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Acromioclavicular Joint Injections

  • Author: Stephen Kishner, MD, MHA; Chief Editor: Erik D Schraga, MD  more...
 
Updated: Apr 20, 2015
 

Overview

Introduction

The acromioclavicular (AC) joint is a diarthrodial joint that joins the distal end of the clavicle with the acromion. It is surrounded by a joint capsule in which lies a meniscal disk. The AC ligaments, comprising the superior, inferior, anterior, and posterior ligaments, help with anteroposterior stability and inhibit superior translation. The coracoclavicular ligaments, comprising the trapezoid and conoid ligaments, insert on the coracoid process and provide superior-inferior stability and inhibit AC joint compression. (See the image below.)

Acromioclavicular joint anatomy. Acromioclavicular joint anatomy.

Injection of corticosteroid (combined with an anesthetic) into the AC joint is one method of treatment for AC joint injuries. Such injuries can occur both in the general population and in people participating in athletics.[1]

Indications

Injections into the AC joint are usually performed for primary osteoarthritis, traumatic osteoarthritis, and distal clavicle osteolysis. Primary osteoarthritis is the leading cause of pain in the AC joint.[2] Traumatic arthritis can occur after injuries such as distal clavicle fractures or AC joint dislocations. Osteolysis is usually seen in weight lifters who have sustained repetitive microtrauma to the shoulder and AC joint. (See Acromioclavicular Injury.)

Injections can be diagnostic, therapeutic, or both. Most clinicians advocate AC joint injections after conservative treatment modalities have been exhausted and pain persists. Conservative treatments include relative rest, activity modification, nonsteroidal anti-inflammatory drugs (NSAIDs), and physical therapy.

Contraindications

Contraindications for AC joint injections include the following[3] :

  • Bleeding diathesis
  • Infection at the site
  • Known hypersensitivity to the contents of the injection
  • Skin breakdown at the site
  • Fracture of the joint
  • Severe joint destruction

Relative contraindications include the following[3] :

  • Joint instability
  • Infection or severe osteoporosis adjacent to the site
  • Anticoagulation therapy
  • Overlying skin lesions
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Technique

To locate the joint line, palpate the acromion from the lateral edge medially until it meets the clavicle. Alternatively, follow the clavicle laterally until it meets the acromion. At the lateral edge of the clavicle, a bony rim lies 2 cm medial from the joint line. At the articulation of the acromion and clavicle, a slight depression is usually evident; this depression indicates the joint line.[6]

After the medial edge of the acromion and the distal edge of the clavicle are palpated and the joint has been accurately identified, attach a 25-gauge needle to a 3-mL syringe that contains the solution of local anesthetic and steroid.

Inject into the joint space using a superior and anterior approach. The injectate should enter the space smoothly and with minimal resistance. If resistance is encountered, reposition the needle. To further open the joint space, the patient’s arm can be pulled into full lateral rotation. (See the video below.)

Patient (48-year-old woman with preexisting acromioclavicular [AC] joint arthritis), was hit by motor vehicle, which exacerbated her AC joint arthritis. Video courtesy of James R Verheyden, MD.

Some studies have suggested that the use of ultrasonographic guidance may enhance the accuracy of AC joint injection.[7, 8]

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Complications

Complications of acromioclavicular (AC) joint injection include the following:

Rare but possible complications include the following:

  • Systemic effects of the steroid
  • Elevated blood sugar levels (in patients with diabetes)
  • Tendon rupture
  • Hypopigmentation of the skin
  • Facial flushing
  • Steroid arthropathy
  • Fat atrophy
  • Muscle wasting
  • Steroid flare reaction
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Preparation

Equipment

Acromioclavicular (AC) joint injection is performed with the following equipment:

  • Needle, 25 gauge, 1-1.5 in.
  • Syringe, 3-5 mL
  • Povidone-iodine swabs or solution
  • Gauze pads, 4 × 4 in.

Anesthesia

Typical anesthetics used include 0.5-1 mL of 1-2% lidocaine or 0.25-0.5% bupivacaine. A 2007 survey of western US physicians by Skedros et al found broad variations in the amount of anesthetic injected for painful shoulder conditions, with surgeons using larger volumes.[4]

Positioning

The patient can sit or stand, with the affected arm in a neutral position at the side.

Corticosteroids

No consensus exists on the type or amount of steroids to be used for an AC joint injection. Typically, 0.25-0.5 mL of one of the following steroids is injected[5] :

  • Betamethasone sodium phosphate
  • Betamethasone acetate
  • Methylprednisolone, 40 mg/mL
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Contributor Information and Disclosures
Author

Stephen Kishner, MD, MHA Professor of Clinical Medicine, Physical Medicine and Rehabilitation Residency Program Director, Louisiana State University School of Medicine in New Orleans

Stephen Kishner, MD, MHA is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Chief Editor

Erik D Schraga, MD Staff Physician, Department of Emergency Medicine, Mills-Peninsula Emergency Medical Associates

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Drugs & Diseases gratefully acknowledge the contributions of previous author Alex Minh Nguyet Tran, MD, to the development and writing of the source article, as well as the assistance of James R Verheyden, MD, Consulting Surgeon, Department of Orthopedic Surgery, The Orthopedic and Neurosurgical Center of the Cascades, with the video contribution to this article.

References
  1. Mazzocca AD, Arciero RA, Bicos J. Evaluation and treatment of acromioclavicular joint injuries. Am J Sports Med. 2007 Feb. 35(2):316-29. [Medline].

  2. Shaffer BS. Painful conditions of the acromioclavicular joint. J Am Acad Orthop Surg. 1999 May-Jun. 7(3):176-88. [Medline].

  3. Bell AD, Conaway D. Corticosteroid injections for painful shoulders. Int J Clin Pract. 2005 Oct. 59(10):1178-86. [Medline].

  4. Skedros JG, Hunt KJ, Pitts TC. Variations in corticosteroid/anesthetic injections for painful shoulder conditions: comparisons among orthopaedic surgeons, rheumatologists, and physical medicine and primary-care physicians. BMC Musculoskelet Disord. 2007 Jul 6. 8:63. [Medline]. [Full Text].

  5. Tallia AF, Cardone DA. Diagnostic and therapeutic injection of the shoulder region. Am Fam Physician. 2003 Mar 15. 67(6):1271-8. [Medline].

  6. Ombregt L. A System of Orthopedic Medicine. 2nd ed. Churchill Livingstone; 2002. 327-31.

  7. Edelson G, Saffuri H, Obid E, Lipovsky E, Ben-David D. Successful injection of the acromioclavicular joint with use of ultrasound: anatomy, technique, and follow-up. J Shoulder Elbow Surg. 2014 Oct. 23(10):e243-50. [Medline].

  8. Aly AR, Rajasekaran S, Ashworth N. Ultrasound-guided shoulder girdle injections are more accurate and more effective than landmark-guided injections: a systematic review and meta-analysis. Br J Sports Med. 2014 Nov 17. [Medline].

 
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Acromioclavicular joint anatomy.
Patient (48-year-old woman with preexisting acromioclavicular [AC] joint arthritis), was hit by motor vehicle, which exacerbated her AC joint arthritis. Video courtesy of James R Verheyden, MD.
 
 
 
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