AC Separation >> Treatment

How is an acromioclavicular separation treated?

The treatment of an AC separation depends on the grade of the injury. The classification helps the physician choose the correct treatment approach. Grades I - III are usually treated non-operatively. The vast majority of patients will have a period of discomfort. Once this discomfort disappears, the shoulder is usually fully functional, although the patient may still have a minor cosmetic defect at the injury site.

Some patients with grade III AC separations may be candidates for early surgical reconstruction. A discussion between the physician and patient should focus on the patient's expectations and possible return to sports. Many surgeons prefer to first treat the AC separation conservatively. If grade III patients develop problems or do not heal properly surgical reconstruction is an option. (Conservative and surgical treatment for grades I - III have essentially the same results after 1 year.)

Non-Operative Treatment

Most Grade I - III AC separations are treated successfully with non-operative treatment that may include:

ice to reduce pain and swelling.

rest and a protective sling until pain subsides. This usually takes about 1-2 weeks.

pain and anti-inflammatory medications.

A rehabilitation program to restore normal motion and strength is begun as soon as tolerated with gentle exercises and progresses as healing allows.

Depending on the grade of injury, most patients heal within 2 to 3 months without surgical intervention. The patient is allowed to return to sports when there is full and painless range of motion, no more tenderness when the AC joint is touched, and manual traction does not cause pain. This usually takes about 2 weeks for a grade I injury, 6 weeks for a grade II injury, and up to 12 weeks for a grade III injury.

Operative Treatment

Surgery may be necessary for AC separations that do not respond well to non-operative treatment. If, after 2 to 3 months, pain continues in the AC joint with overhead activity or in contact sports, surgery may be necessary. There are some physicians who offer early surgery for a select group of Grade III AC separations based upon the activities and demands these patients place upon the shoulder.
These patients include:

young, active individuals (over the age of 13).
laborers whose jobs require heavy overhead work.
athletes in non-contact sports whose overhead movements are stressful and frequent.

A variety of surgical methods have been used to stabilize a separated AC joint. The surgical technique most often performed involves the reconstruction of the coracoclavicular ligaments and the excising (removal) of the distal (shoulder) end of the clavicle. Distal clavicle resection without the repair of the ligaments may lead to excessive rotation of the scapula. Reconstruction studies show that the AC joint can be adequately stabilized by :

a fixation across the acromioclavicular space with pins or plates.
loop fixation from the clavicle to the coracoid process using synthetic materials.
The most common reconstructive procedures today use a screw or suture loop to stabilize the joint.

In a distal clavicle resection, about 10-15mm of the clavicle is removed through a two-inch incision above the joint. The AC ligament is then transferred from the bottom of the acromion into the cut end of the clavicle to replace the torn ligament.

What types of complications may occur?

Complications of AC joint injuries are persistent instability of the shoulder girdle or residual pain with activity. These complications can be present with either non-operative treatment or operative treatment. Failure of the acromioclavicular ligament and coracoclavicular ligaments to heal can lead to pain and a sense of instability with overhead activity. If the end of the clavicle remains unstable because of lack of scarring, contact sports or overhead tasks may be painful.

Other complications associated with the reconstruction of the AC or CC ligaments are related to hardware failure. Fixation of the clavicle to the coracoid process is difficult because of the rotation of the clavicle with all overhead activity. The screws used to fix these two bones together can pull out if the patient does not wear a sling after surgery as instructed.

Most surgeons today will securely fix the clavicle to the coracoid with dissolvable sutures or with a screw that is removed at about three months.