Skip to main content
Symptom
dx.
Menu
Clinical Reference
Approaches
I have a symptom
Management
I know the diagnosis
Orthopedic Injuries
Fractures & dislocations
Calculators
Clinical calculators
Practical Skills
ECG
Interpretation guide
POCUS
Bedside ultrasound
Procedures
Step-by-step guides
Resuscitation
ACLS / PALS / NRP
Learn
Blog
Articles & updates
Deep Dive
In-depth clinical reviews
About
Our mission
Symptom
dx.
Clinical Reference
Approaches
I have a symptom
Management
I know the diagnosis
Orthopedic Injuries
Fractures & dislocations
Calculators
Clinical calculators
Practical Skills
ECG
Interpretation guide
POCUS
Bedside ultrasound
Procedures
Step-by-step guides
Resuscitation
ACLS / PALS / NRP
Learn
Blog
Articles & updates
Deep Dive
In-depth clinical reviews
About
Our mission
Get Started
Menu
Clinical Reference
Approaches
I have a symptom
Management
I know the diagnosis
Orthopedic Injuries
Fractures & dislocations
Calculators
Clinical calculators
Practical Skills
ECG
Interpretation guide
POCUS
Bedside ultrasound
Procedures
Step-by-step guides
Resuscitation
ACLS / PALS / NRP
Learn
Blog
Articles & updates
Deep Dive
In-depth clinical reviews
About
Our mission
Loading...
Acromioclavicular Separation
Cardiovascular Presentations
Abdominal aortic aneurysm
Acute coronary syndrome (NSTEMI)
Acute coronary syndrome (STEMI)
Acute decompensated heart failure
Acute limb ischemia
Acute mesenteric ischemia
Aortic dissection
Aortic stenosis
Atrial fibrillation and flutter
Bradyarrhythmia and heart block
Cardiac arrest
Deep vein thrombosis
Myocarditis
Pericarditis
Pulmonary embolism
Stable angina
Superficial thrombophlebitis
Superior vena cava syndrome
Supraventricular tachycardia
Syncope (cardiogenic)
Unstable angina
Ventricular tachycardia
Respiratory Presentations
Acute bronchitis
Acute respiratory failure
Aspiration pneumonia
Asthma exacerbation
Bronchiolitis
Community-acquired pneumonia
COVID-19 pneumonia
COPD exacerbation
Croup
Croup (laryngotracheobronchitis)
Epiglottitis
Hemothorax
Hospital-acquired pneumonia
Pleural effusion
Pneumothorax (traumatic)
Pulmonary contusion
Spontaneous pneumothorax
Neurological Presentations
Bell's palsy
Benign paroxysmal positional vertigo
Brain abscess
Cauda equina syndrome
Cervical radiculopathy
Concussion (mild traumatic brain injury)
Encephalitis
Guillain-Barré syndrome
Hemorrhagic stroke (intracerebral)
Ischemic stroke
Lumbar radiculopathy
Malignant spinal cord compression
Migraine
Peripheral neuropathy (acute)
Retropharyngeal abscess
Schizophrenia (acute exacerbation)
Seizure (breakthrough:known epilepsy)
Seizure (first-time)
Spinal cord injury
Status epilepticus
Subarachnoid hemorrhage
Tension headache
Transient ischemic attack
Traumatic brain injury (moderate-severe)
Vestibular neuritis
Viral meningitis
Gastrointestinal Presentations
Acute appendicitis
Acute cholecystitis
Acute diverticulitis
Acute pancreatitis
Anal fissure
Choledocholithiasis and cholangitis
Clostridioides difficile colitis
Gastritis
Gastroenteritis (viral and bacterial)
Gastroesophageal reflux disease
Incarcerated or strangulated hernia
Inflammatory bowel disease flare
Large bowel obstruction
Lower GI hemorrhage
Peptic ulcer disease
Perforated viscus
Small bowel obstruction
Upper GI hemorrhage
Genitourinary and Reproductive Presentations
Acute prostatitis
Acute urinary retention
Ectopic pregnancy
Epididymitis
Orchitis
Ovarian torsion
Paraphimosis
Pelvic inflammatory disease
Priapism
Pyelonephritis
Renal laceration
Ruptured ovarian cyst
Testicular torsion
Tubo-ovarian abscess
Urinary tract infection (uncomplicated)
Urolithiasis (renal colic)
Vaginal bleeding (non-pregnant)
Infectious Disease Presentations
Acute sinusitis
Acute tonsillitis
Acute upper respiratory infection
Animal bite
Bacterial meningitis
Cellulitis
Conjunctivitis (bacterial)
Dental abscess
Endocarditis
Febrile neutropenia
Fournier gangrene
Hand-foot-mouth disease
Hepatitis (acute)
Herpes zoster
HIV-related illness
Human bite
Impetigo
Infected diabetic foot ulcer
Infectious mononucleosis
Influenza
Necrotizing fasciitis
Osteomyelitis
Otitis externa
Parasitic infection
Periorbital cellulitis
Peritonsillar abscess
Scabies
Sepsis
Septic arthritis
Spontaneous bacterial peritonitis
Tick-borne illness (Lyme disease)
Tinea infection
Tuberculosis
Viral exanthem
Wound infection
Trauma Presentations
Achilles tendon rupture
ACL and mceniscus tear
Ankle fracture
Ankle sprain
Burn
Calcaneus fracture
Cervical spine fracture
Clavicle fracture
Dental avulsion
Distal radius fracture
Drowning
Elbow fracture and dislocation
Electrical injury
Facial bone fracture
Facial laceration
Femur fracture
Fingertip amputation
Forearm fracture (radius and ulna)
Frostbite
Hand:finger laceration
Heat exhaustion
Heat stroke
Hip fracture
Humeral shaft fracture
Knee dislocation
Knee sprain
Lightning injury
Mandible fracture
Metacarpal fracture
Metatarsal fracture
Muscle strain
Nasal fracture
Non-accidental trauma
Orbital fracture
Patella fracture
Phalanx fracture (finger)
Proximal humerus fracture
Pulmonary contusion
Rib fracture
Rotator cuff tear (acute traumatic)
Scalp laceration
Scaphoid fracture
Shoulder dislocation
Skull fracture
Splenic laceration
Sternal fracture
Supracondylar pediatric fracture
Tendon laceration (hand:wrist)
Thoracic and lumbar spine fracture
Tibia:fibula fracture
Tibial plateau fracture
Toe fracture
Traumatic epistaxis
Traumatic hyphema
Toxicologic Presentations
Acetaminophen toxicity
Alcohol intoxication
Alcohol withdrawal
Anticholinergic toxicity
Anticoagulant overdose
Benzodiazepine overdose
Benzodiazepine:sedative overdose
Beta-blocker and calcium channel blocker toxicity
Carbon monoxide poisoning
Caustic ingestion
Digoxin toxicity
Drug eruption
Foreign body ingestion
Opioid intoxication
Opioid overdose
Opioid withdrawal
Organophosphate
Salicylate toxicity
Serotonin syndrome
Stimulant intoxication (cocaine, methamphetamine)
Tricyclic antidepressant overdose
Psychiatric Presentations
Acute anxiety
Acute psychosis
Agitation:behavioral emergency
Bipolar disorder
Conversion disorder
Major depressive episode
Neuroleptic malignant syndrome
Suicidal ideation and attempt
Musculoskeletal and Rheumatologic Presentations
Acute low back pain (mechanical)
Bursitis
Cervical radiculopathy
Costochondritis
Gout (acute)
Lumbar radiculopathy
Pseudogout
Tendinitis
Dermatology Presentations
Acute eczema (Eczema acute flare)
Allergic contact dermatitis
Erythema multiforme
Henoch-Schönlein purpura
Pressure injury
Psoriasis (acute flare)
Stevens-Johnson syndrome
Toxic epidermal necrolysis
Urticaria (acute)
Environmental and Exposure Presentations
Envenomation (snake, spider, insect)
High-altitude illness
Hypothermia
Hematologic and Oncologic Presentations
Acute chest syndrome
Coagulopathy
Hyperviscosity syndrome
Sickle cell crisis (vaso-occlusive)
Symptomatic anemia
Thrombocytopenia (severe)
Tumor lysis syndrome
Pediatric-Specific Presentations
Bronchiolitis
Croup
Emergency delivery
Febrile seizure
Kawasaki disease
Neonatal jaundice
Neonatal sepsis
Nursemaid's elbow
Pediatric fever 0 to 28 days
Pediatric fever 29 to 60 days
Pediatric fever 61 to 90 days
Pyloric stenosis
Slipped capital femoral epiphysis
Intussusception
Endocrine and Metabolic Presentations
Adrenal crisis
Diabetic ketoacidosis
Hypercalcemia
Hyperosmolar hyperglycemic state
Hypertensive emergency
Hypertensive urgency
Hypoglycemia
Myasthenia gravis crisis
Myxedema coma
Severe hyperkalemia
Severe hyponatremia
Thyroid storm
ENT and Maxillofacial Presentations
Acute laryngitis
Acute otitis media
Acute pharyngitis
Cerumen impaction
Epistaxis (anterior)
Nasal foreign body
Otitis externa
Tympanic membrane perforation
Ophthalmologic Presentations
Acute angle-closure glaucoma
Central retinal artery occlusion
Chemical eye injury
Corneal abrasion
Corneal ulcer
Globe rupture
Ocular foreign body
Orbital cellulitis
Retinal detachment
Obstetric Presentations
Hyperemesis gravidarum
Painful vaginal bleeding in pregnancy
Placenta previa
Placental abruption
Preeclampsia:eclampsia
Preterm labor
Threatened:inevitable:incomplete abortion
Systemic and Miscellaneous Presentations
Anaphylaxis
Angioedema
Cannabis-induced hyperemesis
Acromioclavicular Separation
POCUS
Procedures
Calculators
Resuscitation
ECG Guide
Back
Clinical Assessment Checklist
Browse categories and answer follow-up questions to refine your symptom profile.
Approach to the Critical Patient
Immediate priorities
Injury severity triage
▶
Low-energy isolated mechanism
▶
Sports or fall onto point of shoulder
Likely isolated AC injury
High-energy mechanism
▶
Motor vehicle collision
Fall from height
Screen for polytrauma and associated injuries
If high-energy, apply trauma primary survey before focusing on shoulder
▶
ATLS ABCDE sequence
Defer isolated-extremity workup until life threats cleared
Airway and breathing threats
▶
Pneumothorax risk
▶
Ipsilateral chest wall impact
Decreased breath sounds
Tracheal or great-vessel proximity injury
▶
Posterior medial clavicle displacement
Stridor or dysphagia
If respiratory distress with chest trauma, immediate chest imaging
▶
Upright chest radiograph
eFAST for pneumothorax
Limb-threatening features
▶
Skin tenting by distal clavicle
▶
Type IV to VI marker
Pressure necrosis risk
Open injury
▶
Skin breach over joint
Surgical emergency
Neurovascular compromise
▶
Absent or diminished distal pulses
Progressive paresthesias
Monitoring and targets
Serial reassessment
▶
Neurovascular checks
▶
Radial pulse and capillary refill
Axillary nerve sensation over deltoid
Skin integrity over distal clavicle
▶
Blanching or tenting progression
Color change of overlying skin
Pain control adequacy
▶
Numeric pain score trend
Response to initial analgesia
Analgesia and immobilization targets
▶
Comfortable resting position
▶
Arm supported in sling
Reduced traction on joint
Early multimodal analgesia
▶
Acetaminophen plus NSAID
Ice to AC joint
Immediate consults
Orthopedic surgery triggers
▶
High-grade displacement
▶
Type IV posterior clavicle through trapezius
Type V severe superior displacement
Type VI inferior subacromial or subcoracoid displacement
Open injury or skin compromise
▶
Tenting at risk of necrosis
Wound communicating with joint
Associated injury requiring fixation
▶
Displaced distal clavicle fracture
Coracoid fracture
Trauma team triggers
▶
High-energy multisystem mechanism
▶
Concurrent chest or head injury
Hemodynamic instability
History
Presentation pattern
Core symptom complex
▶
Superior shoulder pain
▶
Localized to AC joint
Worse with cross-body adduction
Pain with overhead reaching
▶
Limits dressing and lifting
Limits sport participation
Visible deformity
▶
Step-off or prominent bump
Clicking or popping sensation
Onset and timing
▶
Acute onset at moment of trauma
▶
Immediate pain and swelling
Functional loss from outset
Insidious onset without trauma
▶
Consider distal clavicle osteolysis
Common in weightlifters
Mechanism of injury
Direct mechanisms
▶
Direct blow to lateral or superior shoulder
▶
Most common mechanism
Arm adducted at impact
Fall onto the acromion
▶
Point-of-shoulder contact
Cycling fall pattern
Indirect mechanisms
▶
Fall onto outstretched hand
▶
Force transmitted to AC joint
Less common than direct blow
Force and direction of impact
▶
Magnitude correlates with grade
Arm position at injury
Risk factors
Demographic and activity factors
▶
Male sex
▶
Age 20 to 49 years peak
Higher participation in collision sport
Contact and collision sports
▶
Football and hockey
Rugby and martial arts and boxing
Cycling
▶
Fall onto point of shoulder
Over-the-handlebars mechanism
Overuse and occupational factors
▶
Overhead athletes and weightlifters
▶
Distal clavicle osteolysis risk
Repetitive loading of AC joint
High-demand occupations
▶
Military personnel
Manual labor
Predisposing host factors
▶
Prior AC joint injury
▶
Recurrence risk
Residual instability
Generalized ligamentous laxity
▶
Ehlers-Danlos syndrome
Marfan syndrome
Important negatives and red flags
Associated-injury screen
▶
Neck pain or radicular symptoms
▶
Cervical spine source
Dermatomal sensory change
Hand numbness or tingling
▶
Brachial plexus involvement
Vascular compromise
Chest pain or dyspnea
▶
Pneumothorax with high-energy mechanism
Thoracic injury
Past medical and collateral history
▶
Prior shoulder surgery
▶
Distal clavicle excision
Rotator cuff repair
Sideline witnesses to mechanism
▶
Athletic trainer account
Arm position confirmation
Occupation and activity level
▶
Guides Type III decision
Overhead-demand assessment
Physical Exam
Inspection and palpation
Visual deformity assessment
▶
Step-off at AC joint
▶
Prominent elevated distal clavicle
Compare with contralateral shoulder
Swelling and ecchymosis
▶
Localized over AC joint
Skin tenting in high-grade injury
Posterior prominence
▶
Clavicle through trapezius suggests Type IV
Inferior displacement suggests Type VI
Palpation findings
▶
Point tenderness over AC joint
▶
Maximal directly over joint line
Crepitus with motion
Distal clavicle mobility
▶
Increased anteroposterior translation
Vertical instability
Provocative and stability tests
Piano key sign
▶
Downward pressure reduces deformity
▶
Springs back on release
Indicates Type III or higher instability
Cross-body adduction (Scarf) test
▶
Pain with passive horizontal adduction
▶
Sensitivity approximately 77%
Localizes pain to AC joint
O'Brien active compression test
▶
Resisted forward flexion at 90 degrees
▶
Arm adducted 10 to 15 degrees and internally rotated
Pain relieved with supination
Specificity approximately 95% for AC pathology
AC resisted extension test
▶
Pain on resisted horizontal extension
▶
Sensitivity approximately 72%
Combining tests improves accuracy
Neurovascular and complication screen
Neurovascular exam
▶
Axillary nerve function
▶
Deltoid strength
Regimental badge sensation
Distal perfusion
▶
Radial pulse
Capillary refill
Scapular and range-of-motion assessment
▶
Scapular dyskinesis
▶
May indicate high-grade Type IIIB instability
Altered scapulohumeral rhythm
Range of motion
▶
Limited abduction beyond 90 degrees by pain
Limited cross-body adduction
PITFALLS
Missed associated injury
▶
SLAP tear overlap
▶
Increased incidence with AC injury
Pain with overhead activity
Distal clavicle fracture mimics separation
▶
Radiographs differentiate
Neer Type II behaves like AC separation
Grading errors
▶
Under-grading without contralateral comparison
▶
CC distance reference needed
Type IIIA versus IIIB distinction
Overlooking subtle posterior displacement
▶
Axillary lateral view required
Type IV easily missed on AP alone
Differential Diagnosis
Traumatic shoulder differentials
Bony injuries
▶
Distal clavicle fracture
▶
ICD-10 S42.031A for displaced lateral clavicle fracture
Neer Type II disrupts CC ligaments
Coracoid fracture
▶
Associated with high-grade AC injury
Point tenderness over coracoid
Proximal humerus fracture
▶
Greater tuberosity tenderness
Different deformity pattern
Joint and soft-tissue injuries
▶
Glenohumeral dislocation
▶
Loss of normal shoulder contour
Arm held in abduction and external rotation
Sternoclavicular joint injury
▶
Medial clavicle tenderness
Posterior dislocation airway risk
Rotator cuff tear
▶
Weakness on specific testing
May coexist with AC injury
Non-traumatic and chronic mimics
AC joint pathology
▶
Distal clavicle osteolysis
▶
ICD-10 M89.51 osteolysis shoulder region
Insidious onset in weightlifters
Radiographic distal clavicle resorption
AC joint osteoarthritis
▶
Chronic joint-line pain
Positive cross-body adduction
Referred and developmental
▶
Cervical radiculopathy
▶
Dermatomal sensory change
Neck movement reproduces pain
Os acromiale
▶
Unfused acromial apophysis
Mimics injury on imaging
Primary AC separation coding
▶
Acromioclavicular joint sprain or dislocation
▶
ICD-10 S43.50 series for AC joint sprain
SNOMED CT acromioclavicular joint injury disorder
Laboratory Tests
Routine testing
Isolated AC separation labs
▶
No routine labs indicated
▶
Diagnosis is clinical and radiographic
Labs reserved for specific concerns
Analgesia safety considerations
▶
Renal function before sustained NSAID use
Bleeding history before NSAID
Infection workup
Subacute or chronic presentation with infection signs
▶
Inflammatory markers
▶
CBC for leukocytosis
ESR and CRP elevation
Microbiology
▶
Blood cultures before antibiotics
Joint aspirate culture if septic arthritis suspected
If erythema warmth and fever, evaluate for septic AC joint
▶
Joint aspiration for cell count
Crystal analysis to exclude gout
Preoperative labs
Surgical candidates
▶
Standard preoperative panel
▶
CBC and electrolytes
Coagulation studies per protocol
Type and screen when indicated
▶
Reconstruction with graft
Institutional protocol
Diagnostic Tests
Scoring Systems
Rockwood classification
▶
Type I
▶
Partial AC ligament tear with intact CC ligaments
Normal CC distance
Nonoperative sling management
Type II
▶
Complete AC tear with partial CC tear
Normal or slightly increased CC distance
Nonoperative management
Type III
▶
Complete AC and CC ligament tears
CC distance increased up to 100% versus contralateral
Controversial conservative versus surgical
Type IV
▶
Clavicle displaced posteriorly through trapezius
Variable CC distance
Surgical management
Type V
▶
CC distance increased 100% to 300%
Severe superior displacement
Surgical management
Type VI
▶
Clavicle displaced inferiorly under acromion or coracoid
Rare and associated with severe trauma
Surgical management
ISAKOS subclassification of Type III
▶
Type IIIA stable
▶
No overriding on cross-arm adduction view
Favors conservative management
Type IIIB unstable
▶
Clavicle overrides acromion
Favors surgical consideration
Diagnostic adjuncts
▶
Diagnostic AC joint injection
▶
Lidocaine confirms joint as pain source
Useful in chronic or equivocal cases
MRI
Role in AC separation
▶
Not routinely indicated acutely
▶
Diagnosis usually radiographic
Reserve for equivocal cases
Problem-solving indications
▶
CC ligament integrity in equivocal injury
Concomitant SLAP or rotator cuff injury
Chronic AC joint pain evaluation
Findings
▶
Ligament discontinuity and edema
Distal clavicle marrow edema in osteolysis
Limitations
▶
Cost and availability
▶
Not needed for clear high-grade injury
ACR Appropriateness Criteria reserve for selected cases
CT
Role in AC separation
▶
Rarely needed
▶
Reserved for complex patterns
Not first-line for grading
Indications
▶
Complex fracture characterization
Preoperative planning
Coracoid or glenoid involvement
Findings
▶
Three-dimensional displacement assessment
Associated fracture delineation
Considerations
▶
Radiation exposure
▶
Limit in young athletes
Use only when radiograph insufficient
Ultrasound
Point-of-care ultrasound
▶
CC ligament assessment
▶
Sensitivity approximately 89% versus MRI
Specificity approximately 90% versus MRI
Bedside AC joint evaluation
▶
Joint widening and step-off
Dynamic comparison with contralateral side
Advantages
▶
No radiation
Rapid ED adjunct
Limitations
▶
Operator dependent
▶
Requires musculoskeletal expertise
Adjunct rather than definitive grading tool
Radiographs
First-line imaging
▶
Standard views
▶
AP shoulder
Axillary lateral to detect posterior displacement
Zanca view with 10 to 15 degree cephalic tilt
Comparison imaging
▶
Contralateral side for CC distance
Increased CC distance indicates higher grade
Specialized views
▶
Cross-body adduction (Alexander) view
▶
Distinguishes Type IIIA from IIIB
Demonstrates clavicle overriding acromion
Weighted stress views
▶
Historically used and now falling out of favor
Delphi consensus finds AP and axillary sufficient
Disposition
Discharge versus consultation
Copy
ED discharge candidates
▶
Type I to III injuries
▶
Sling and analgesia provided
Orthopedic follow-up within 1 to 2 weeks
Neurovascularly intact
▶
Normal distal pulses
Intact axillary nerve function
In-ED orthopedic consultation
▶
High-grade injury
▶
Type IV to VI
Skin tenting at risk of necrosis
Open injury or neurovascular compromise
▶
Wound over joint
Diminished pulses or progressive deficit
Associated fractures requiring urgent care
▶
Displaced clavicle fracture
Coracoid fracture
Admission and observation
Admission indications
▶
Polytrauma
▶
Concurrent injuries requiring inpatient care
Hemodynamic concerns
Failed reduction of high-grade dislocation
▶
Persistent skin compromise
Operative timing planning
Observation role
▶
Generally not required
▶
Isolated AC separation managed outpatient
Reassess only if neurovascular concern
Follow-up planning
Copy
Follow-up timing by grade
▶
Type I
▶
Primary care follow-up acceptable
Expected recovery 2 to 4 weeks
Type II to III
▶
Orthopedic follow-up
Reassess at 2, 6, and 12 weeks
Referral pathways
▶
Sports medicine for athletes
▶
Return-to-sport planning
Functional rehabilitation
Surgical referral if conservative failure
▶
Persistent symptoms at 3 to 6 months
Reconstruction candidacy
Treatment
Analgesia
Multimodal pain control
▶
First-line oral analgesia
▶
Acetaminophen 650 to 1000 mg PO every 6 hours, maximum 4 g per day
Ibuprofen 400 to 600 mg PO every 6 to 8 hours
Naproxen 250 to 500 mg PO every 12 hours
Topical options
▶
Topical NSAID for localized pain
Adjunct to oral analgesia
Opioid use
▶
Use sparingly if at all
Short course only for severe pain
NSAID precautions
▶
Short-course use does not impair ligament healing
▶
Avoid prolonged use
Reassess renal and GI risk
Avoid in contraindicated patients
▶
Renal impairment
Active peptic ulcer disease
Immobilization and ice
Sling immobilization
▶
Sling for comfort
▶
Typically 2 weeks
Jones strapping offers no clear advantage over sling
Ice application
▶
15 to 20 minutes several times daily
Reduces swelling in acute phase
Activity modification
▶
Avoid overhead and cross-body loading
▶
Protect healing ligaments
Limit lifting on affected side
Grade-specific management
Types I and II nonoperative
▶
Conservative protocol
▶
Sling 2 weeks then early gentle ROM
Pendulum exercises as pain allows
Progressive rehabilitation
▶
ROM then scapular stabilization
Rotator cuff strengthening then sport-specific conditioning
Return-to-activity criteria
▶
Pain-free with full ROM
Symmetric strength
Type III individualized
▶
Initial conservative trial for most
▶
Sling 2 weeks then rehabilitation
Up to 80% have good outcomes without surgery
Early surgical referral candidates
▶
High-demand athletes and overhead workers
Military personnel
Type IIIB unstable injuries
If conservative treatment fails after 3 to 6 months, surgical reconstruction
▶
Persistent pain and dysfunction
Scapular dyskinesis
Types IV to VI surgical
▶
Orthopedic operative management
▶
Reduction and ligament reconstruction
Urgent if skin compromise
Surgical techniques
▶
CC ligament reconstruction with autograft or allograft
Hook plate fixation
Suture-button or arthroscopic-assisted techniques
Rehabilitation and return to sport
Postsurgical rehabilitation
▶
Early phase
▶
Sling 2 to 4 weeks then pendulum exercises
Active ROM at 4 to 6 weeks
Strengthening phase
▶
Resisted exercises at 6 weeks
Return to sport at approximately 4.5 to 6 months
Return-to-sport data
▶
Operative outcomes
▶
Pooled return-to-sport rate 91.5%
85.6% return to pre-injury level
Mean time to return approximately 5.7 months
Nonoperative timeline
▶
Mean return approximately 52 days
Faster than operative mean of 127 days
Return criteria
▶
Pain-free with full ROM
Symmetric strength and sport-specific testing
Adjunct considerations
Corticosteroid injection
▶
Reserved for chronic AC pain or osteoarthritis
▶
Diagnostic and therapeutic
Not standard in acute traumatic setting
Procedural cautions
▶
Avoid in suspected infection
Limit repeat injections
Nutrition for healing
▶
Adequate protein and calories
▶
Supports tissue repair
Maintain hydration during rehabilitation
Bone health
▶
Adequate calcium and vitamin D
Address metabolic bone disease
Special Populations
Pregnancy
Imaging approach
▶
Radiographs with shielding
▶
Shoulder is remote from uterus
Minimal fetal exposure with abdominal shielding
Avoid unnecessary CT
▶
Use ultrasound adjunct when feasible
MRI without contrast if advanced imaging needed
Analgesia safety
▶
Acetaminophen first-line
▶
Preferred analgesic in pregnancy
Avoid exceeding maximum dose
NSAID avoidance
▶
Avoid after 20 weeks gestation
Risk of oligohydramnios and ductal closure
Opioids minimized
▶
Short course only if essential
Neonatal withdrawal risk near term
Geriatric
Modified clinical approach
▶
Lower-energy mechanisms cause injury
▶
Ground-level falls
Osteoporotic distal clavicle
Concurrent fracture risk
▶
Distal clavicle fracture more likely
Screen for proximal humerus fracture
Treatment considerations
▶
Conservative management favored
▶
Lower functional demand
Surgical risk higher with comorbidity
Analgesia adjustments
▶
Renal dosing of NSAIDs
Fall-risk caution with opioids
Rehabilitation focus
▶
Early mobilization to prevent stiffness
Fall-prevention counseling
Pediatrics
Anatomic differences
▶
Pseudodislocation pattern
▶
Periosteal sleeve avulsion
Clavicle displaces out of periosteal tube
Physeal involvement
▶
Distal clavicle physis closes late
Apparent separation may be physeal injury
Management considerations
▶
High remodeling potential
▶
Most pediatric injuries managed conservatively
Periosteal sleeve enables reossification
Weight-based analgesia
▶
Ibuprofen 10 mg/kg PO every 6 to 8 hours
Acetaminophen 15 mg/kg PO every 6 hours
Nonaccidental injury screen
▶
Mechanism inconsistent with injury
Safeguarding referral when indicated
Background
Epidemiology
Frequency and burden
▶
Proportion of shoulder injuries
▶
Approximately 9% of all shoulder injuries
Up to 40% in elite contact-sport athletes
Demographic distribution
▶
Male predominance
Peak age 20 to 49 years
Grade distribution
▶
Vast majority are Types I to III
Types IV to VI are uncommon
Outcomes data
▶
Type III nonoperative outcomes
▶
Up to 80% have good outcomes without surgery
No significant functional difference versus surgery at one year
Distal clavicle osteolysis incidence
▶
Approximately 6% after AC separation
Overuse form in weightlifters
Pathophysiology
Ligamentous anatomy
▶
Acromioclavicular ligaments
▶
Provide horizontal stability
Torn first in injury progression
Coracoclavicular ligaments
▶
Conoid and trapezoid components
Provide vertical stability
Injury progression
▶
Sequential ligament failure
▶
AC ligaments fail before CC ligaments
Increasing displacement with higher grade
Deltotrapezial fascia involvement
▶
Disrupted in high-grade injury
Contributes to instability
Late sequelae
▶
Post-traumatic AC arthritis
▶
Develops months to years later
Chronic joint-line pain
Scapular dyskinesis
▶
Weakness with overhead activity
Associated with high-grade instability
Therapeutic Considerations
Conservative-first principle
▶
Most injuries heal without surgery
▶
Types I to III managed nonoperatively in most cases
Excellent outcomes with structured rehabilitation
Surgery reserved for high grade or failure
▶
Types IV to VI operative
Type III after failed conservative trial
Type III controversy
▶
Equivalent functional outcomes
▶
No significant difference at one year
Surgery may offer better cosmesis and UCLA scores
Decision factors
▶
Patient activity and occupational demand
Stability subtype IIIA versus IIIB
Cosmetic counseling
▶
Residual bump common with conservative care
▶
Does not necessarily correlate with function
Set expectations before discharge
Patient Discharge Instructions
copy discharge instructions
Copy
Diagnosis explanation
▶
You have a separated shoulder at the AC joint
Most separations heal without surgery
A visible bump may remain and usually does not affect function
Home care
▶
Wear the sling for comfort for about 2 weeks
Apply ice for 15 to 20 minutes several times a day
Take acetaminophen and anti-inflammatory medication as directed
Begin gentle pendulum movements as pain allows
Activity guidance
▶
Avoid heavy lifting and overhead reaching until cleared
Avoid contact sports until pain-free with full motion and normal strength
Follow the prescribed rehabilitation progression
Return to ER red flags
▶
Worsening deformity or new step-off
Increasing pain despite treatment
Numbness tingling or weakness in the arm or hand
Skin over the bump turning pale or breaking down
Inability to move the shoulder after initial improvement
Fever wound redness or drainage after surgery
Follow-up
▶
Orthopedic or sports medicine follow-up within 1 to 2 weeks
Type I may follow up with primary care
Keep scheduled reassessment appointments
References
Guidelines and key sources
Clinical guidance
▶
Simon LM et al, Acute Shoulder Injuries in Adults, American Family Physician 2023
ACR Appropriateness Criteria Acute Shoulder Pain 2024 Update
Team Physician Consensus Statement on musculoskeletal injuries 2024
Evidence and systematic reviews
▶
Cochrane review of surgical versus conservative treatment of AC dislocation 2019
Berthold DP et al, Current Concepts in AC Joint Instability, BMC Musculoskeletal Disorders 2022
Systematic reviews of return to sport after AC injury
Coding standards
▶
ICD-10 S43.50 series acromioclavicular joint sprain
ICD-10 M89.51 osteolysis shoulder region
SNOMED CT acromioclavicular joint injury disorder concept
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.
← Management Protocols
Home
Management Protocols
Acromioclavicular Separation