- Discussion: 
- patients may note pain with activities that occur in adduction (golf back swing);
- Clinical Findings:
- local tenderness to palpation and to hyper-adduction;
- trapezial spasm;
- patients will often note pain located posterior to the AC joint;
- steroid-lidocaine injection:
- remember that AC joint injections are often a difficult "stick" and are often painful;
- if the diagnosis is in question, consider a subacromial lidocaine-steroid injection on the initial patient visit;
- if the patient recieves good pain relief from the subacromial injection, then AC joint arthrosis is probably not the patient's primary problem;
- if the patient does not receive relief from the subacromial injection, then AC joint arthrosis is a more likely diagnosis;
- references:
- Diagnostic value of physical tests for isolated chronic acromioclavicular lesions
- Diagnostic values of tests for acromioclavicular joint pain.
- Therapeutic efficacy of corticosteroid injections in the acromioclavicular joint.
- The active compression test: a new and effective test for diagnosing labral tears and acromioclavicular joint abnormality.
- cautions:
- be sure to consider a slap tear or biceps tendonitis in the differential diagnosis;
- references: The SLAP lesion: A cause of failure after distal clavicle
resection
- Radiographs: (Zanca view):
- AC joint subluxation;
- narrowing of the joint space w/ sclerosis of distal end of the clavicle;
- inferior osteophytes;
- in some cases distal clavicular resorption may be present, which might indicate RA, scleroderma, or which may occur in weight lifters);
- MRI:
- reactive bone edema on MRI is most reliable predictor of symptomatic AC pathology than degenerative changes seen on MRI
- other findings include caudal osteophytes, capsular hypertrophy, and subchondral cysts;
- in the study by Stein et al, the authors sought to detection of AC joint pathology in asymptomatic shoulders with magnetic resonance imaging;
- ACJ arthritic changes were graded on a scale from 1 to 4 (none, mild, moderate, and severe), based on the amount of subacromial fat effacement, joint
space narrowing, irregularity, capsular distension, and osteophyte formation;
- 41 (82%) of 50 shoulders had abnormalities consistent with arthritis on MRI;
- A comparison of magnetic resonance imaging findings of the acromioclavicular joint in symptomatic versus asymptomatic patients.
- Atraumatic osteolysis of the distal clavicle: MR findings
- Detection of acromioclavicular joint pathology in asymptomatic shoulders with magnetic resonance imaging.
- A comparison of magnetic resonance imaging findings of the acromioclavicular joint in symptomatic versus asymptomatic patients.
- Increased T2 signal intensity in the distal clavicle: incidence and clinical implications.
- MRI features of the acromioclavicular joint that predict pain relief from intraarticular injection.
- Indications For Excision:
- pts w/ incomplete AC separation (type I & II) who develop degenerative changes & persistant symptoms may require excision of distal clavicle;
- references:
- The influence of distal clavicle resection and rotator cuff repair on the effectiveness of anterior acromioplasty.
- The management of acromioclavicular joint osteoarthrosis: débride, resect, or leave it alone.
- Contra-indications:
- it is inappropriate to excise the distal clavicle in chronic type III, IV, V or VI AC separations;
- this may increase the patients symptoms, by converting a displaced long clavicle, into a short displaced clavicle;
- references:
- Arthroscopic resection of the distal clavicle with a superior approach
- Surgical Technique:
- Subacromial Decrompression
- Open Clavicle Excision: Surgical Technique:
- Distal clavicular excision: a detailed functional assessment
- The results of operative resection of the lateral end of the clavicle.
- Resection of the lateral end of the clavicle. A 3 to 30-year follow-up
- Arthroscopic Excision:
- acromioclavicular joint is identified with an 18-gauge spinal needle passed from above the joint
- need to visualize the superior aspect of the joint because of the overhanging acromion (which is difficult even after acromioplasty)
- anterior portal is modified to come in directly perpendicular to the AC joint;
- soft-tissue shaver was used to remove all fibrous tissue from the medial border of the acromion and acromioclavicular joint region;
- burr is used to gently remove the inferomedial edge of the acromion and the associated joint capsule
- arthroscope is introduced into the bursa from the lateral portal (allows more direct view of the acromioclavicular joint region);
- manually depress distal aspect of clavicle during resection inorder to optimize exposure;
- outline the tip of the clavicle frequently with a cautery device as the clavicle is being resected medially (to address periosteal vessels);
- power burr is introduced from the posterior portal, and resection of the acromioclavicular joint and distal clavicle
- degree of distal clavicle excision - only requires 5-6 mm of distal excision;
- ref: Arthroscopic distal clavicle resection: a biomechanical analysis of resection length and joint compliance in a cadaveric model.
- references:
- Arthroscopic distal clavicle excision. Technique and early results.
- Our technique for the arthroscopic Mumford procedure.
- Arthroscopic versus open acromioplasty: a prospective, randomized, blinded study
- Arthroscopic resection of the distal aspect of the clavicle with concomitant subacromial decompression.
- Arthroscopic versus open distal clavicle excision: comparative results at six months and one year from a randomized, prospective clinical trial.
- Arthroscopic distal clavicle resection from a bursal approach.
- Long-term results of arthroscopic resection of the distal clavicle with concomitant subacromial decompression.
- Incidence of acromioclavicular joint complications after arthroscopic subacromial decompression.
- Coplaning of the AC joint:
- references:
- Coplaning of the acromioclavicular joint.
- Long-term results of acromioclavicular joint coplaning.
- Midterm results of arthroscopic co-planing of the acromioclavicular joint.
- Long-term Results of Acromioclavicular Joint Coplaning.
- Acromioclavicular stability: a biomechanical comparison of acromioplasty to acromioplasty with coplaning of the distal clavicle.
- Modified Weaver Dunn Procedure:
- Complications:
- lateral elevation of the clavicle:
- lateral elevation is often associated w/ pain;
- references:
- Complications after open distal clavicle excision.
The results of operative resection of the lateral end of the clavicle. A. Eskola MD, JBJS Vol 78-A, No 4, Apr 1996.
Painful conditions of the acromioclavicular joint
