ACROMIOCLAVICULAR INJURIES

IN ATHLETE

VIRGINIA A NUGROHO (188071700011003)

PPDS IKFR FKUB MALANG
P E M B I M B I N G : D R . S A M I A H R A C H M AWAT I , S P K F R
04 AGUSTUS 2019
 Definition

injury to the acromioclavicular (AC) joint with disruption of the AC

ligaments with or without coracoclavicular (CC) ligament disruption

Epidemiology
• Incidence
common injury making up 9% of shoulder girdle injuries
• demographics
more common in males and athletes

Mechanism
• direct trauma from a fall or
• blow to the acromion
• chronic injuries from overuse stress.

https://www.orthobullets.com/shoulder-and-elbow/3047/acromio-clavicular-injuries-ac-separation
 ANATOMY
ACROMIOCLAVICULAR
JOINT

• diarthrodial joint:
the articulation between the
lateral end of the clavicle and
the medial acromion of the
scapula

• covered by fibrocartilage

https://www.orthobullets.com/shoulder-and-elbow/3047/acromio-clavicular-injuries-ac-separ
ation
• acromioclavicular (AC) ligaments
ANATOMY OF
• controls horizontal motion and anterior-posterior
stability LIGAMENTS AC
• has superior, inferior, anterior and posterior
components
• posterior and superior AC ligaments are most
important for stability
• coracoclavicular (CC) ligaments
• controls vertical motion and superior-
inferior stability
• two ligaments
• conoid
• medial
• inserts on clavicle 4.5cm medial to lateral edge
• most important for vertical stability

• trapezoid
• lateral
• inserts on clavicle 3cm medial to lateral edge
https://www.orthobullets.com/shoulder-and-elbow/3047/acromio-clavicular-injuries-ac-separation
MOTION

a) primarily gliding motion

b) rotational motion is minimal 

• clavicle rotates 40-50° posteriorly with shoulder elevation
• only 5~8° rotation through the AC joint, due to synchronous
scapuloclavicular motion

https://www.orthobullets.com/shoulder-and-elbow/3047/acromio-clavicular-injuries-ac-separation
 CLASSIFICATION OF
ACROMIOCLAVICULAR
JOINT INJURIES

Ellenbecker, T.S., 2011. Shoulder

rehabilitation: Non-operative
 SIGN & SYMPTOMS

• Type 1 : Minimal tenderness and swelling  pain is generally self-

limiting  discomfort with full-arm abduction and flexion
• Type 2 : minimal to moderate strength and ROM deficiencies.
• Type 3 : pain and an easily identifiable deformity (step-off deformity)
 holding the arm in the adducted position to counteract the pain
produced by the weight of the arm.
• Type 4 : bump in the posterior skin of the shoulder.
• Type 5 : severe shoulder droop, marked pain, and a CC distance increase
up to three times
• Type 6 : acromion will be prominent on palpation with an obvious step
down to the clavicle. It has been reported that occasional transient
paresthesia accompanies this dislocation; however, it subsides with
reduction

Ellenbecker, T.S., 2011. Shoulder rehabilitation: Non-operative treatment. Thieme.

 EXAMINATION

• observation of the static

position of the shoulder
girdle,
• palpation of the AC joint
and surrounding structures,
• provocative testing, which
may include radiographs.

Cuccurullo, S.J., 2014. Physical medicine and rehabilitation board review. Demos Medical Publishing.
Brotzman, S.B. and Manske, R.C., 2011. Clinical orthopaedic rehabilitation e-book: An evidence-
based approach-expert consult. Elsevier Health Sciences.
Essentials, A.A.O.S., Essentials of Musculoskeletal Care. Section, 5, p.585588.
Essentials, A.A.O.S., Essentials of Musculoskeletal Care. Section, 5, p.585588.
Stanley, H., 1976. Physical examination of the spine and extremities. New York.
 IMAGING

• Radiographs required views

• bilateral anteroposterior (AP) view of AC joints
• compare displacement to contralateral side
• measured as distance from top of coracoid to bottom of clavicle
• axillary lateral view 
• required to diagnose Type IV (posterior)
• zanca view 
• performed by tilting the x-ray beam 10-15° cephalad and using only 50% of the standard shoulder AP penetrance 
• additional veiws
• cross-body adduction view (Basmania)
• scapular Y performed with cross-body adduction stress
• weighted stress views 
• usually no longer used
• may help differentiate Type II from Type III
• findings
• fractures can mimic AC separations
• base of coracoid fracture
• Neer type 2A distal clavicle fracture
• ligaments remain attached to distal fragment as proximal (medial) fragment displaces

https://www.orthobullets.com/shoulder-and-elbow/3047/acromio-clavicular-injuries-ac-separation
 zanca view 
axillary lateral view 
 DIFFERENTIAL DIAGNOSA

• Coracoid fracture
• base of coracoid fracture can mimic a CC ligament disruption
• has superiorly displaced distal clavicle, but normal CC distance (normal
is 11-13mm) 
• Distal clavicle fracture (Neer 2A)
- can mimic AC separations as well, as ligaments remain
attached to distal component
• Rotator cuff tear (most tenderness over the greater tuberosity,
not the AC joint; no visible deformity or radiographic
findings)
• Fracture of the acromion
Essentials, A.A.O.S., Essentials of Musculoskeletal Care. Section, 5, p.585588.
https://www.orthobullets.com/shoulder-and-elbow/3047/acromio-clavicular-injuries-ac-separation
 TREATMENT
Treatment
• depending on the degree of separation and acuity of injury.
ACUTE AC JOINT INJURIES:
• Types I and II
– Rest, ice, nonsteroidal anti-inflammatory drugs (NSAIDs).
– Sling for comfort for the first 1 to 2 weeks.
– Avoid heavy lifting and contact sports.
– Shoulder–girdle complex stabilization and strengthening.
– Return to play: When the patient is asymptomatic with full ROM.
■ ■ Type I: 2 weeks
■ ■ Type II: 6 weeks
• Type III: Controversial
– Conservative or surgical route depends on the patient’s need (occupation or sport) for
particular shoulder stability.
– Surgical for those indicated (heavy laborers, athletes).
• Types IV, V, and VI
– Surgery is recommended: Open reduction internal fixation (ORIF) or distal clavicular
resection with reconstruction of the CC ligament.
CHRONIC AC JOINT INJURIES/PAIN
• Corticosteroid injection.
• May require a clavicular resection and CC reconstruction
Cuccurullo, S.J., 2014. Physical medicine and rehabilitation board review. Demos Medical Publishing.
 TREATMENT NON-OPERATIVE

• Type 1 : often not be medically treated , patients typically

ignore the injury.
• If treated, the Goals  (1) regulate the pain
response, (2) promote a healing environment
as well as protect the damaged tissue, and
(3) deter ROM loss.
• icing the injured area incrementally and positioning the arm in
an arm sling up to 1 week. Passive or active assisted ROM
exercises

Ellenbecker, T.S., 2011. Shoulder rehabilitation: Non-operative treatment. Thieme.

• Type 2 : wear a Kenny Howard sling or an AirCast AC Joint
Sports Sling (Aircast Corp., Summit, NJ) up to 3 weeks

Ellenbecker, T.S., 2011. Shoulder

rehabilitation: Non-operative treatment.
Thieme.
• return to activities and sports within 2 to 4 weeks, once full
ROM and strength are normal.

Ellenbecker, T.S., 2011. Shoulder rehabilitation:

Non-operative treatment. Thieme.
 COMPLICATION

• Residual pain at AC joint

•  30-50%
• AC arthritis 
• more common with surgical management than with nonoperative
treatment
• Hardware failure  
• CC screw breakage/pullout
• Coracoid fracture
• can occur with coracoid tunnel drilling
- Deformity, weakness on lifting the arm, chronic shoulder pain, and
numbness in the arm are possible.

https://www.orthobullets.com/shoulder-and-elbow/3047/acromio-clavicular-injuries-ac-separation
HOME EXERCISE PROGRAM FOR
ACROMIOCLAVICULAR INJURIES

Essentials, A.A.O.S., Essentials of Musculoskeletal Care. Section, 5, p.585588.

Essentials, A.A.O.S., Essentials of Musculoskeletal Care. Section, 5, p.585588.
Essentials, A.A.O.S., Essentials of Musculoskeletal Care. Section, 5, p.585588.
Essentials, A.A.O.S., Essentials of Musculoskeletal Care. Section, 5, p.585588.
Essentials, A.A.O.S., Essentials of Musculoskeletal Care. Section, 5, p.585588.
Brotzman, S.B. and Manske, R.C., 2011. Clinical orthopaedic rehabilitation e-book: An evidence-
based approach-expert consult. Elsevier Health Sciences.
 REFERENCE

• Brotzman, S.B. and Manske, R.C., 2011. Clinical orthopaedic rehabilitation e-

book: An evidence-based approach-expert consult. Elsevier Health Sciences.
• Cuccurullo, S.J., 2014. Physical medicine and rehabilitation board review.
Demos Medical Publishing.
• Cifu, D.X., 2015. Braddom's physical medicine and rehabilitation E-book.
Elsevier Health Sciences.
• Ellenbecker, T.S., 2011. Shoulder rehabilitation: Non-operative treatment.
Thieme.
• Essentials, A.A.O.S., Essentials of Musculoskeletal Care. Section, 5, p.585588.
• https://www.orthobullets.com/shoulder-and-elbow/3047/acromio-clavicular-injur
ies-ac-separation
• Stanley, H., 1976. Physical examination of the spine and extremities. New York.