New York State Medical Treatment Guidelines for

The New York State workers compensation board has developed these guidelines to help physicians, podiatrists, and other healthcare professionals provide appropriate treatment for Acromioclavicular.

These Workers Compensation Board guidelines are intended to assist healthcare professionals in making decisions regarding the appropriate level of care for their patients with ankle and foot disorders.

The guidelines are not a substitute for clinical judgement or professional experience. The ultimate decision regarding care must be made by the patient in consultation with his or her healthcare provider.

Acromioclavicular (AC Joint Sprains / Dislocations of Shoulder

The term “shoulder separation” is frequently used to describe an acute AC joint injury.

Injury classification: The severity of injuries to the AC and Coracoclavicular (CC) ligaments, the AC joint capsule, and the shoulder stabilising muscles (trapezius and deltoid) that attach to the clavicle determine the degree of clavicular displacement.

History and Mechanism for Acromioclavicular injury

Mechanism of Injury (AC Joint Sprains/Dislocations): Patients typically suffer an AC joint injury when they land on the tip of the shoulder, which forces the acromion downward, or when they fall on an extended hand or elbow, which forces the shoulder outward and backward.The exclusion of alternative causes of shoulder discomfort from an acute injury, such as rotator cuff tears, fractures, and nerve injuries, is crucial.

Physical Findings of Acromioclavicular injury

Physical findings could consist of:

• A protrusion or asymmetry in the shoulder, tenderness at the AC joint, and/or contusions and/or abrasions at the joint region.
• The distal end of the clavicle is tender to palpation, there may be increased clavicular translation, and cross-body adduction can be excruciatingly painful.
• Positive piano sign is produced by applying downward pressure to the outstretched limb while placing one fingertip on the acromion and the other on the collarbone.When the clavicle depresses “like depressing a piano key” and the acromion moves distally, this is a good sign.

Laboratory Tests of Acromioclavicular is Recommended -When a systemic illness or disease is suspected in a subset of patients.

Testing Procedures of Acromioclavicular X-ray is Recommended -For certain patients, as clinically indicated.

Plain x-rays may include:

• AP view;
• AP radiograph of the shoulder taken in the “Zanca view,” with the beam tilted 10 degrees cephalad;
• Lateral views of the axilla; and
• Side-by-side comparison with 10-15 lbs. of weight in each hand, stress perspective.

Non-Operative Treatment Procedures is Recommended – For certain patients, as clinically indicated.

Non-Operative Treatment Techniques could consist of:

• Procedures like immobilization and patient-directed heat treatment (up to six weeks for Type I-III AC joint separations). Treatments for Type III injuries that involve immobilisation are debatable.
• Narcotics are typically not necessary; instead, medication such as nonsteroidal anti-inflammatories and analgesics is recommended.
• Steroid Injection in the Subacromial Space

Indications: If the patient responded favorably to a diagnostic injection of anesthetic, this procedure may be therapeutic. Direct steroid injections into the tendons are not advised.

Frequency: One or two injections are typically sufficient. It is advised to wait at least three weeks between injections. Local anaesthetics take immediate impact, but corticosteroids take three days to start working. Maximum duration: Three injections at the same place per year is the maximum allowed.

• Manipulation may be indicated in a Type II sprain.
• Interventions in physical therapy should stress a gradual improvement in range of motion without exacerbating the damage to the AC joint. A strengthening programme should be started once the patient can move more freely and the discomfort is under control.

  At this point, returning to a modified or limited duty schedule might be contemplated. With the restoration of complete or nearly full mobility by eight to eleven weeks, return to full duty should be anticipated.

Operative Procedures of Acromioclavicular

• An appropriate orthopedic evaluation should be considered after conservative treatment fails to improve function in a Type III AC joint injury.
• Orthopaedic surgical advice is advised for Type IV–VI AC joint injuries.

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Post-Operative Procedures of Acromioclavicular

The primary care physician and the orthopaedic specialist should coordinate these under the direction of the interdisciplinary team. Following the therapeutic and rehabilitation protocols outlined in this Shoulder NYS WCB MTG – Shoulder Injury 20 Guideline, the patient may be immobile for two to three weeks, restricted from work-related and extracurricular activities for six to eight weeks, and then expected to progress to return to full duty based on his or her response to the rehabilitation process and the demands of the job.

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