Acromioclavicular Joint Disorders

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Original Editors - Mathilde De Dobbeleer

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Search Strategy

Databases searched: Pubmed, Pedro and Web of Knowledge

Keywords searched: Acromioclavicular Joint, Physiotherapy, Treatment, Examination, Dysfunction

Definition/Description

The term 'disorders' includes several aspects, it's a very generalized term. It can be caused by a trauma (for example joint dislocation) of the acromioclavicular joint or some degenerative conditions (for example osteoarthritis).  ( level of evidence A1)

Clinically Relevant Anatomy

The acromioclavicular joint is a diarthrodial joint that connect the clavicle with the acromion. It is characterized by the various angles of inclination in the sagittal and coronal planes and by a discus. The acromioclavicular joint is surrounded by a capsule and the anterior/posterior AC joints and the superior/inferior AC joints. Also the coracoclavicular ligaments (trapezoid and conoid) are important for the stabilization.

Epidemiology /Etiology

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Characteristics/Clinical Presentation

First something about a disorder caused by a trauma. Acromioclavicular injuries are frequent in contact sports: in American football, rugby and ice hockey but also by alpine skiing, snowboarding and bicycling.   AC -joints often occur when falling on the shoulder, collision whit another player or while being tackled. During the fall will the shoulder hit the ground and the scapulae will be pushed down. The clavicle can only partially follow this movement and there will be a great deal of strain on the ligaments causing them to rupture or dislocation due to market.

Important to know is that when someone fall on the ground, not only the acromioclavicular joint can be injured, also other structures can be involved. Most dislocations are situated in the Glenohumeral_Joint and 90% of this dislocations are anterior what can caused some concomitant pathologies such as a Hill sachs lesion, injury of the brachial plexus...
(level of evidence B)

The acromioclavicular joint injuries are divided into three groups, this classification is the most common:
o Type I: In a type I is a partial injury to the joint capsule. Paired whit an incomplete tear of the acromioclavicular ligaments and joint capsule. 
o Type II: A type II injury is a moderate injury. A partial tear of the ligament coracoclavicular (ligament between coracoideus and clavicle) with a rupture of the capsule and the acromioclavicular ligament. Often described as a subluxation.
o Type III: A type III injury is a severe injury. Complete rupture of the acromioclavicular ligament but also the coracoclavicular ligament. This can lead to displacement of the clavicle and are therefore very unstable. 
This is often described as a dislocation.

Type III dislocation problems, which are very complex and therefore further divided into 3.
o Type IV: Dislocation with posterior dislocation of the clavicle. 
o Type V: Dislocation whit severe upward displacement of the clavicle into or through the Trapezius.
o Type VI: This is a rare injury. Dislocation of the clavicle inferiorly, locked under the coracoids process.
Rockwood classification

Differential Diagnosis

Most common complaints are often pain, numbness and swelling in the AC joint. In type I lesions are swelling and pain the most common, especially in the abduction of the arm.
In type II injuries may be a moderate to severe pain caused and each movement of the arm can pain create. From Type III injuries are in addition to these symptoms are also very pronounced deformations occur. In these types will be clearly felt that the clavicle can move. The displacement of the clavicle can be better seen in adduction of both arms. Also the different shoulder movements will be greatly reduced.

Diagnostic Procedures

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Outcome Measures

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Examination

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Medical Management

The treatment of injuries of the AC joint will vary depending on the severity or degree of the injury. The first treatment that is best used is ice application within 24 hours to 48 hours and anti-inflammatories. Also used is a atella that is tied to the shoulder, but a high quality atella should be used which unable the patient to use arm holding the arm against the abdomen(add illustration), this will provide a temporary but strict immobilization. For large dislocations (type IV –VI) when the clavicle has shifted is a surgery necessary.

In a type III lesion and a severe dislocation, there is sometimes a surgical procedure needed. For example with a screw for the stabilization of clavicle to the processus coracoideus. First a sling or brace will be applied for 2 a 3 week. After removing the brace, a physiotherapeutic treatment can beginning.

Physical Therapy Management

The distinction between treatment for type I and type II lies in the speed of rehabilitation. The rehabilitation is often longer when you have a type II injury but the rehabilitation is the same for type I. After the application of ice and anti-inflammatory products it is important to start as soon as possible with mobilization and active exercises. Active exercises like moving the fingers, wrist and elbow to prevent stiffness. After that you can begin with more targeted shoulder exercises. When the pain is reduced and mobility promoted you can start strengthening exercises.

Key Research

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Resources

1. Gloria M. Beim, MD, ‘Acromioclavicular joint injuries’, Journal of Athletic Training, 2000, p.261- 267

2. A Lizaur, L Marco, R cebrian,’Acute dislocation of the arcomioclavicular joint’, Journal of Bone and Joint Surgery, 1994, p.602-606 

3. K Takase, K Yamamoto, A Imakiire, ‘Therapeutic result of acromioclavicular joint dislocation complicated by rotator cuff tear’, Journal of Orthopaedic Surgery, 2004, p.96-101

4. Cem Zeki ESENYEL, Kahraman ÖZTÜRK, etal., ‘Coracoclavicular ligament repair and screw fixation in acromioclavicular dislocations’, Acta Orthop Traumatol Turc, 2009, p.194 -198

Clinical Bottom Line

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Recent Related Research (from Pubmed)

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References

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1. J. Codsi, M.,' the painful shoulder: when to inject and when to refer', Cleveland clinic journal of medicine, VOL. 74 (2007), July, nr7, p.473-482 (level of evidence 1A)
2. Ewout Heijmans, Just Eekhof, Arie Knuistingh Neven, Acromioclaviculaire luxatie, huisarts & wetenschap, november 2010(level of evidence 1A)
3. Gloria M. Beim, MD, ‘Acromioclavicular joint injuries’, Journal of Athletic Training, 2000, p.261- 267 (level of evidence 2A)
4. Johansen JA, Grutter PW, McFarland EG, Petersen SA. Acromioclavicular joint injuries: indications for treatment and treatment options. J Shoulder Elbow Surg. 2011;20 p.S70-82 (level of evidence 2A)
5. Lisa B Culp and William A Romani, Physical Therapist Examination, Evaluation, and Intervention Following the Surgical Reconstruction of a Grade III Acromioclavicular Joint Separation, journal of the American physical therapy association. 2006; 86:857-869.( level of evidence 3B)
6. Rockwood CA Jr, Young DC. Disorders of the acromioclavicular joint. In: Rockwood CA Jr, Matsen FA Hi, eds. The Shoulder. Philadelphia, PA: WB Saunders; 1990:413-476.
7. V. Nepola, J., E. Newhouse, K., 'Recurrent shoulder dislocation', The iowa orthopaedic journal, VOL. 13 (1993), p. 97-106 (level of evidence 2A)
8. Lizaur A, Sanz-Reig J, Gonzalez-Parreño S. Long-term results of the surgical treatment of type III acromioclavicular dislocations: an update of a previous report. J Bone Joint Surg Br. 2011;93(8)p.1088-1092 (level of evidence 3B)
9. Jennifer M. Hootman. Acromioclavicular Dislocation: Conservative or Surgical Therapy. Athl Train. 2004; 39(1). p 10–11. (level of evidence 2A)
10. Gstettner C, Tauber M, Hitzl W, Resch H. Rockwood type III acromioclavicular dislocation: surgical versus conservative treatment. J Shoulder Elbow Surg. 2008;17(2), p.220-225. (level of evidence 2A)
11. Bannister GC, Wallace WA, Stableforth PG, Hutson MA.The management of acute acromioclavicular dislocation. A randomised prospective controlled trial. Bone Joint Surg Br. 1989;71(5)p.848-850. (level of evidence 1B)
12. Glick JM, Milburn LJ, Haggerty JF, Nishimoto D. Dislocated acromioclavicular joint: follow-up study of 35 unreduced acromioclavicular dislocations. Am J Sports Med 1977;5:264-70. doi:10.1177/ 036354657700500614
(hyperlink: http://www.deepdyve.com/lp/sage/dislocated-acromioclavicular-joint-follow-up-study-of-35-unreduced-68pKcCF6qC )