Clinical Notes : Orthopedics and Trauma

74. Acromioclavicular Joint pain

If the presenting shoulder pain is not referred from the neck then consider :

  1. Frozen shoulder

  2. Acromioclavicular joint pain

  3. Rotator cuff pain

    • Impingement

    • Tear

    • Calcific tendonitis

  4. Shoulder instability

    • SLAP tear

    • Dislocation

  5. Glenohumeral arthritis

Urgent referral if shoulder pain in the presence of :

  • History of trauma with acute pain & weakness

    • AC joint tear or displacement

    • Rotator cuff tear

  • History of trauma or epileptic fit leading to loss of rotation

    • SLAP tear

  • History of instability or subluxation

    • Dislocation

  • Mass/swelling/erythema

    • Infective process


Acromioclavicular disruption

Etiology :

Commonly, injury happens when :

  • falling onto an outstretched hand or elbow

  • direct blows to the shoulder

  • falling onto the point of the shoulder.


Diagnosis :

With an AC joint injury pain is often felt radiating to the neck and deltoid.

The AC joint may also become swollen, the upper extremity often held in adduction with the acromion depressed, which may cause the clavicle to be elevated.

When injury is minimal, a positive "cross arm" or "scarf" test points to the diagnosis

​​Video : Scarf Test   (0:34)


An AC joint injury and an injury to the biceps tendon both present with pain in same area.

Careful clinical examination may differentiate between the two.

Biceps tear

Biceps rupture

Video : Examination of AC joint and biceps tendon  (1:48)


Management :

  • Minor AC joint injury

    • week 1 and 2 post-injury

      • rest

      • NSAIDs

    • week 3 and 4 post-injury

      • physiotherapy

      • consider steroid injection

    • after 4 weeks

      • refer for imaging and specialist management

  • More severe AC joint injury with suspected tear or displacement

    • refer urgently to secondary care

Acromioclavicular osteoarthritis


Subtypes :

  • Post traumatic arthritis

    • following AC joint injury in youth

    • most common

  • Osteoarthritis

    • > 50yo

  • Rheumatoid arthritis

    • any age

Diagnosis :

  • MRI scan

  • determines severity ogf arthritic changes

  • predicts degree of success from intrarticular steroid injection

Management :

  • Mild and moderate arthritis

    • similar to acromioclavicular disruption

  • Severe arthritis

    • resection arthroplasty (can be arthroscopic)

Resection arthroplasty


Pathology and Intervention in Musculoskeletal Rehabilitation.

Magee DJ, Zachazewski JE, Quillen WS.

Elsevier Health Sciences, 2008.

Micheli LJ. Encyclopedia of Sports Medicine.

London: SAGE Publications, 2010.

Acromioclavicular joint injuries: indications for treatment and treatment options.

Johansen JA, Grutter PW, McFarland EG, Petersen SA.

J Shoulder Elbow Surg. 2011;20 p.S70-82


Injuries to the acromioclavicular joint

Fraser-Moodie JA, Shortt NL, Robinson CM.

J Bone Joint Surg. 2008 ;90-B: 697-707.


MRI Features of the Acromioclavicular Joint That Predict Pain Relief from Intraarticular Injection

Klaus Strobel, Christian W. A. Pfirrmann, Marco Zanetti, Ladislav Nagy and Juerg Hodler
American Journal of Roentgenology. 2003;181: 755-760.


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