Shoulder Pain Management

Acromioclavicular Arthritis

Treatment choices for acromioclavicular (AC) arthritis are limited, with initial treatment consisting of NSAIDs and an emphasis on activity modification. Additionally, the treatment regimen should include a stretching program designed to maintain active range of motion, with an emphasis on scapular stabilization.

Treatment Options
• NSAIDs
• Activity modification and exercise/stretching
• Intra-articular injection of cortisone
• Surgical excision of joint if pain persists

Key Clinical Points

Intra-articular Corticosteroids

If a diagnostic local anesthetic injection provides relief, the practitioner may want to consider therapeutic corticosteroid injections for the patient. Although there is no consensus regarding dosage, 10 to 20 mg of methylprednisolone may be injected. Current practice patterns limit intra-articular steroid injections to four per year.¹ Physicians should be aware that the possible side effects of corticosteroid injections include:

• Skin blanching
• Localized fat atrophy
• Infection
• Transient hyperglycemia in patients with diabetes

Patients should be advised to avoid provocative activities for 2 to 3 days after the injection; pain relief can last up to several months.

Surgical Intervention

If the AC joint pathology interferes with activities of daily living and/or conservative measures are not productive enough to provide adequate pain relief, referral to a surgical specialist may be warranted. Up to 6 months of conservative treatment may be necessary prior to considering surgical options. Surgical options consist of open or arthroscopic distal clavicle resection (Fig. 3).

Figure 3: Preoperative (A) and postoperative (B) radiographs of a successful arthroscopic distal clavicle resection.²

Patient Considerations

The patient should be reminded to avoid repetitive motions that exacerbate symptoms. Activity modification usually requires a change in the exercise routine for patients involved in a physical fitness program. Exercises to be avoided are push-ups, dips, flies, and bench presses. Physical therapy, unfortunately, has little to offer because therapeutic exercise and range-of-motion play only a minor role.¹

Clinical Course

The clinical course of patients with AC joint arthritis is similar to other joints with osteoarthritis. Over time the arthritis gradually increases in severity and it may take decades for the symptoms to become very severe. Throughout the clinical course, symptoms are usually intermittent and may depend upon activity level. Surgical interventions are effective but should be reserved for patients that fail conservative therapy or have significant structural changes within the joint.

Know When to Refer
• Patient not responding to conservative treatment after 3 to 6 months
• Glenohumeral instability
• Full-thickness rotator cuff tears
• Rheumatoid arthritis
• Symptomatic os acromiale
• Spinoglenoid notch cyst (Ganglion cyst of the shoulder)
• Recalcitrant adhesive capsulitis (frozen shoulder)

References