Acromioclavicular Joint Injuries: Effective Rehabilitation

Abstract

Purpose: To perform a review of the literature focusing on rehabilitation protocols in patients with acromioclavicular (AC) joint injuries treated operatively and nonoperatively and to provide an updated rehabilitation treatment algorithm.

Methods: Studies were identified by searching the MEDLINE database from 01/1995 to 09/2020. Included studies contained detailed rehabilitation protocols with physiologic rationale for AC joint injuries. Biomechanical studies, technique articles, radiographic studies, systematic reviews, case studies, editorials, and studies that compared nonoperative versus operative treatment without focus on rehabilitation were excluded. Following identification of the literature, an updated treatment algorithm was created.

Results: The search strategy yielded 1742 studies, of which 1654 studies were excluded based on title, 60 on the abstract, and 25 on the full manuscript. One study was manually identified using article reference lists, yielding four publications presenting detailed rehabilitation protocols based on physiologic rationale. No randomized controlled trials or comparative studies were identified or cited as a basis for these rehabilitation protocols.

Conclusion: Few detailed rehabilitation protocols in patients with AC joint injuries have been published. These protocols are limited by their standardization, arbitrary timelines, and provide minimal assessment of individual patient characteristics. The quality of patient care can be improved with more practical guidelines that are goal-oriented and allow for critical thinking among clinicians to address individual patient needs. Three common barriers preventing successful rehabilitation were identified and addressed: Pain, Apprehension, and (anterior chest wall) Stiffness to regain Scapular control, effectively termed "PASS" for AC joint rehabilitation.

Clinical relevance: Rehabilitation protocols for AC joint injuries should be less formulaic and instead allow for critical thinking and effective communication among clinicians and therapists to address individual patient needs.

Keywords: AC joint; acromioclavicular joint; physical therapy; rehabilitation.

Figure 1

Flowchart of included studies.

Figure 2

Scapular clocks are effective closed-chain exercises that allow recruitment of the periscapular musculature, while limiting AC joint stress by unweighting the arm. Top, directing the affected scapula to the contralateral pant pocket with sustained contraction helps emphasize scapular retraction. Bottom, the examiner’s hand placed at the inferomedial border of the scapula is helpful for tactile feedback.

Figure 3

Phase 3 involves periscapular and rotator cuff strengthening. Top, rowing exercises with resistance tubing at various level of forward elevation are helpful, but the patient needs to focus on scapular retraction rather than compensation with shoulder extension. Middle, kinetic chain exercises including lawn mower and disco exercises help re-build functional strength. Bottom, Blackburn exercises, also called “T’s and “Y’s” are advanced strengthening exercises, recruiting high levels of middle and lower trapezius, at the expense of high stress placed at the AC joint. These are generally reserved for later in the rehabilitation process.

Figure 4

Patients in acute pain benefit from gentle range of motion (top) and active-assisted range of motion (bottom) working on external rotation and forward elevation. Active-assisted motion can be moderated using a cane/L-bar or the patient can use their contralateral upper extremity.

Figure 5

In those with apprehension, closed chain exercises including table slides (top), roller exercises (middle), and wall slides (bottom) unweight the arm, allowing the patient to isolate and focus on periscapular muscle activation. With the arm in a fixed position, asynchronies between the trunk, scapula, and arm are minimized.

Figure 6

Anterior chest wall stiffness results in a protracted scapula with limitations on functional range of motion. Top, a rolled up towel can be placed at the midline of the thoracic spine to allow gravity-dependent scapular retraction. Asymmetry evidenced by unilateral shoulder elevation off the examination table can be mitigated using slow and sustained manual downward pressure by the therapist. Bottom, various stretching exercises for pectoralis minor stiffness should be utilized while focusing on scapular retraction.