The guidelines developed by the New York State Workers Compensation Board are intended to assist healthcare professionals in providing appropriate treatment for acromioclavicular joint sprains/dislocations.
Tailored for medical practitioners, these Workers Compensation Board guidelines offer support in determining the right course of action for individuals experiencing acromioclavicular joint sprains or dislocations.
It’s important to emphasize that these guidelines do not replace clinical judgment or professional experience. The ultimate decision regarding treatment for acromioclavicular joint issues should be a collaborative one, involving the patient and their healthcare provider in consultation.
Acute Acromioclavicular (AC) Joint Injury
A shoulder separation is a common term used to describe an acute acromioclavicular (AC) joint injury.
Injury Classification:
The extent of clavicular displacement is contingent upon the severity of the injury to the AC and Coracoclavicular (CC) ligaments, the AC joint capsule, and the supportive shoulder muscles (trapezius and deltoid) connected to the clavicle.
Traditional Allman and Tossy Classification:
The classical Allman and Tossy classification system comprises three grades. It categorizes injuries based on the degree of clavicular displacement.
Rockwood’s Expansion:
Rockwood expanded this classification, introducing six types of injuries. Rockwood Type I corresponds to the original Allman/Tossy Grade I, Rockwood Type II aligns with the original Allman/Tossy Grade II, and Rockwood Types III-VI fall into the original Grade III Allman/Tossy category. This expansion provides a more nuanced understanding of AC joint injuries.
History and Mechanism of Injury
Mechanism of Injury (AC Joint Sprains/Dislocations):
Patients typically experience an AC joint injury by landing on the shoulder point, causing the acromion to move downward, or by falling on an outstretched hand or elbow, exerting a backward and outward force on the shoulder. It is crucial to eliminate other potential sources of shoulder pain resulting from acute injuries, including rotator cuff tears, fractures, and nerve injuries.
Physical Findings:
Physical findings may encompass tenderness at the AC joint, occasionally accompanied by contusions and/or abrasions in the joint area. Prominence or asymmetry of the shoulder might be observable, along with reduced shoulder motion and tenderness of the clavicle’s distal end upon palpation. Increased clavicular translation may occur, and cross-body adduction can induce severe pain. The positive piano sign is elicited by downward traction on the extended limb, with one finger on the acromion and the other fingertip on the clavicle. A positive sign is indicated when the acromion displaces distally, and the clavicle depresses, resembling the action of depressing a piano key.
Laboratory Tests:
Generally, laboratory tests are not deemed necessary. They are recommended only in select patients where a systemic illness or disease is suspected.
Testing Procedures – X-ray:
X-ray testing is recommended selectively based on clinical indications. Plain X-rays may involve an AP view, an AP radiograph of the shoulder with a 10-degree cephalad angle (Zanca view), axillary lateral views, and a stress view with side-to-side comparison using 10-15 lbs. of weight in each hand.
Non-Operative Treatment Procedures:
Non-operative treatment procedures are recommended selectively based on clinical indications. These procedures may involve patient-directed thermal treatment and immobilization, extending up to six weeks for Type I-III AC joint separations. The use of immobilization treatments for Type III injuries remains a matter of controversy. Medications, such as nonsteroidal anti-inflammatories and analgesics, are indicated, while narcotics are generally not recommended.
Subacromial Space Injection with Steroids:
Subacromial space injection with steroids is recommended selectively based on clinical indications. It may be therapeutic if the patient responds positively to a diagnostic injection of an anesthetic. However, injections directly into the tendons are discouraged. Typically, one or two injections are sufficient, with a recommended minimum interval of three weeks between injections. The time to produce an effect is immediate with local anesthetic or within three days with corticosteroids. The maximum duration is limited to no more than three injections annually at the same site.
Manipulation and Physical Medicine Interventions:
Manipulation may be considered in a Type II sprain. Physical medicine interventions should prioritize a gradual increase in range of motion without worsening the AC joint injury. As motion improves and pain is controlled, a strengthening program should be initiated, and a return to modified/limited duty could be contemplated. Around eight to 11 weeks, with the restoration of full or near-full motion, a return to full duty is anticipated.
Operative Procedures for Type III AC Joint Injury:
In the case of a Type III AC joint injury, it may be prudent to consider an appropriate orthopedic consultation initially. However, such consultation should be particularly contemplated when conservative care proves ineffective in enhancing function.
Orthopedic Surgical Consultation for Type IV-VI AC Joint Injury:
For a Type IV-VI AC joint injury, it is strongly recommended to seek an orthopedic surgical consultation due to the complexity of the injury.
Post-Operative Procedures:
Post-operative procedures should be collaboratively managed by the orthopedic specialist and the primary care physician, working in conjunction with the interdisciplinary team. Following the therapeutic and rehabilitation procedures outlined in this shoulder protocol, the patient might undergo immobilization for two to three weeks. During the rehabilitation phase, activities—both work-related and avocational—should be restricted for six to eight weeks. The progression towards a return to full duty will be contingent upon the patient’s response to rehabilitation and the specific demands of their job.
