This 41-year-old male recreational player presents following an acute injury to his shoulder. He describes jumping to contest a header and falling landing on the point of this shoulder. It was immediately painful, and he was unable to continue. One examination he had localised tenderness and deformity over the acromioclavicular joint (ACJ). He was unable to abduct his shoulder beyond 90 degrees due to pain and guarding.
The x-ray images show 100% displacement of the ACJ with the inferior border of the clavicle being elevated above the superior border of the acromion. The coracoclavicular distance is less than twice normal.
This player was managed with a period of rest and avoidance of pain-provoking injury. He followed a physiotherapy-based strengthening programme and was able to gradually return to play over a three-month period.
Imaging can be used to classify ACJ injuries. The Rockwood system is most commonly used and consists of six grades. It takes into account not only the acromioclavicular joint, the coracoclavicular ligament, the deltoid and trapezius muscles. It also considers the direction the clavicle dislocates with respect to the acromion. In most cases, x-rays are sufficient for accurate grading with an up-angled (Zanca) view and/or stress views providing further information about the ACJ. In some cases, CT or MRI may be useful.
The treatment used to manage ACJ injuries depends on the age and lifestyle of the patient as well as the type of the injury. In general types I and II are treated with rehabilitation while types IV, V and VI are treated surgically (with reconstruction of the joint). The available evidence does not support surgery for the majority of type III injuries. Elite players or those who are required to do heavy lifting and physical work may consider surgical management. Players with ongoing pain following their injury may also benefit from surgical treatment.
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