M u s c u l o s k e l e t a l I m a g i n g • R ev i ew
Ha et al.
Imaging the Acromioclavicular Joint
Musculoskeletal Imaging
Review
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Acromioclavicular Joint:
The Other Joint in the Shoulder
Alice S. Ha1 OBJECTIVE. The purpose of this article is to provide a review of acromioclavicular joint
Jonelle M. Petscavage-Thomas 2 anatomy, describe common pathologies at the joint, and present normal and abnormal post-
Gino H. Tagoylo1 operative imaging findings after surgical treatments.
CONCLUSION. Knowledge of anatomy with related pathologies, orthopedic trends,
Ha AS, Petscavage-Thomas JM, Tagoylo GH imaging findings, and complications, is important in assessing the acromioclavicular joint.
T
he acromioclavicular joint is a
common source of “shoulder pain”
aside from the glenohumeral joint
and rotator cuff. In the study by
Jordan et al. [1], symptomatic acromioclavicu-
lar joints were present in 23% of patients un-
dergoing shoulder MRI. Acromioclavicular
joint dislocation accounts for approximately
12% of all shoulder injuries [2], which is likely
an underestimation because minor injuries are
often not reported. Successful radiologic eval-
uation of the acromioclavicular joint requires
an understanding of anatomy and physiologic
function, common pathologies, and normal and
abnormal postoperative imaging appearance
after common orthopedic surgical treatments.
Anatomy of Acromioclavicular Joint
The acromioclavicular joint is a key com-
ponent of the shoulder girdle that provides
Keywords: acromioclavicular, classification, CT, MRI, connection between scapulohumeral motion
radiography, trauma and clavicular motion. The clavicle functions
as a strut between the upper arm and the axial
DOI:10.2214/AJR.13.11460
skeleton. Scapular motion relative to the tho-
Received June 28, 2013; accepted after revision rax occurs with simultaneous motion at the ac-
September 18, 2013. romioclavicular and the sternoclavicular joints
1
with greater motion at the latter [3]. A healthy
Department of Radiology, University of Washington,
4245 Roosevelt Way NE, Seattle, WA 98105. Address
acromioclavicular joint can undergo up to 6
correspondence to A. S. Ha (aha1@uw.edu). mm of translation in anterior, posterior, and
superior directions under a load [4]. In addi-
2
Department of Radiology, Penn State Hershey Medical tion, the acromioclavicular joint rotates 5–8°
Center, Hershey, PA.
with scapulothoracic motion and 40–45° with
This article is available for credit. shoulder abduction and elevation [5].
The acromioclavicular joint is a diarthrodial
AJR 2014; 202:375–385
synovial joint between the flat medial surface
0361–803X/14/2022–375 of the acromion and the convex distal end of
the clavicle (Fig. 1). On the frontal view, the
© American Roentgen Ray Society acromioclavicular joint can appear to be ver-
AJR:202, February 2014 375
tical or downward medially with the clavicle
overriding the acromion by up to 50° [6]. A
fibrocartilagenous disk cushions two relative-
ly small joint surfaces while the joint is en-
cased in a thin joint capsule [7]. The exact role
of the meniscal disk is unknown. Many disks
are incomplete and most are found to be de-
generated by the fourth decade of life [6]. No
disks were seen in all 28 cadaveric dissections
of the acromioclavicular joint by Stine and
Vangsness [8]. The acromioclavicular joint
has a dual nerve supply from the suprascapu-
lar nerve and the lateral pectoral nerve.
Dynamic and static stabilizers maintain
the acromioclavicular joint. Dynamic stabi-
lizers include the deltoid muscle anteriorly
and trapezius muscle posteriorly. Static sta-
bilizers include the acromioclavicular, cora-
coclavicular, and coracoacromial ligaments
along with the joint capsule. The acromio-
clavicular ligament is composed of superior,
inferior, anterior, and posterior components.
Normal acromioclavicular ligament compo-
nents are each about 2.5 mm in thickness [8].
The acromioclavicular ligament resists 50%
anterior and 90% posterior displacement.
The superior component (Fig. 2A) is the
strongest and is further augmented by merg-
ing fibers of the deltotrapezial fascia [7].
An important static stabilizer is the cora-
coclavicular ligament. Composed of conoid
and trapezoid ligaments (Fig. 2B), the cora-
coclavicular ligament is responsible for ver-
tical stability of the acromioclavicular joint.
The conoid ligament is more posteromedial
and provides restraint against anterosupe-
rior clavicle displacement and rotation. The
trapezoid ligament is more anterolateral and

serves as the primary restraint against an-
teroposterior translational forces [9].
The coracoacromial ligament is triangular
shaped with a broad attachment on the lat-
eral aspect of the coracoid process (Fig. 2C).
The coracoacromial ligament inserts onto
the tip of the acromion. Along with the acro-
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mion, it forms an arch to protect the humeral
head from superior subluxation.
Normal Imaging Appearance of
the Acromioclavicular Joint
Standard radiography of the acromioclavic-
ular joint includes a frontal view of the shoul-
der, axillary view, and scapular Y view. The
axillary view is important for detection of pos-
terior clavicular displacement and an os acro-
miale. In addition, Zanca view or stress view
may be performed. Zanca view images the
acromioclavicular joint in a standing patient
with 10–15° cephalic tilt of the x-ray beam to
clear the acromioclavicular joint off the scap-
ular spine (Fig. 3A) [6]. Stress view is an an-
teroposterior view of the bilateral acromiocla-
vicular joints with and without 10–15 pounds
(5–7 kg) of weight suspended from each fore-
arm [2] (Fig. 3B). The acromioclavicular in-
terval is normally 1–3 mm in width whereas
the coracoclavicular interval should be 11–13
mm [7]. An acromioclavicular interval greater
than 6–7 mm or a difference in acromioclavic-
ular interval of greater than 2–3 mm between
left and right sides are considered pathologic.
A greater than 5-mm difference in the cora-
coclavicular interval is also considered abnor-
mal. The ligaments should appear thin and low
signal intensity on all MR sequences.
Congenital Variations
There are variations to the shape of the
acromion, which is mainly differentiated by
TABLE 1: Rockwood Classification of Acromioclavicular Joint Injury
Acromioclavicular Coracoclavicular
Type Ligament Ligament
I Sprained Intact
II Torn Intact
III Torn Torn
IV Torn Torn
V Torn Torn
VI Torn Torn
376 AJR:202, February 2014
Ha et al.
the contour of the inferior surface. Type 1
is flat, and type 2 is concave. Type 3 is for
a hooked or beaked appearance anteriorly,
and type 4 has an upturned inferior surface.
Types 3 and 4 are thought to decrease the su-
praspinatus outlet and are associated with
impingement (Fig. 4).
The acromion has four ossification cen-
ters: preacromion, mesoacromion, meta­
acromion, and basiacromion (Fig. 5A).
These ossification centers fuse by 25 years
of age [10]. In 1–15% of the population, one
or more ossification centers fail to fuse, re-
sulting in an os acromiale. When an os ac-
romiale is present, 60% will be bilateral and
will most commonly occur at the junction of
meso- and metaacromion. On a frontal view
radiograph, an os acromiale can be easily
missed; the axillary view or an axial CT im-
age is key in the diagnosis (Fig. 5B).
Os acromiale syndrome is a symptomat-
ic ossicle due to micromotion between the
os and the acromion. This abnormal micro-
motion may lead to pseudoarthrosis. Imag-
ing findings of pseudoarthrosis at the os are
similar to osteoarthritis at the acromiocla-
vicular joint. CT shows subchondral sclero-
sis, subchondral cystic change, and osteo-
phyte formation at the pseudoarthrosis. MR
findings include bone marrow edema of the
ossicle and degenerative change at the pseu-
doarthrosis (Figs. 5C and 5D) [11]. The os
acromiale is also implicated in pain related
to shoulder impingement, either from osteo-
phytic spurs at the pseudoarthrosis or deltoid
muscle contraction pulling the ossicle infe-
riorly onto the rotator cuff. The first line of
treatment is nonoperative and includes rest,
ice, and antiinflammatory medicine. Surgi-
cal options include débridement of the small
ossicle, fixation of the ossicle to the acromi-
Deltotrapezial
Acromioclavicular Dislocation Fascia
None Intact
< 50% Acromioclavicular subluxation Intact
100% Superior subluxation Intact
100% Posterior subluxation Torn
> 100% Superior subluxation Torn
100% Inferior dislocation Intact
on with hardware (Fig. 6), and débridement
of the acromial undersurface.
Trauma to the Acromioclavicular
Joint
Acromioclavicular joint injuries occur most
commonly in men (8:1 ratio) in their third de-
cade of life during contact sports (e.g., foot-
ball, rugby) or heavy overhead manual labor
[12]. The superficial location makes the acro-
mioclavicular joint more vulnerable to direct
trauma. Among National Collegiate Athletic
Association football players, acromioclavicu-
lar joint injuries (> 96% Rockwood grade III
or higher) accounted for 32% of all shoulder
injuries [13]. Indirect trauma is less common
and occurs with falls on outstretched hands.
Acromioclavicular joint separation is catego-
rized using the Rockwood classification [14]
(Table 1).
Type I involves a sprain or partial tear of
the acromioclavicular ligament with a nor-
mal acromioclavicular interval, which is oc-
cult on nonstress radiographs. Type II (Fig.
3) has torn acromioclavicular and intact cor-
acoclavicular ligaments with less than 100%
elevation of the clavicle in relation to the
acro­m ion. Type III (Figs. 7A and 7B) inju-
ries show complete disruption of both the
acro­m ioclavicular and coracoclavicular liga-
ments, with greater superior displacement of
the distal clavicle. Types IV to VI occur in
more severe injuries. Type IV (Fig. 7C) oc-
curs when the distal clavicle moves posteri-
orly into the trapezius muscle. This type is
often missed on frontal radiographs and can
be associated with concomitant anterior dis-
location of the proximal clavicle at the ster-
noclavicular joint. Type V is a more severe
form of type III with a more superiorly dis-
placed clavicle. Type VI (Fig. 7D) is rare and
Joint
Capsule Radiography
Intact Widening of acromioclavicular
joint with stress
Torn Wide acromioclavicular joint
Torn Wide acromioclavicular and
coracoclavicular joints; superior
position of distal clavicle by less
than 50% shaft width
Torn Distal clavicle posterior to
acromion
Torn More superiorly displaced clavicle
than type III
Torn Distal end of clavicle lies inferior to
acromion

is characterized by inferior displacement of
the distal clavicle with respect to the acro-
mion. MR images show discontinuity of nor-
mally low-signal-intensity acromioclavicular
and coracoclavicular ligaments, surrounding
soft-tissue edema, and bone marrow edema
in the subjacent bone.
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In addition to direct palpation, loading the
joint using a cross-arm adduction test is di-
agnostic of acromioclavicular joint injury. If
shrugging the shoulder reduces the acromio-
clavicular joint, then the deltotrapezial fas-
cia is intact, thereby distinguishing a type III
from a type IV injury [7].
The acromioclavicular joint can also be
injured as part of distal clavicular fractures
[15] (Neer classification in Fig. 8). Type II
fractures (10–30% of all clavicle fractures)
are unstable due to coracoclavicular liga-
ment disruption and are associated with a
high rate of delayed or nonunion [15, 16].
Treatment of Acromioclavicular
Joint Injury
Rockwood type I and II acromioclavicular
joint injuries are treated conservatively with
activity modification, ice, and nonsteroidal
antiinflammatory drugs followed by physical
therapy. Nonoperative treatments can fail and
patients can present with residual joint insta-
bility, osteoarthritis, pain, and distal clavicu-
lar osteolysis [7]. Navy recruits with type I
and II injuries treated nonoperatively showed
residual symptoms (36–48%) and positive
physical examinations (43–77%) [17].
Treatment of type III injuries is more con-
troversial and includes both nonoperative and
operative therapies. In a recent meta-analy-
sis of type III injuries, there was no statisti-
cally significant benefit for surgical therapy
versus nonoperative therapy [18]. Severe in-
juries (types IV to VI) are treated with surgi-
cal repair. Since the late 19th century, more
than 60 different surgical approaches have
been developed to treat acute and chronic ac-
romioclavicular joint dislocation. The choice
of a specific type of surgical repair depends
on patient demographics, acuity of injury,
and surgeon preference.
Anatomic Acromioclavicular Joint
Reconstruction
Historically, surgical therapy concentrat-
ed on anatomic reconstruction of the acro-
mioclavicular ligament. Use of rigid fixations
with pins, screws, and wires were compli-
cated by hardware migration into the lung,
spinal canal, and carotid artery [19]. Distal
clavicle excision (Mumford procedure) was
AJR:202, February 2014 377
Imaging the Acromioclavicular Joint
originally performed to prevent the develop-
ment of posttraumatic arthritis [20].
For Neer type IIB and III distal clavicu-
lar fractures, hook plates are commonly used
because of advantages such as easy implan-
tation technique and early postoperative mo-
bilization [21]. The lateral edge of the hook
plate “hooks” underneath the acromion and
keeps the lateral clavicle reduced (Fig. 9).
Disadvantages include the need for hardware
removal, subacromial osteolysis, and wound
complications. More rare complications in-
clude rotator cuff impingement and peri-
hardware fractures [7].
Anatomic Coracoclavicular Ligament
Reconstruction
In severe acromioclavicular joint dislo-
cations, there is a growing trend toward sur-
gical reconstruction of the coracoclavicular
ligament, thereby maintaining reduction of
the acromioclavicular joint, which facilitates
healing. Accelerated failure of coracoclavicu-
lar ligament reconstruction involving rigid fix-
ation with screws is likely due to physiolog-
ic motion between the coracoid and clavicle.
The current trend is to reconstruct the coraco-
clavicular ligament using flexible grafts, both
synthetic (TightRope or GraftRope, both Ar-
threx) or biologic (semitendinosus, gracilis, or
tibialis anterior tendons) [22], fixated with en-
dobuttons or small screws (Fig. 10). Synthetic
grafts are strong but can lead to graft abrasion
and osteolysis around the graft insertion site.
The tightrope double-button system has been
shown to be more stable compared with the
native ligaments. Disadvantages include in-
creased axial stiffness [21].
Other Pathologies at the
Acromioclavicular Joint
Distal Clavicular Osteolysis
Distal clavicular osteolysis was first de-
scribed as osteolysis in the distal clavicle after
trauma in 1936 [23]. Since then, distal clavic-
ular osteolysis has also been described in sce-
narios without acute trauma. Recently these
“atraumatic” cases have been hypothesized
to be due to occult subchondral fractures [24],
most likely related to repeated microtraumas
such as weightlifting. Distal clavicular osteol-
ysis must be distinguished from other causes
of distal clavicular destruction, including in-
flammatory causes such as rheumatoid ar-
thritis (Fig. 11C), hyperparathyroidism, and
scleroderma [25]. The differential diagnosis
also includes lytic metastasis and hematoge-
nously spread osteomyelitis. On radiographs,
distal clavicular osteolysis shows destruction
of the distal clavicle with small subchondral
cysts and erosions and associated subchon-
dral sclerosis along with a normal acromial
articular surface. MRI shows loss of the nor-
mal low-signal-intensity cortical margin of the
clavicle along with bone marrow edema. Sub-
chondral or periosteal bone marrow edema
with acromioclavicular joint synovitis can be
seen. The acromion should be devoid of bone
marrow edema, a distinguishing feature from
septic arthritis and degenerative change.
Septic Joint
Infection in the acromioclavicular joint is
rare but must be considered when acute pain,
fever, and joint effusion are present [26].
Most commonly, septic arthritis of the acro-
mioclavicular joint is related to trauma, re-
cent surgery, or hematogenous seeding. In
acute cases, a joint effusion may be the only
sign and is later followed by bony destruction
on both sides of the joint, bone marrow ede-
ma, and adjacent soft-tissue edema (Fig. 12).
Osteoarthritis
Small joint surface areas and an often-in-
complete fibrocartilagenous disk at the ac-
romioclavicular joint under high loads dur-
ing everyday activities are thought to lead
to early osteoarthritis. Other risk factors in-
clude prior trauma or distal clavicular osteol-
ysis (Fig. 13). The fibrocartilagenous disk, a
meniscal homolog, begins to degenerate ear-
ly, by age 20 years [27]. As in other joints, ra-
diologic signs of osteoarthritis do not always
correspond with patient symptoms. Acro-
mioclavicular joint pain has been associated
with variable findings, such as bone marrow
edema [28] or superior capsular distention
[29]. Symptomatic acromioclavicular joint
osteoarthritis is also frequently associated
with other pathologies in the shoulder, in-
cluding rotator cuff tears (81%), labral tears
(33%), and biceps tendinosis (22%) [30].
Enlarging osteophytes of a degenerative
acromioclavicular joint, possibly in com-
bination with chronic friction from a high-
riding humeral head in patients with rotator
cuff tears, can result in defects in the inferi-
or articular portion of the acromioclavicular
joint capsule [31]. The defect allows gleno-
humeral synovial fluid to decompress across
a degenerated acromioclavicular joint and es-
cape superiorly through the acromioclavicu-
lar joint in the form of a ganglion cyst. On
MRI and ultrasound, cysts may be unilocated
or multilocated fluid-signal-intensity masses
(hypoechoic on ultrasound) with a neck com-
municating with the acromioclavicular joint

(Fig. 14). Internal debris and a thick wall are
often present.
Treatment of acromioclavicular joint os-
teoarthritis starts with nonoperative therapy.
Anesthetic or steroid injections are often di-
agnostic and therapeutic (discussed further in
the next section). Common surgical therapy is
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distal clavicular excision, such as the Mum-
ford procedure. Distal clavicular excision has
had equally positive results when performed
in an open or arthroscopic approach. Exces-
sive resection of the clavicle leads to antero-
posterior instability because of ligamentous
injury [32] likely due to disruption of the supe-
rior acromioclavicular ligament complex [33].
Currently, resection less than 1 cm is recom-
mended by many authors [34]. A recent in vi-
tro study showed improved joint stability after
symmetric acromioclavicular joint resection
(5 mm from either side of joint) versus distal
clavicular resection (1 cm) [33].
Imaging-Guided Procedures for
the Acromioclavicular Joint
Imaging-guided procedures for the acro-
mioclavicular joint include joint injections
(with anesthetics or steroids), joint aspira-
tion, and ganglion cyst aspiration or injec-
tion. Needle guidance can be performed
with fluoroscopy or ultrasound (Fig. 15).
With fluo­ roscopy, the needle can be ad-
vanced perpendicular to the joint and skin,
aiming for the center of the joint. Because of
its small size, no more than 4–5 mL of fluid
should be placed within the joint space. Ul-
trasound guidance is more accurate than in-
jection by palpation. With ultrasound, both
in- and out-of-plane approaches can be used
to access the joint (Figs. 15B and 15C). Out-
of-plane is useful when there is little overly-
ing soft tissue for a full needle throw. Hy-
perechoic steroid and hypoechoic anesthetic
will be seen distending the joint under real-
time ultrasound. Both procedures should be
performed under sterile technique. In a study
by Strobel et al. [35] of 50 acromioclavicu-
lar joint injections, 38% achieved pain relief,
and caudal osteophytes and capsular hyper-
trophy were MRI predictors of response. Po-
tential complications include infection and
bleeding. Aspiration of ganglion cysts aris-
ing from the acromioclavicular joint may re-
quire 16- to 20-gauge needle sizes because of
the viscous nature of cyst fluid.
Conclusion
Knowledge of anatomy, common pathol-
ogies, and normal postoperative imaging as-
378 AJR:202, February 2014
Ha et al.
sessment and findings of complications are
important for providing a meaningful radio-
logic evaluation of the acromioclavicular joint.
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34. Corteen DP, Teitge RA. Stabilization of the clavi-
cle after distal resection: a biomechanical study.
Am J Sports Med 2005; 33:61–67
35. Strobel K, Pfirrmann CW, Zanetti M, Nagy L,
Hodler J. MRI Features of the acromioclavicular
joint that predict pain relief from intraarticular
injection. AJR 2003; 181:755–760

Fig. 1—Drawing shows anatomy at acromioclavicular joint.

A B C
Fig. 2—Normal appearance of static stabilizers of acromioclavicular joint.
A–C, MR images show acromioclavicular ligament (white arrow, A), coracoclavicular ligament consisting of conoid (white arrow, B) and trapezoid (black arrow, B)
components, and coracoacromial ligament (white arrow, C).

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A B

Fig. 3—Acromioclavicular joint radiography.

A, Zanca image of acromioclavicular joint in 34-year-old man after fall from bicycle
shows comminuted extraarticular fracture of distal clavicle.
B, Nonstress image of right acromioclavicular joint in 44-year-old man shows
widening of acromioclavicular joint but normal coracoclavicular distance.
C, Stress view in same patient as in B shows increased widening of
acromioclavicular joint and now abnormal widening of coracoclavicular joint.

A B C
Fig. 4—Acromial morphology.
A–C, Sagittal T2-weighted fat-saturated image (A) shows type 1, sagittal T1-weighted image (B) shows type 2, and sagittal T1-weighted image (C) shows type 3.

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 Imaging the Acromioclavicular Joint

Preacromion
Clavicle
Mesoacromion
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Metaacromion

Basiacromion

A B

C D
Fig. 5—Os acromiale.
A, Drawing shows four ossification centers in distal acromion.
B, Axial CT image in 55-year-old woman shows unfused ossification center separated, representing os acromiale.
C, Axial T2-weighted fat-saturated MR image in 50-year-old woman shows os acromiale with pseudoarthrosis with
native acromion. Bone marrow edema and degenerative change are present.
D, Coronal T2-weighted fat-saturated image in same patient shows os in inferiorly impinging supraspinatus tendon.

A B
Fig. 6—Os acromial treatment for symptomatic os in 51-year-old woman.
A and B, Postsurgical radiograph (A) and CT image (B) show screw and wire fixation.

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 Ha et al.

Fig. 7—Rockwood classification of acromioclavicular

separation.
A and B, Sagittal T2-weighted fat-saturated image
in 54-year-old woman (A) shows disruption of
coracoclavicular ligament whereas coronal T2-
weighted fat-saturated image in 33-year-old man (B)
shows tear of superior and inferior components of
acromioclavicular ligament with bone marrow edema
in acromion and soft-tissue edema. Findings are
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consistent with type III injury.

C, Axial radiograph in 28-year-old man shows
posterior displacement of clavicle consistent with
type IV injury.
D, Anteroposterior radiograph in 27-year-old man
shows inferior displacement of clavicle, seen in type
VI injury.

A B

C D

Fig. 8—Drawings show Neer classification of distal

clavicular fractures.

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A B
Fig. 9—Hook plate for distal clavicle fracture.
A, Radiograph shows normal appearance with hook (arrow) flush with
undersurface of acromion in 66-year-old man.
B, Radiograph of blade hook plate in 55-year-old woman shows unhooking of plate
from undersurface of acromion.
C, Radiograph in same patient as in A now shows periprosthetic fracture (arrow)
adjacent to medial aspect of blade hook plate after plate placement.

A B

Fig. 10—Anatomic coracoclavicular reconstruction.

A and B, Anteroposterior radiograph (A) in 30-year-
old woman shows coracoclavicular reconstruction
with semitendinosus allograft and #5 fiberwire
fixated by two biotenodesis screws with distal
clavicle excision, which went on to fail, as seen in
radiograph (B) with widening of acromioclavicular
and coracoclavicular intervals.
C and D, Anteroposterior radiograph (C) in
39-year-old woman shows tightrope repair with
endobuttons. Subsequent radiograph (D) shows
failure of coracoclavicular reconstruction with
acromioclavicular and coracoclavicular interval
widening and migration of clavicular endobutton into
widened hole in distal clavicle.
C D

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A B C
Fig. 11—Distal clavicular osteolysis.
A, Anteroposterior radiograph in 32-year-old male weightlifter shows erosion of distal clavicle.
B, Axial T2-weighted fat-saturated MR image in same patient shows bone marrow edema only in distal clavicle, with erosion of distal clavicle cortex.
C, Anteroposterior radiograph in 54-year-old woman with rheumatoid arthritis shows advanced distal clavicular destruction. Also note severe glenohumeral joint space
narrowing.

Fig. 12—Acromioclavicular septic joint in 50-year-old

man.
A and B, Axial CT image (A) shows erosive changes
on both sides of joint, and axial T2-weighted
fat-saturated image (B) shows joint effusion and
adjacent bone marrow edema.

A B

Fig. 13—Acromioclavicular joint osteoarthritis in

63-year-old man.
A, Coronal T1-weighted image shows osteophytes,
joint space narrowing, and subchondral cysts.
B, Long-axis ultrasound image shows osteophytes
with calcific deposit on clavicular end, likely
hydroxyapatite deposit. There is associated
moderate joint effusion and distention of superior
joint capsule. Acr = acromion, Cla = clavicle.
A B

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A B
Fig. 14—Acromioclavicular ganglia.
A, Ultrasound long-axis image in 62-year-old woman shows multiloculated anechoic cyst arising from acromioclavicular joint (arrow) and
extending superiorly, consistent with ganglion.
B, Axial MR proton density fat-saturated image in 91-year-old woman shows high-signal-intensity septate ganglion (arrow) arising laterally
from acromioclavicular joint.

Fig. 15—Imaging guided

acromioclavicular joint
procedures.
A, Anteroposterior
fluoroscopic image
in 45-year-old man
shows needle within
A B acromioclavicular
joint, with contrast
enhancement confirming
intraarticular location.
B and C, In- (B) and
out-of-plane (C) needle
approaches shown
with positioning of
needle with respect to
transducer.
D, Long-axis
ultrasound image of
acromioclavicular joint
in 61-year-old man with
moderate joint effusion
and superior capsular
distention. In-plane
needle approach for joint
aspiration is shown with
arrow pointing to needle.
C D

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