eMedicine Specialties > Sports Medicine > Shoulder

Acromioclavicular Joint Injury: Differential Diagnoses & Workup

Author: L. Edward Seade, MD, Chief of Shoulder Service, Orthopaedic Specialists of Austin
Coauthor(s): Reed L Bartz, MD, Consulting Staff, Division of Sports Medicine, Nebraska Orthopaedic and Sports Medicine PC; Robert Josey, MD, Consulting Staff, Department of Orthopedic Surgery, Orthopaedic Specialists of Austin
Contributor Information and Disclosures

Updated: Oct 27, 2008

Differential Diagnoses

Clavicular Injuries
Rotator Cuff Injury
Shoulder Dislocation
Shoulder Impingement Syndrome
Superior Labrum Lesions

Other Problems to Be Considered

Glenoid labrum tear

Workup

Imaging Studies

  • Radiographs
    • As with all skeletal injuries, a minimum of 2 radiographic views is necessary to evaluate the individual injury in cases of suspected acromioclavicular joint injury.
      • AP and lateral views are the minimum needed to evaluate an acromioclavicular joint injury. The AP view should be taken with the arms at the side, and both acromioclavicular joints should be imaged for comparison. If a true AP view is obtained, the acromioclavicular joint can be seen superimposed on the spine of the scapula; hence, some authorities have recommended the Zanca view, in which 10-15° of cephalic tilt of the radiographic beam provides a clearer image of the acromioclavicular joint. (See Images 2-3 or below.)
        Type III acromioclavicular joint separation.

        Type III acromioclavicular joint separation.

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        Type III acromioclavicular joint separation.

        Type III acromioclavicular joint separation.


        Type III acromioclavicular joint separation.

        Type III acromioclavicular joint separation.

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        Type III acromioclavicular joint separation.

        Type III acromioclavicular joint separation.

      • An axillary lateral view is also needed in suspected acromioclavicular joint injuries to account for any anterior or posterior displacement of the distal clavicle.
    • If an unstable acromioclavicular joint injury is suspected, yet not confirmed on routine AP and lateral views, stress views may be indicated.
      • Ten to 15 lb of weight should be attached to the wrist of the affected side, and an AP view can be taken. This stress tests the integrity of the coracoclavicular ligament, and, if the ligament has been disrupted completely, the test will demonstrate the complete dislocation.
      • Routine use of stress radiographs is not recommended in the emergency department setting because of the painful nature of the test. Weighted stress tests may be valuable in follow-up care if the clinician has any doubt about the instability of the acromioclavicular joint. Even with conservative care of types III-VI acromioclavicular disruptions, this test may be helpful for determining a timetable for return to conditioning and sporting activities.
    • Athletes with a previous history of acromioclavicular injury or a history of heavy weight lifting may present with relatively acute shoulder pain over the distal clavicle, and they may have classic radiographic findings of distal clavicle osteolysis or acromioclavicular osteoarthritis (ie, joint narrowing, distal clavicle or acromial spurring). When these radiographic findings are present, the clinician may expect that seemingly little trauma may result in significant pain.
  • Magnetic resonance imaging (MRI)
    • MRI is not routinely ordered in the management of straightforward acromioclavicular disruptions. Detailed knowledge of acromioclavicular and coracoclavicular ligamentous injury is not needed for conservative or, in rare cases, surgical care.
    • In middle-aged and older patients who continue to have disabling shoulder pain after the acute pain of an acromioclavicular disruption abates, one may consider an MRI to evaluate for a possible rotator cuff tear.
    • Very rarely, athletes with persistent pain over the acromioclavicular joint merit an MRI to determine whether or not the cartilaginous disk has been damaged irreversibly and to determine whether or not the process of distal clavicle osteolysis or early osteoarthritis has begun.

More on Acromioclavicular Joint Injury

Overview: Acromioclavicular Joint Injury
Differential Diagnoses & Workup: Acromioclavicular Joint Injury
Treatment & Medication: Acromioclavicular Joint Injury
Follow-up: Acromioclavicular Joint Injury
Multimedia: Acromioclavicular Joint Injury
References
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References

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  2. Macdonald PB, Lapointe P. Acromioclavicular and sternoclavicular joint injuries. Orthop Clin North Am. Oct 2008;39(4):535-45. [Medline].

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

  4. Slawski DP, Cahill BR. Atraumatic osteolysis of the distal clavicle. Results of open surgical excision. Am J Sports Med. Mar-Apr 1994;22(2):267-71. [Medline].

  5. Cahill BR. Osteolysis of the distal part of the clavicle in male athletes. J Bone Joint Surg Am. Sep 1982;64(7):1053-8. [Medline]. [Full Text].

  6. Murphy OB, Bellamy R, Wheeler W, Brower TD. Post-traumatic osteolysis of the distal clavicle. Clin Orthop Relat Res. 1975;109:108-14. [Medline].

  7. Flatow EL, Duralde XA, Nicholson GP, Pollock RG, Bigliani LU. Arthroscopic resection of the distal clavicle with a superior approach. J Shoulder Elbow Surg. Jan-Feb 1995;4(1 pt 1):41-50. [Medline].

  8. Allman FL Jr. Fractures and ligamentous injuries of the clavicle and its articulation. J Bone Joint Surg Am. Jun 1967;49(4):774-84. [Medline]. [Full Text].

  9. Fukuda K, Craig EV, An KN, Cofield RH, Chao EY. Biomechanical study of the ligamentous system of the acromioclavicular joint. J Bone Joint Surg Am. Mar 1986;68(3):434-40. [Medline]. [Full Text].

  10. Le Corroller T, Cohen M, Aswad R, Pauly V, Champsaur P. Sonography of the painful shoulder: role of the operator's experience. Skeletal Radiol. Nov 2008;37(11):979-86. [Medline].

  11. Lee SJ, Keefer EP, McHugh MP, Kremenic IJ, et al. Cyclical loading of coracoclavicular ligament reconstructions: a comparative biomechanical study. Am J Sports Med. Oct 2008;36(10):1990-7. [Medline].

  12. Rolf O, Hann von Weyhern A, et al. Acromioclavicular dislocation Rockwood III-V: results of early versus delayed surgical treatment. Arch Orthop Trauma Surg. Oct 2008;128(10):1153-7. [Medline].

  13. Seade LE. Coracoclavicular ligament reconstruction with semitendinosus allograft for AC joint separations, 2-5 year follow-up. Presented at: Annual Meeting of Texas Orthopaedic Association; May 14, 2004; Austin, Texas.

  14. Seade LE. Coracoclavicular ligament reconstruction with semitendinosus allograft for AC joint separations, 2-5 year follow-up. Presented at: Western Orthopaedic Association; October 13, 2006; Santa Fe, New Mexico.

  15. Urist MR. Complete dislocation of the acromioclavicular joint: the nature of the traumatic lesion and effective methods of treatment with analysis of 41 cases. J Bone Joint Surg Am. 1946;28A:813-37. [Full Text].

  16. Zanca P. Shoulder pain: involvement of the acromioclavicular joint. (Analysis of 1,000 cases). Am J Roentgenol Radium Ther Nucl Med. Jul 1971;112(3):493-506. [Medline].

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Further Reading

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Keywords

acromioclavicular joint injury, shoulder pain, shoulder injury, shoulder dislocation, shoulder separation, acromioclavicular joint separations, dislocated shoulder, AC joint injury, AC separation, AC joint disruption, acromioclavicular disruption, shoulder joint

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Contributor Information and Disclosures

Author

L. Edward Seade, MD, Chief of Shoulder Service, Orthopaedic Specialists of Austin
Disclosure: Nothing to disclose.

Coauthor(s)

Reed L Bartz, MD, Consulting Staff, Division of Sports Medicine, Nebraska Orthopaedic and Sports Medicine PC
Disclosure: Nothing to disclose.

Robert Josey, MD, Consulting Staff, Department of Orthopedic Surgery, Orthopaedic Specialists of Austin
Robert Josey, MD is a member of the following medical societies: American Medical Association, Phi Beta Kappa, and Texas Medical Association
Disclosure: Nothing to disclose.

Medical Editor

David T Bernhardt, MD, Director of Adolescent and Sports Medicine Fellowship, Associate Professor, Department of Pediatrics, University of Wisconsin
David T Bernhardt, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Sports Medicine, and American Medical Society for Sports Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Russell D White, MD, Professor of Medicine, Department of Community and Family Medicine, University of Missouri-Kansas City School of Medicine, Truman Medical Center Lakewood
Disclosure: Nothing to disclose.

CME Editor

Jon B Whitehurst, MD, Clinical Instructor of Surgery, University of Illinois College of Medicine; Partner and Executive Board Member, Rockford Orthopedic Associates; Orthopedic Chairman, Rockford Memorial Hospital
Jon B Whitehurst, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, and Arthroscopy Association of North America
Disclosure: Nothing to disclose.

Chief Editor

Craig C Young, MD, Professor, Departments of Orthopedic Surgery and Community and Family Medicine, Medical Director of Sports Medicine, Sports Medicine Fellowship Director, Medical College of Wisconsin
Craig C Young, MD is a member of the following medical societies: American Academy of Family Physicians, American College of Sports Medicine, American Medical Society for Sports Medicine, Phi Beta Kappa, and Wilderness Medical Society
Disclosure: Nothing to disclose.

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