Depending on your patient population, you may treat acromioclavicular joint (ACJ) injuries on a daily basis or only on a rare occasion. While the ACJ is often involved in shoulder dysfunction, it may or may not be directly injured. A specific ACJ injury occurs with either a fall (or similar trauma) to the lateral shoulder with the arm adducted or with a FOOSH (fall on outstretched hand) injury. Pain is anatomically localized with this joint as it is primarily located directly over the ACJ.
To test for ACJ injury, first start with observation. ACJ injuries are sometimes palpable/visible with a step-off. The amount of step-off will depend on the severity of injury. As far as our clinical tests go, the Horizontal Adduction Test (the shoulder is adducted and may be elevated simultaneously as well) is preferred as it stresses the ACJ directly. Additionally, an x-ray series of the shoulder is often ordered to assess alignment and rule-out clavicular fractures.
How Do We Classify the Severity of Injury?
If there is no visual deformity (meaning if it is Type I or II), it will most likely be managed conservatively. This incorporates a period of rest and relative immobilization for up to a week before transitioning to protective ROM and isometric exercises. During the initial stages, we will limit end-range elevation with strength training as this position strains the ACJ. After the acute phase, isotonics, closed kinetic chain, end range of motion exercises, and higher level strengthening can be initiated. Below are several higher level exercises that the patient can progress to during later stage therapy.
Type IV-VI ACJ injuries will almost always be managed surgically, so these patients are rarely seen in the PT clinic prior to surgery. The type of injury and procedure will dictate the rehab. As always, use the physician's protocol and EBP to guide the program. As you may have noticed, we have not talked about type III ACJ injuries. These are the most difficult type manage as they can be treated either surgically or conservatively. The decision is based off the patient's occupation, hand dominance and activities he/she likes to perform. Typically, conservative management is tried first for a few months. Should the patient have a difficult time getting back to their desired level of function, surgery may be performed, however, this delay may impact the prognosis.
As we have highlighted, the staging of the injury is essential to dictating how to proceed with rehab. At times, surgical consultation is recommended and/or necessary for proper recovery. My recommendation is to start with conservative management if no step-off deformity is present; however, be ready to reach out for a second opinion as needed.