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Acromioclavicular joint disorders

Acromioclavicular joint disorders
Literature review current through: Jan 2024.
This topic last updated: Jun 30, 2022.

INTRODUCTION — Acromioclavicular (AC) joint disorders can be classified into acute injuries, repetitive strain injuries, degenerative conditions, and other conditions. The diagnosis of acute AC joint injury (sometimes referred to as a sprain or "separated" shoulder) is often straightforward due to the presence of focal tenderness, swelling, and deformity.

AC joint disorders from overuse, inflammation, or chronic degeneration can be more difficult to diagnose, particularly if concomitant shoulder problems exist. This topic will review the evaluation and management of AC joint disorders. AC joint injuries are discussed separately. (See "Acromioclavicular joint injuries ("separated" shoulder)".)

ANATOMY AND PATHOPHYSIOLOGY — The acromioclavicular (AC) joint unites the distal clavicle and the acromion of the scapula. It contains an intra-articular disc, a synovial membrane, and articular cartilage that cover the distal end of the clavicle and the opposing surface of the acromion [1]. The AC joint is supported by a ligament complex, as well as surrounding fascia and muscles (picture 1). The anatomy and biomechanics of the AC joint are described in greater detail separately. (See "Acromioclavicular joint injuries ("separated" shoulder)", section on 'Anatomy and biomechanics'.)

The AC joint normally degenerates over several decades but in most cases, remains asymptomatic. The joint gradually narrows as the articular disc and chondral cartilage wear away. This degeneration is often more rapid than in other joints, with the articular disc beginning to break down in the second decade of life [1]. By the age of 40, most patients have painless narrowing of the joint space and possibly other degenerative findings [2].

EVALUATION OF THE PAINFUL AC JOINT — The patient with a painful acromioclavicular (AC) joint often complains of focal shoulder pain, and when asked to point to the most painful spot typically indicates the top of the shoulder. However, pain arising from the AC joint may be more generalized since the joint is innervated by branches of both the axillary and lateral pectoral nerves. Symptoms arising from the AC joint may be felt anywhere from the base of the neck and trapezius region to the lateral deltoid [3].

Note that patients with symptoms in the region of the AC joint may have other shoulder conditions or pain referred from the cervical spine, chest, or abdomen. Extraneous sources of pain are listed in the accompanying table (table 1). A general approach to shoulder pain is provided separately. (See "Evaluation of the adult with shoulder complaints".)

History — When evaluating a patient for a possible AC joint disorder, inquire about the onset, duration, quality, and pattern (eg, worse at night) of any discomfort. The patient may describe the classic pattern of pain at the top of the shoulder when their arms are outstretched or moved across their body (eg, reaching for a seat-belt shoulder strap). The pain may be vague, sharp, or grinding, and may awaken the patient at night when they roll onto the affected shoulder. Some patients may try to alleviate their discomfort by avoiding moving their arms across their body.

Inquire about any past or recent trauma. Falls onto the point of the shoulder often lead to AC injury, which is discussed separately. (See "Acromioclavicular joint injuries ("separated" shoulder)".)

Perform a review of symptoms for cervical spine, cardiac, lung, chest wall, or abdominal problems, as well as any symptoms of infection or inflammation around the shoulder. A personal or family history of inflammatory arthritis may be relevant.

Examination — Although the history and location of symptoms may suggest that the AC joint is the most likely source of pain, the clinician must also consider disorders in other parts of the shoulder and elsewhere (eg, pain radiating from the neck). Thus, a complete shoulder examination should be performed, as rotator cuff pathology may mimic or refer symptoms to the AC joint. A systematic approach to the patient with shoulder pain and a more detailed discussion of the shoulder examination are provided separately. Aspects of the examination of particular relevance to AC joint disorders are discussed below. (See "Evaluation of the adult with shoulder complaints".)

Inspection — Observe the AC joint for asymmetry, enlargement, and deformity. Note any swelling, rash, erythema, or atrophy. For a proper examination, both shoulders should be completely exposed. Obvious asymmetric bony deformity suggests an AC joint separation or clavicle fracture. Soft tissue swelling directly over the AC joint may represent the "geyser sign," suggesting a cyst arising from the AC joint that develops following a massive rotator cuff tear [4]. (See "Acromioclavicular joint injuries ("separated" shoulder)" and "Clavicle fractures" and "Presentation and diagnosis of rotator cuff tears".)

Palpation — Careful palpation of the AC joint, particularly along its superior aspect, can help identify the source of pain (picture 2). Direct palpation that elicits focal tenderness at the joint is a sensitive but nonspecific finding [5]. Therefore, an AC joint that is not tender to palpation is unlikely to be the source of pain. Conversely, focal tenderness at the AC joint may be due to pathology within the joint itself or surrounding structures. If an appropriate examination reveals an absence of tenderness or other suggestive clinical findings at other sites at and around the shoulder, AC joint pathology is the likely cause of pain.

Shoulder range of motion — Assess shoulder range of motion (table 2). The patient with a painful AC joint may exhibit limitations in shoulder flexion, cross body adduction, and internal rotation. The patient may be able to reproduce their pain by actively reaching across to put their hand on the opposite shoulder. Include active adduction in the range of motion evaluation of any patient with possible AC joint symptoms.

Neurovascular function — A screening neurovascular examination of the involved upper extremity should be performed. (See "Physical examination of the shoulder", section on 'Neurovascular assessment' and "The detailed neurologic examination in adults".)

Special maneuvers for the AC joint — Many tests for differentiating among painful conditions of the shoulder have been described, but few have been rigorously assessed and of these few have demonstrated diagnostic accuracy [6]. A systematic review of studies of shoulder examination techniques found only three studies that looked specifically at techniques to assess the AC joint, and no technique demonstrated sufficient accuracy to make a diagnosis independent of other data [5,7,8]. A subsequent systematic review found that no combination of examination tests significantly improved the post-test probability of confirming the cause of AC joint pathology [9]. These findings reinforce the importance of taking a careful history and then integrating examination findings and the results of imaging studies when developing a diagnosis. Intra-articular injection of local anesthetic is reported to increase the accuracy of diagnosis when examination is inconclusive [9].

The provocative tests described below, and evaluated in the three studies alluded to above, provide some help when trying to determine whether an AC disorder is responsible for a patient's symptoms. There is limited data on the diagnostic accuracy of combining these tests. We generally make an initial diagnosis based upon a suggestive history combined with focal tenderness at the AC joint and positive provocative maneuvers. The patient's response to treatment, the absence of clear alternative diagnoses, serial evaluations, and ultrasound-guided intra-articular injection can be used to confirm the initial diagnosis. (See 'Diagnostic approach' below.)

Cross body adduction test — To perform the test, the examiner holds the patient's involved arm with the elbow fully extended (straight arm), lifts it to 90 degrees of shoulder flexion while maintaining neutral rotation, and then passively adducts it across the patient's body, thereby compressing the AC joint of the involved arm (picture 3).

Data are limited on the accuracy of this test. In a retrospective study of 35 patients with painful AC joint lesions that were subsequently confirmed surgically, compression of the AC joint by adducting the patient's arm across their body was 77 percent sensitive and 79 percent specific [7]. As an example of the relatively low specificity, patients with rotator cuff tendinopathy may also complain of pain from cross body adduction, particularly if the arm is internally rotated (picture 4). (See "Rotator cuff tendinopathy".)

AC shear testing — Shear force can be applied to the AC joint by simultaneously pushing the scapula from a posterior direction and the clavicle from an anterior direction (picture 5). A one-handed shear test is referred to as the Paxinos test. In this test, the examiner places the thumb on the posterior acromion and fingers on the mid clavicle and tries to squeeze the thumb and fingers together (picture 6). In a prospective observational study of 38 patients who mapped pain within an area bounded by the midpart of the clavicle and the deltoid insertion, the Paxinos text was 79 percent sensitive but nonspecific for pain originating in the AC joint [5].

Active compression test — The active compression test is performed in two parts. The first part consists of holding the patient's affected arm in 90 degrees of shoulder flexion with the elbow fully extended, adducting the arm 10 to 15 degrees, and then internally rotating the arm so the thumb points to the ground. While the patient maintains their arm in this position, the examiner pushes down on the arm while the patient resists (picture 7). In the second part of the test, the patient maintains the same position but now supinates the arm (palm up position). Then the examiner again pushes down on the arm while the patient resists (picture 8). If the test causes pain atop the shoulder, this suggests a disorder of the AC joint; if the test elicits pain or a painful "click" inside the shoulder (glenohumeral joint), this suggests labral pathology.

The efficacy of the active compression test was evaluated in a prospective observational study in which 55 of 62 patients (89 percent) with a positive test preoperatively had AC joint pathology at surgery [8]. There were no false negative results. High specificity (95 percent) was also noted in the retrospective series of 35 patients cited above, but the sensitivity was only 41 percent [7].

Diagnostic imaging

Plain radiographs — Plain radiographs of the AC joint are often abnormal in the adult due to the joint's relatively rapid, natural degeneration. (See 'Anatomy and pathophysiology' above.)

A standard shoulder series (anteroposterior [AP] shoulder, AP glenoid, and scapular Y views (image 1)) may provide adequate information, but an axillary and Zanca view may be needed. The Zanca view is an AP radiograph of the shoulder with 15 to 30 degrees of cephalic tilt such that the image of the AC joint appears above the acromion (picture 9 and image 2) [10]. The shoulder may need to be abducted to obtain the proper position.

Bone scan — A three-phase bone scan can help identify an AC joint disorder [11]. The presence of increased metabolic bone activity increases the likelihood of an actively painful joint. According to one small prospective observational study, the post-test probability of the AC joint being the source of pain is 99 percent when both the Paxinos text and a bone scan are positive, while the combination of a negative Paxinos text and a negative bone scan virtually rules out an AC joint disorder [5]. The Paxinos text is described above. (See 'AC shear testing' above.)

Ultrasound — The AC joint is a superficial structure amenable to evaluation with musculoskeletal ultrasound (US), which can provide useful diagnostic information [12]. As examples, US can be used to identify changes from degenerative joint disease (DJD) as well as Os acromiale (unfused acromial process epiphysis), which occurs in up to 8 percent of patients. The AC joint cysts associated with advanced DJD or massive rotator cuff tears also have classic US findings [4]. Ultrasound guidance improves the accuracy of AC joint injections [13-18]. (See "Musculoskeletal ultrasound of the shoulder".)

Magnetic resonance imaging — Magnetic resonance imaging (MRI) scans provide great detail of AC joint degeneration (image 3). Unfortunately, the degree of abnormality does not correlate well with symptoms and is therefore of limited use in clinical evaluation [11]. If a patient presents with a mixed clinical picture, MRI may be helpful for evaluating other shoulder pathology (eg, rotator cuff tear). MRI may also be helpful for ruling out other pathology before pursuing surgical treatment of an AC joint disorder [19].

Diagnostic injection — Injection of an analgesic (eg, lidocaine) into the AC joint can help to confirm that it is the source of pain [2,11,20]. The technique involves identifying the superior aspect of the joint and then injecting directly into the joint or against the periosteum within a few millimeters of the joint [20]. A radiograph of the region provides a useful reference for positioning and identifying landmarks (eg, osteophyte lateral to the joint) while palpating and injecting (picture 10). Injection accuracy using palpation alone is limited and inferior to injection under ultrasound or fluoroscopic guidance [21-23].

Ultrasound guided injection — The AC joint lies just below the skin and is readily accessible to ultrasound-guided injection, which improves the accuracy of needle positioning within the joint [17,18,21-23]. Using sterile technique, the needle is advanced in the plane of the ultrasound image (picture 11). Once the needle is visualized within the joint, the medication is injected and can be seen flowing into the joint space (image 4). In addition to improved accuracy, ultrasound-guided injection provided greater improvements in symptoms and function for up to six months when compared with injection by palpation in a retrospective study of 100 patients [17].

DIAGNOSTIC APPROACH — For patients in whom the history, examination, and imaging studies suggest acromioclavicular (AC) joint pathology, a trial of conservative management is usually indicated. Pain stemming from AC joint pathology is confirmed by the following:

History consistent with AC joint disorder (see 'History' above)

Tenderness directly over the AC joint without focal tenderness elsewhere.

Pain in the AC joint with provocative maneuvers (we use the cross body adduction test) (see 'Special maneuvers for the AC joint' above)

Absence of pain when shoulder examination maneuvers unrelated to the AC joint are performed.

Abnormal findings in the AC joint on radiographic studies (see 'Diagnostic imaging' above)

Relief of pain with anesthetic injection of the AC joint, preferably performed under ultrasound guidance

If the diagnosis remains in question following the initial evaluation, a trial of medical treatment with serial follow-up examinations is a common approach. Injection of the AC joint or further imaging can provide additional insight. An MRI may be helpful if other shoulder pathology is a concern. Specialist referral is indicated if the diagnosis remains unclear despite this additional workup. The management of specific AC joint disorders is discussed in the following section.

SPECIFIC DISORDERS

Acromioclavicular joint injuries — Acromioclavicular (AC) joint injuries from direct trauma are common and, if moderate to severe, are often referred to as a shoulder "separation." Treatment is based upon the type of injury and is discussed in detail elsewhere. (See "Acromioclavicular joint injuries ("separated" shoulder)".)

Overuse injuries — The AC joint is subject to inflammation from repetitive motion and stress, particularly activities involving an outstretched arm moving across the body. As an example, an athlete may develop AC joint arthralgia after adding overhead lifts or cross-body pulley exercises to a strength training routine. With low grade inflammation, the patient may have mild or moderate symptoms and pain when provocative AC maneuvers are performed, but few or no findings with diagnostic imaging. Treatment with rest, ice, and avoidance of painful activities may be sufficient. Acetaminophen, nonsteroidal antiinflammatory drugs (NSAIDs), and postural exercises may help allow the joint to heal. For athletes and workers with more demanding activities, physical therapy to adjust posture and techniques can be helpful.

Osteolysis of the distal clavicle — Osteolysis (ie, resorption of bone) of the distal clavicle is not common but can occur with overload of the AC joint from repetitive activity, and less commonly following direct trauma [24,25]. It develops most often in weight-lifters or other athletes who regularly perform heavy bench presses or military presses over many months or years, but can also occur in overhead athletes (eg, tennis players, swimmers) and workers [24,26].

Examination findings include tenderness over the distal clavicle and AC joint. Provocative tests for AC disorders often reproduce the pain. (See 'Special maneuvers for the AC joint' above.)

Patients may have radiographic evidence of osteolysis. Early radiographic findings include bone loss or subchondral cyst formation at the distal clavicle. As the condition progresses, varying degrees of focal osteoporosis, loss of bone detail, and more severe cystic changes are seen. If stress continues unabated, the entire distal third of the clavicle may show signs of bone resorption (image 5 and image 6).

The clinical evaluation combined with a suggestive radiograph is generally sufficient to make the diagnosis, and the patient can be followed clinically. Further imaging can be obtained if the patient does not respond to treatment or has atypical clinical features. The diagnosis can be confirmed with a positive bone scan [24] or bone marrow edema on MRI (image 7) [26], which has the advantage of assessing other structures in the shoulder.

Treatment consists of ice, over-the-counter analgesics, and rest from the offending activity. Technique changes, such as scapular retraction and a wide grip when performing the bench press may help to decrease the stress on the AC joint, but such interventions have not been formally studied. A glucocorticoid injection in combination with a rehabilitation program may allow an in-season athlete to tolerate symptoms and defer long-term treatment until after the season [26].

If a patient has ongoing pain despite conservative therapy or is unable or unwilling to decrease activity, resection of the distal clavicle successfully treats most cases of osteolysis [24,27,28]. One case series reported good results at seven year follow-up in all 19 patients treated with distal clavicle resection for nontraumatic osteolysis, and 14 were able to return to weight training and sports [24].

Painful degeneration of the AC joint — The AC joint typically degenerates more rapidly than most other joints in the body. Radiographic signs of degeneration are often present in asymptomatic individuals in their mid-40s. However, less than 5 percent of the population develops a painful AC joint [20]. The term AC joint arthrosis refers to asymptomatic joints with radiographic evidence of degeneration [2].

Degeneration is described radiographically using the typical findings of osteoarthritis, including joint space narrowing, subchondral sclerosis, subchondral cyst formation, and osteophyte formation. Such findings may develop more rapidly following trauma or repetitive stress. The progression of AC arthrosis or arthritis is readily seen on serial radiographs or MRI imaging (image 8 and image 9). Some authors differentiate post-traumatic and primary osteoarthritis, but management is similar [11].

In cases of symptomatic AC degeneration, pain may extend over the AC joint, deltoid, or trapezius areas, and often worsens with activities involving overhead or cross body movement of the arm. The patient may experience a painful grinding around the joint. Examination findings include palpable enlargement of the joint and reproduction of pain with provocative maneuvers. The severity of a patient's symptoms may not correlate with the extent of radiographic changes.

Treatment of painful AC joint degeneration begins with activity modification, rest, ice, and over-the-counter analgesics. Exercises to improve strength, postural control, and scapular retraction may be useful.

Injection with glucocorticoids may help some patients by providing short-term pain relief of acute flares but is unlikely to alter the long-term course of AC joint arthritis. Uncontrolled observational studies suggest that relief from injections is variable. In a retrospective study of patients with isolated, painful AC joint degeneration, 25 of 27 patients had short-term improvement of pain lasting an average of 21 days following glucocorticoid injection [29]. However, 18 of the 27 patients ultimately required distal clavicle resection due to persistent pain. Better outcomes were noted in a prospective study of the long-term effectiveness of AC injections for osteoarthritis in 25 shoulders in 20 consecutive patients: improvement in pain and functioning persisted at 6 and 12 months but tended to diminish over the longer term out to five years [30].

Conservative nonsurgical and surgical management both appear to produce good long-term outcomes, but randomized trials have not been completed [31]. According to observational studies, distal clavicle resection for painful AC joint degeneration provides good to excellent results in most patients [11,27,28,31]. A complete evaluation and diagnostic injection test should be performed prior to surgery, preferably by the surgeon. A major reason for poor outcomes after distal clavicle resection is persistent pain from other shoulder pathology. A preoperative MRI or intraoperative arthroscopic evaluation of the rotator cuff and labrum can help to identify other sources of pain and possibly prevent this complication [19,32]. Arthroscopic resection allows a faster return to activities compared with open surgical resection, with both approaches providing good long-term success [27,31]. In addition to surgical risks, instability of the AC joint is an uncommon complication of surgical management [31].

Other conditions — Since the AC joint is a synovial joint, it may develop inflammatory or septic arthritis [33]. Two-thirds of rheumatoid arthritis patients develop AC joint involvement in their lifetime [34]. Infections, tumors, cysts, and other conditions may develop in and around the joint and cause pain. The accompanying table lists other conditions that may affect the AC joint (table 3).

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Shoulder soft tissue injuries (including rotator cuff)".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

Basics topic (see "Patient education: Separated shoulder (The Basics)")

Beyond the Basics topics (see "Patient education: Acromioclavicular joint injury (shoulder separation) (Beyond the Basics)" and "Patient education: Shoulder impingement syndrome (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

Diagnostic evaluation – Evaluation of the patient with pain around the acromioclavicular (AC) joint not caused by acute trauma involves a careful history and physical examination, along with plain radiographs. No single examination technique is definitive. A suggestive history, focal tenderness at the AC joint, pain with provocative maneuvers (eg, cross body adduction test (picture 3)), and the absence of pain when shoulder examination maneuvers unrelated to the AC joint are performed suggest AC joint pathology. Injection of an analgesic (ideally under ultrasound guidance) may help to confirm the diagnosis. (See 'Evaluation of the painful AC joint' above and 'Diagnostic approach' above.)

Traumatic injury (eg, “separated” shoulder) – Pain caused by trauma to the AC joint is common. This subject is discussed separately. (See "Acromioclavicular joint injuries ("separated" shoulder)".)

AC arthralgia – Patients with early AC arthralgia may respond to conservative management, consisting of anti-inflammatory medication, rest, and activity modification. For athletes and workers with more demanding activities, physical therapy is often helpful. (See 'Overuse injuries' above.)

Osteolysis of the distal clavicle – Osteolysis at the AC joint usually occurs in athletes and active patients with a long history of repetitive motion of the shoulder. The condition may respond to rest and activity modification. Surgery is helpful for the majority of patients with persistent symptoms. (See 'Osteolysis of the distal clavicle' above.)

AC joint degeneration – Degeneration of the AC joint is common. However, only a small percentage of those with degenerative arthrosis develop painful osteoarthritis. Initial treatment for painful degeneration consists of ice, over-the-counter analgesics, and activity modification. If persistent, pain may be treated with glucocorticoid injection for short-term relief, but this is unlikely to alter the long-term course. Resection of the distal clavicle is helpful for patients with ongoing pain. (See 'Painful degeneration of the AC joint' above.)

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