfusion; reversible leukopenia may occur; discontinue if persistent leukopenia, granulocytopenia, or thrombocytopenia occurs |
| Drug Name | Diclofenac (Voltaren, Cataflam) |
|---|---|
| Description | Inhibits prostaglandin synthesis by decreasing activity of enzyme cyclo-oxygenase, which in turn decreases formation of prostaglandin precursors. |
| Adult Dose | Persistent night pain or morning stiffness: Up to 100 mg hs may help to relieve pain; not to exceed total daily dose of 200 mg |
| Pediatric Dose | >12 years: Administer as in adults <12> |
| Contraindications | Documented hypersensitivity; do not administer into CNS; do not give to patients with peptic ulcer disease, recent GI bleeding or perforation, or renal insufficiency; do not administer to those at high risk of bleeding |
| Interactions | Coadministration with aspirin increases risk of inducing serious NSAID-related side effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently |
| Pregnancy | B - Usually safe but benefits must outweigh the risks. |
| Precautions | Category D in third trimester of pregnancy; acute renal insufficiency, hyperkalemia, hyponatremia, interstitial nephritis, and renal papillary necrosis may occur; increases risk of acute renal failure in patients with preexisting renal disease or compromised renal perfusion; low white blood cell counts occur rarely and usually return to normal in ongoing therapy; discontinuation of therapy may be necessary if persistent leukopenia, granulocytopenia, or thrombocytopenia occurs |
| Drug Name | Sulindac (Clinoril) |
|---|---|
| Description | Decreases activity of cyclo-oxygenase and in turn inhibits prostaglandin synthesis. Results in a decreased formation of inflammatory mediators. |
| Adult Dose | 150-200 mg PO bid or 300-400 qd; not to exceed 400 mg/d |
| Pediatric Dose | Not established |
| Contraindications | Documented hypersensitivity; patients in whom aspirin, iodides, or other NSAIDS induce hypersensitivity; gastrointestinal (GI) bleed; renal insufficiency |
| Interactions | Coadministration with aspirin increases risk of inducing serious NSAID-related side effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently |
| Pregnancy | C - Safety for use during pregnancy has not been established. |
| Precautions | Category D in third trimester of pregnancy; acute renal insufficiency, hyperkalemia, hyponatremia, interstitial nephritis, and renal papillary necrosis may occur; increases risk of acute renal failure in preexisting renal disease or compromised renal perfusion; low white blood cell counts occur rarely and usually return to normal in ongoing therapy; discontinuation of therapy may be necessary if persistent leukopenia, granulocytopenia, or thrombocytopenia occurs; caution in persons with anticoagulation defects or in those receiving anticoagulant therapy |
Drug Category: Corticosteroids
Have anti-inflammatory properties and cause profound and varied metabolic effects. Corticosteroids modify the body's immune response to diverse stimuli.
| Drug Name | Hydrocortisone (Solu-Cortef, Hydrocortone phosphate) |
|---|---|
| Description | Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reversing increased capillary permeability. |
| Adult Dose | Small joints: 10-25 mg intralesional Large joints: 25 mg intralesional |
| Pediatric Dose | Not established |
| Contraindications | Documented hypersensitivity; viral, fungal, or tubercular skin infections |
| Interactions | Corticosteroid clearance may decrease with estrogens; may increase digitalis toxicity secondary to hypokalemia |
| Pregnancy | C - Safety for use during pregnancy has not been established. |
| Precautions | Caution in hyperthyroidism, osteoporosis, peptic ulcer, cirrhosis, nonspecific ulcerative colitis, diabetes, and myasthenia gravis |
| Drug Name | Triamcinolone (Aristospan Intra-Articular, Aristocort Forte, Kenaject-40) |
|---|---|
| Description | For inflammatory dermatosis responsive to steroids. Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reversing capillary permeability. |
| Adult Dose | 2-20 mg intra-articularly q3-4wk |
| Pediatric Dose | Not established |
| Contraindications | Documented hypersensitivity; fungal, viral, and bacterial skin infections |
| Interactions | Coadministration with barbiturates, phenytoin, and rifampin decreases effects of triamcinolone |
| Pregnancy | C - Safety for use during pregnancy has not been established. |
| Precautions | Multiple complications (eg, severe infections, hyperglycemia, edema, osteonecrosis, myopathy, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, myasthenia gravis, growth suppression) may occur; abrupt discontinuation of glucocorticoids may cause adrenal crisis |
RSS Feed (xml)
