AC Joint Injuries Non-Surgical Treatment

Nonoperative treatment is the standard approach for patients who have:

• Type I injuries: A sprain without ligament tearing, which settles quickly and reliably.
• Type II injuries: Torn AC ligaments with intact coracoclavicular ligaments, which heal well with protection and a staged program.
• Most type III injuries: Complete disruption of both ligament groups with a reducible step. Comparative studies have not shown a consistent functional advantage for surgery in this group, and nonoperative treatment avoids an operation in patients who would have done well regardless. However, this is dependent on patient factors and whether or not horizontal instability is present.
• Higher-grade injuries in patients unsuitable for surgery: Where medical considerations or patient preference make an operation inadvisable.

Type IV, V, and VI injuries are not candidates for nonoperative treatment. They are unstable, and the displacement does not correct itself.

The shoulder blade is suspended from the collarbone by the coracoclavicular ligaments, but it is also supported by the muscles attaching to it. When those ligaments are torn, the scapular stabilizing muscles can take over much of the work, holding the shoulder blade in a functional position even though the ligaments have healed in a lengthened position. This is why a patient can have an obvious step at the top of the shoulder and full, painless overhead function. It is also why the rehabilitation program is built around scapular control rather than around the joint itself.

The step usually remains. Patients should expect the bump to persist and should understand that it does not predict pain, weakness, or limitation.

• Sling immobilization: A sling for comfort, typically a few days for a type I and one to three weeks for higher grades. Prolonged immobilization is avoided, as it produces stiffness without improving the eventual position of the joint.
• Ice and analgesia: Symptom control in the first one to two weeks, which is when the pain is at its worst.
• Early range of motion: Motion begins as pain allows, usually within the first week, with overhead elevation and cross-body reaching introduced progressively.
• Scapular stabilization: The centerpiece of the program. Strengthening the trapezius, serratus anterior, and rhomboids so the shoulder blade is supported by muscle rather than by the torn ligaments. This is what determines the functional outcome.
• Rotator cuff and deltoid strengthening: Added once motion is comfortable, restoring the strength lost in the first weeks.
• Avoiding cross-body and pressing loads early: Bench press, dips, and heavy cross-body work are deferred until the joint is no longer tender, usually four to six weeks in higher grades.
• Staged return to lifting: Pressing is reintroduced with a narrower grip and a shortened range, progressing as tolerated.
• Taping and padding for return to sport: Protective padding over the joint for contact athletes returning to play, which reduces the pain of a direct blow without changing the underlying injury.

Recovery tracks closely with grade. Type I injuries typically return to sport within one to two weeks. Type II injuries generally take two to four weeks. Type III injuries usually require six to twelve weeks, occasionally longer, with return determined by restored motion, strength that matches the other side, and the ability to tolerate contact. Some patients with type III injuries have persistent aching at the top of the shoulder when carrying heavy loads or after prolonged overhead work, and a small proportion go on to require surgery for that reason. Dr. Rynecki Baker discusses this possibility at the outset so that patients understand the plan is a reasonable first choice rather than a guarantee, and so that continued symptoms at three or four months are recognized as a reason to revisit the decision rather than to keep waiting indefinitely.

In-season athletes with type I and type II injuries can often return quickly with padding once pain allows, and Dr. Rynecki Baker works with athletes, trainers, and coaching staff on that timing directly.

Surgery may be discussed if a patient:

• Has a type IV, V, or VI injury, in which case surgery is recommended from the outset rather than after a trial of treatment
• Has a type III injury with persistent pain or functional limitation at three to six months despite a well-executed scapular program
• Has horizontal instability, with the collarbone shifting noticeably forward and backward, which is increasingly recognized as a predictor of poor nonoperative results
• Is a heavy laborer or overhead athlete with a type III injury whose work or sport depends on sustained overhead loading, where the decision is individualized
• Develops scapular dyskinesis, fatigue, or aching that does not resolve with rehabilitation
• Has chronic pain localized to the joint itself years later, which may reflect arthritis of the joint following the original injury