AC Joint Degeneration most commonly affects middle-aged and older adults. However, the condition can also occur in younger adults, particularly those who participate in contact sports or other activities that put repetitive stress on the shoulder. In this article we will explore AC Joint Degeneration, what causes deterioration of the acromioclavicular joint and what treatment options are available.

What is the AC Joint?

What we often refer to as our shoulder is actually a complex of four separate joints. The Acromioclavicular Joint or AC Joint is formed where the outer end of the collarbone or clavicle meets the acromion, a bony process on the scapula bone. The AC Joint attaches the scapula to the clavicle and is therefore the primary connection that suspends the upper limb from the trunk.

Several strong ligaments surround the AC Joint and work together to provide stability and maintain the alignment of the joint. The bony surfaces of the distal clavicle and the acromion are lined with joint cartilage and the joint capsule contains joint fluid to keep things moving smoothly. Some people have a small joint disc made up of fibrocartilage, similar to the meniscus found in the knee joint.

What is the function of the AC Joint?

The AC Joint is not as highly mobile as the Glenohumeral Joint (the ball and socket joint we often refer to as the shoulder) but it serves a few important functions:

1. It allows the scapula to rotate and tip on the thorax.
2. It allows for transmission of forces from the upper limb to the clavicle.

The AC Joint is hard at work whenever you move your upper limb through its range of motion, think of throwing, serving in tennis, push-ups and any other demanding movement of the arm and shoulder.

What causes AC joint degeneration?

The AC Joint is relatively small, but it still needs to deal with significant forces. In other words, we subject our AC Joints to large forces per unit area compared to our other joints. Unfortunately, this means that the AC Joint is extremely susceptible to trauma (often because of sporting injuries) and degenerative change. 

Primary osteoarthritis refers to joint degeneration that occurs with no underlying cause. It develops because of constant stress on the joint over a period of many years, often in people who perform repeated overhead lifting activities. Degenerative change refers to the gradual thinning and destruction of the joint cartilage to where the joint becomes osteoarthritic and painful. Degenerative change can occur as early as the 2nd decade but is very common and almost universal by the 6th decade.

Secondary osteoarthritis occurs because of a traumatic injury or an underlying inflammatory condition like rheumatoid arthritis. In a traumatic injury, a sudden abnormal force separates or dislocates the joint. Besides being extremely painful, these injuries raise the risk for later degenerative change. 

What are the symptoms of AC joint degeneration?

The primary symptom of AC Joint degeneration is pain. The pain is often felt at the top of the shoulder and provoked by overhead movements or sleeping on the affected shoulder. Sometimes there is some swelling or redness on top of the shoulder. Popping, clicking, or grinding sensations may be felt as the damaged cartilage surfaces move against one another. The AC Joint may be tender to the touch and even feel a little warmer than the surrounding area.

Your sports physician will make the diagnosis by performing a clinical examination and perhaps ordering imaging tests such as x-rays, ultrasound scans, or even an MRI.

How is AC joint degeneration treated?

Physiotherapy and activity modification

Physiotherapy is essential to manage pain, maintain the joint range of motion, strengthen stabilising muscles, and correct postural issues. Physiotherapy may include manual therapy, electro-modalities and exercise prescription.

Activity modification helps to avoid stressing the joint further and worsening the symptoms. Your physio will advise you to avoid push-ups, dips, flies, bench-press, and any repetitive overhead activities.

Oral analgesia

Pain-killing medications like non-steroidal anti-inflammatory drugs (NSAIDs) can diminish the pain from ACJ degeneration but have side-effects to consider.

Local corticosteroid injection

Your doctor will inject a mix of cortisone and local anaesthetic directly into the joint, usually under the guidance of an ultrasound scan. Corticosteroid injections can provide good pain relief but are ineffective in the long term. The pain usually comes back over a period of weeks to months.

Surgery

Surgical treatment is reserved for those severe cases that do not respond to at least six months of conservative treatment. Surgery can be done as an open or arthroscopic procedure (“keyhole surgery”). Arthroscopic procedures are generally associated with less pain and a faster return to function. 

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Frozen shoulder occurs more commonly in women than in men, tends to present in middle age, occurs in 1 in 5 diabetics, and can sometimes occur in both shoulders.

The good news is that the condition generally resolves or “thaws” spontaneously. The bad news is that this recovery can take from 6 months to more than 2 years. Furthermore, some patients report that their shoulder never recovers fully.

Fortunately, several treatment options are available that may ease the symptoms of this debilitating condition and even hasten the recovery to a full, pain-free range of motion. 

In this article, we’ll explore the pros and cons of the most common treatment options ranked from least invasive to most invasive.

Physiotherapy

For most patients, enrolling in a physical therapy program is the key to recovery and should be considered the backbone of frozen shoulder treatment.

Patient education is one of the most vital components of the physiotherapist’s role. By gaining an understanding of their own condition and being made aware of their own progress, patients can manage their expectations, reduce their frustration and be more compliant with their home exercise programmes.

Physiotherapists will invariably employ some manual muscle release techniques, passive and active mobilisations and various stretches. Depending on the stage of the condition, the physiotherapist may choose to include dry needling, TENS machines or kinesiotherapy techniques.

Hot and cold therapy

The joint is inflamed and painful during the initial “freezing stage” of frozen shoulder.

At this point, applying a heat pack might well make things worse. Choose a cold compress or ice pack instead to ease the pain. 

In the later adhesive or “thawing” stages, heat packs can be very effective when used before a stretching or home exercise session to promote an increased range of motion.

Topical creams and lotions

Various warming and cooling gels are available over the counter. Although these ointments might feel pleasant or tingly when applied, they will not impart any significant benefit.

In the initial painful phase, gels and patches containing non-steroidal anti-inflammatory drugs (NSAIDs) such as diclofenac may help to ease pain and inflammation.

Oral medication

Doctors often prescribe non-steroidal anti-inflammatory drugs to Frozen Shoulder patients. However, there is no high-level evidence that confirms their effectiveness. Nevertheless, many patients report they do provide relief during painful phases.

Oral corticosteroids are also prescribed to patients with frozen shoulder. The drugs mimic cortisol, a hormone produced by the body to temper an overreactive immune response. Corticosteroids rapidly reduce inflammation either directly or throughout the body. Many patients report some improvement in function after their use.

Long term oral steroid use does run the risk of significant side effects and so these drugs should be used in short bursts, if at all.

Corticosteroid injections

By injecting a corticosteroid medication directly into the shoulder joint, the powerful anti-inflammatory effects of the steroid can be concentrated where they are needed most. If performed early in the disease process the degree of inflammation within the joint can be lessened leading to less severe fibrosis and fewer adhesions forming. For this reason, corticosteroid injections are considered more effective in the painful and freezing stage of the condition. The corticosteroid is almost always mixed with a local anaesthetic agent that will also reduce pain and aid with improving the motor control of the shoulder complex.

Success rates range from 44 to 80% and many patients report rapid pain relief and improved function within the first few weeks of the injection. The injection may be given at the sub-acromial site or as an intra-articular injection but a recent study suggested that combining both sites may be the most effective. Corticosteroid injection should be considered a first-line treatment for patients with pain as their predominant complaint in the early stages of frozen shoulder. By combining a corticosteroid injection with ongoing physiotherapy, patients may give themselves the best chance at a rapid recovery without the need for surgery.

Manipulation under anaesthesia (MUA)

This involves going to an operating theatre and undergoing a general or regional anaesthetic. Once anaesthetised, the surgeon forcefully moves the shoulder in all planes in an attempt to stretch and disrupt the capsule to regain range of motion. It is not without risk of complications such as dislocation or fractures or even nerve injuries.

MUA should be considered a last resort and reserved for patients who are resistant to physical therapy. After manipulation, an extensive post-manipulation programme is necessary to preserve any range of motion gained.

Hydrodilatation

Also known as distension arthrography, hydrodilatation has emerged as a potential non-surgical option in the management of frozen shoulder. It involves the injection of a large volume of fluid (usually containing some steroid and local anaesthetic) into the shoulder joint under x-ray guidance. The goal is to stretch and expand the joint capsule like a water balloon.

There is no high-level evidence to support the technique yet but some studies have shown that it can provide short-term pain relief and improved function for up to 3 months.

Arthroscopic capsular release

Open shoulder surgery is almost never performed for frozen shoulder anymore. Arthroscopic surgery or so-called “key-hole surgery” however, is a reliable and effective method for restoring range of motion in non-responsive patients. It allows a controlled release of tight capsular structures under direct vision and avoids many of the side effects associated with MUA (although nerve injuries remain a concern).

Arthroscopic treatment should be considered in patients unresponsive to at least 6 months of good conservative treatment.

Conclusion

When it comes to curing frozen shoulder quickly, we may need to redefine what we mean by “quickly”. Frozen shoulder is a condition that can grumble on for years and expectations of a “quick-fix” are unrealistic. That said, there are many treatment options available that can accelerate the journey to healing. 

Early diagnosis is vital so that a corticosteroid injection has a chance to extinguish the inflammatory process. Ongoing physiotherapy can then restore any lost range of motion. 

All hope is not lost for patients who fail to respond to conservative measures – more invasive treatments including MUA, hydrodilatation or arthroscopy can be effective at treating this frustrating condition.

By Dr. Jarrad Van Zuydam, Sports Physician

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