AC joint

Acromioclavicular symptoms can present either as a gradual onset pain associated with overuse / degeneration or following trauma such as a fall directly onto the shoulder or road traffic collision, etc.  Patients who have suffered  trauma often present with associated step deformity of the joint. Pain is localised to AC Joint area / epaulette area of shoulder and commonly patients can pinpoint location directly over the AC Joint. Common symptoms include inability to lie on the affected shoulder, restricted range of overhead movements and can be associated with manual or overhead work.

No single test has been found to accurately diagnose AC Joint pathology but a combination of tests may increase diagnostic certainty (Hattam & Smeaton 2010).  Tests with the strongest evidence are as follows:

• Scarf test (AKA; Crossover impingement test, horizontal adduction impingement test, cross arm adduction test ) (Video Link) (Link updated 12/07/19) : 
  The therapist stands in front of the patient.  The patient flexes their should joint to 90° and then brings their arm into adduction.  The therapist provides an overpressure.  A positive test is reproduction of the patient's pain localised to the AC Joint.  This is a useful non specific test as the position may also induce pain and/or apprehension in the presence of posterior instability (Hattam & Smeaton 2010).
• Palpation of AC joint: The patient is in a seated position with arm relaxed by their side.  Therapist directly palpates the joint and a positive test is that which reproduces the patient pain. It is important to compare with the opposite side (Hattam & Smeaton 2010).

X-rays are accurate in diagnosing AC Joint Osteoarthrosis (OA) but are not routinely required prior to commencing rehabilitation (of note false positives have been reported in asymptomatic patients with radiologically confirmed OA, Walton et al 2004).

Overview

• Optimise pain management
• Ex / advice to normalise posture, Cx, Sh girdle, & GH joint function
• Consider CSI if pain problematic
• Return to normal activities

Patient Centred Care

Treatment should take into account individual patient needs, preferences, expectations and functional status.  Clinical reasoning should inform treatment based on subjective and objective findings. Good communication between therapist and patient is essential if a successful outcome is to be achieved. Treatment options should be clearly explained so that patients can make informed decisions with regard to their care and management.

Evidence based strategies

Pharmacology - advice regarding NSAIDS/ Analgesia. Patient to discuss with pharmacist/GP if suboptimal.

Rehabilitation - conservative management for non-surgical cases - no specific guidance on exercises, aim to restore range of motion (ROM) /strength/ posture etc.

• Advice / education to maintain correct shoulder girdle and spinal posture.
• Exercises to ensure normal function of cervical spine, shoulder girdle and Glenohumeral Joint.
• Advice/education as to returning to normal activity levels.

Non-evidence based strategies

Progressing as expected (up to 3 Rxs) before discharge or onward referral. 

Refer to ortho, GP, other 

Escalation within MSK Pathway:
Trauma -  CSI should not be considered as a first option for recent trauma < 3/12. However it may be considered after this timescale if pain severity warrants and/or patient not coping.
OA - CSI should be considered as a first option if pain severity warrants and/or patient not coping.

Escalation outwith MSK Physiotherapy:
Trauma - will normally have been seen via A&E/orthopaedic clinic prior to referral. However, adequate time should be given to rehabilitation process up to 6/12. If there is significant pain, loss of power then onward referral to orthopaedics can be considered.
OA- patient can be referred on if pain is significant and rehabilitation is failing. It should be estabilished whether patient would consider surgery prior to onward referral.

Buttaci, C.J., Stitik, T.P., Yonclas, P.P. 2004. Osteoarthritis of the acromiocalvicular joint: a review of anatomy, biomechanics, diagnosis, and treatment.  American Journal of Physical Medicine and Rehabilitation 83(10): 791-7.  Link here (link correct as of 18/03/2024) 

Hattam, P., and Smeaton, A. 2010. Special tests in musculoskeletal examination: an evidence base for clinicians.  Search the catalogue at The Knowledge Network Library Search (link updated 18/03/2024) for available copies.

Walton, J., Mahajan, S., Paxinos, A. et al (2004) Diagnostic values of tests for acromioclavicular joint pain.  Journal of Bone and Joint Surgery (American Volume) 86(4), 807 -812.  Link here  (link correct as of 18/03/2024).

NHS GGC Physiotherapy Service - shoulder https://www.nhsggc.scot/hospitals-services/services-a-to-z/musculoskeletal-msk-physiotherapy/msk-self-help-and-information-shoulder/

NHS Inform may provide useful information, especially for those presenting to physiotherapy within the time frames of natural recovery.
https://www.nhsinform.scot/illnesses-and-conditions/muscle-bone-and-joints/self-management-advice/shoulder-problems (link correct as of 18/03/2024).

Patient education in terms of time frames and prognosis is paramount. Consider use of local/national publications to support this.