Nonoperative Management of Traumatic Acromioclavicular Joint Injury: A Clinical Commentary with Clinical Practice Considerations

Abstract

Traumatic injuries of the acromioclavicular joint result in pain and potentially long-term alterations in scapulohumeral rhythm that occurs due to disruption of the clavicular strut function which is integral to scapular kinematics. Nonoperative treatment remains a valid option in most acromioclavicular joint injuries with the potential of minimizing pain and restoring scapulohumeral rhythm. However, few studies have provided nonoperative treatment details. Therefore, the purpose of this clinical commentary is to discuss the rationale, indications, and techniques of nonoperative treatment and present an organized approach for evaluating and managing such patients based on the best available evidence. Attention will be focused on identifying the treatment methods employed and the results/outcomes of such treatments. Level of Evidence 5

Acromioclavicular joint injuries revisited: Pathoanatomy, pathomechanics, and clinical presentation

“…Periscapular strengthening may be helpful, but optimal muscle function demands joint stability and clavicular strut function in order to be effective. 15,18…”

“…A recent systematic review of the literature disseminated information specific to non-operative AC joint treatment, noting that the literature has not been helpful in guiding clinicians on how to best manage AC joint injury conservatively. 18 The review identified numerous concerns including low quality critical appraisal evidence as well as methodological inconsistencies within (robust detail for operative measures and limited to non-existent detail for non-operative measures) and between studies (injury heterogeneity, surgical technique variations, and variations in outcome measures). The authors recommended an approach to treatment focused on restoring dynamic function rather than cosmetic realignment.…”

“…Periscapular strengthening may be helpful, but optimal muscle function demands joint stability and clavicular strut function in order to be effective. 15,18 Based on these concepts, a classification method of the spectrum of AC joint injury can be created that is based on the 3-dimensional pathomechanics of AC joint injury that can be observed and clinically and radiographically evaluated: 'low grade' injury, defined as a stable scapula with preserved biomechanics and SHR, relatively normal radiographs, and no clinical evidence of scapular dyskinesis; and 'high grade' injury, defined as an unstable protracted scapula, with altered biomechanics and SHR, altered appearance on radiographs and evidence of scapular dyskinesis; the latter subtype is less amendable to nonoperative care (Table 1).…”

“…The approach advocates using symptom control initially then progressing to a kinetic chain-based treatment program (Table 2). 18 This framework addresses the SHR component of shoulder function by attempting to keep symptoms from being exacerbated while simultaenously utilizing more motor control principles compared to traditional strengthening principles. 35 It should be noted that the literature to date has found that: 1) non-operative treatment often permits earlier improvements in subjective outcomes, but no differences occurring at long-term follow-up after 6 months [36][37][38][39][40][41][42][43][44][45][46] ; 2) operative treatment results in better joint reduction 36,38,41,45,47,48 ; and 3) non-operative treatments can result in faster return to activities, but residual symptoms such as pain and joint instability may persist.…”

“…The approach advocates using symptom control initially then progressing to a kinetic chain-based treatment program (Table 2). 18 This framework addresses the SHR component of shoulder function by attempting to keep symptoms from being exacerbated while simultaenously utilizing more motor control principles compared to traditional strengthening principles. 35…”