ACJ

There are multiple causes of ACJ pain including trauma and degenerative change, symptoms can be traumatic (i.e. falls onto an outstretched hand or sporting injuries results in sprains and dislocation of the ACJ) or atraumatic (gradual insidious onset normally related to OA changes or chronic muscle imbalance issues)

Most common cause of ACJ pain is Osteoarthritic changes.
Magnetic resonance imaging scan showing a torn acromioclavicular joint intraarticular disc with effusion in the joint

Subjective Assessment

Patients will report specific pain local to the tip of the acromion, although they can more rarely present with pain radiating into the deltoid.
Sleep may be disturbed by pain and patients are often unable to lie on either side secondary to pain.
Symptoms can be present in varied population groups with OA related ACJ pain more common in patients over 50 but traumatic incidences and postural related problems can occur at any age. There is no increased frequency dependent on sex.
Can be a common problem in office and desk workers due to poor postural habits and muscle imbalances around the shoulder.
May also be more common in people who do a lot of overhead activity such as plasterers, and athletes i.e. cricketers, tennis players and swimmers.

Objective Assessment

Localised swelling at the ACJ may be witnessed
With traumatic injuries the ACJ may appear raised or more prominent and this may imply a dislocation injury.
Patients will present with reduced Active range of movement (AROM) at the shoulder, more commonly at the end range of movement in all directions with degenerative change, but the reduction can be global and significant particularly with traumatic incidents. They will normally also have reduced Passive range of movement (PROM) at the shoulder.
Often aggravated in impingement positions including tasks such as brushing hair, reaching behind their back and reaching forward with a twist.
Patients may report their symptoms being specifically aggravated by reaching across the body.
They will be painful on palpation of the tip of the acromion.

Management

If a history of trauma increased bony prominence at the ACJ and significant reduction in AROM at the shoulder a dislocation or fracture may be suspected – in this incidence patients should be directed to A+E and will be X-rayed to assess for these complaints.
Patients may also describe the recent onset of a painful clicking from the joint if there is instability.
Treatment will include advice re: activity modification, ice application, analgesia normally including anti-inflammatories and early referral to Physiotherapy to prevent abnormal muscle patterning secondary to pain.
If no evidence of trauma, or no fractures or significant dislocations evidenced (normally less than a grade 4 sprain of the ACJ ligaments) the patient will be managed conservatively with Physiotherapy intervention and should be referred early into their symptoms to prevent further deterioration in their function and mobility.
Physiotherapy treatment may involve taping techniques, specific exercises to improve AROM and muscle patterning, pacing advice and possible use of acupuncture.
In severe cases should patients fail to respond to 6 months of conservative management via Physiotherapy the Physiotherapist will refer on to
Orthopaedics for further investigation and possible invasive treatments which may include:
Intra-articular corticosteroid injection to improve symptom management and aid progress with rehabilitation
ACJ stabilisation Surgery – this may be considered when there is a history of trauma and evidence of instability implying a complete rupture of the acromioclavicular ligament and or the coracoacromial ligament.
With OA changes an arthroscopic ACJ excision may also be considered
As with most surgical interventions of the Shoulder the recovery period for these procedures can be painful and lengthy and the patient should be made aware of the need for rehab post operatively to return to their normal activities without complications