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1st Nov

2011

Orthopedic Manual Therapy for AC Joint Degeneration

Current literature shows that shoulder pain is second only to low back pain in its prevalence. We know that in approximately 30% of patients with shoulder pain, the joint called the AC joint between the collar bone and the top of the shoulder blade, is involved. The AC, or acromioclavicular joint is considered a typical arthritis joint, and starts to show degenerative changes early in life. Osteoarthritis in this joint is extremely prevalent, although many people affected develop stable, painless joints. Recent data have shown that almost 50% of people who have mild to moderate AC joint separations (Grade I or II), develop pain in the joint within six years after the injury.

With pain and osteoarthritis, the AC joint typically does not move well, and therefore can be excessively stressed as we move our shoulder through normal movements. When conservative management is recommended, it may include rest, activity modifications, oral analgesics and non-steroidal anti-inflammatory medications, and ice, however there is no research evidence to support such treatment long term. Cortisone injections have been reported to often produce pain relief for two hours to three months, but in 72-81% of the time have failed to achieve lasting benefits. Less is known about the effect of specific orthopedic manual therapy for non-acute AC joint disorders, as high quality research data have been lacking, although such treatment has been provided by skilled clinicians for decades.

A new well designed study was recently presented at a large national conference, that showed that orthopedic manual therapy including specific manual mobilization techniques to the AC joint followed by mobility and strengthening exercise, produce significant and meaningful improvement in pain and function after four weeks, and at six months follow-up, essentially identical to results, measured with the same instrument, reported by others following the “optimal surgical procedure”.

During rehabilitation exercise and conditioning exercise, people with AC joint pain may have the most problem with reaching all the way up, or reaching across their chest with the arm, and such motions need to be modified. The AC joint is stressed as movements are performed to their end, and therefore many traditional shoulder stretches must be avoided or performed with great care. Some people also have difficulty tolerating loaded exercises such as push-ups, resting on the elbows or dips. One large muscle covers the AC joint, namely the deltoid muscle, which can therefore provide stability to the joint. This muscle has three portions: the anterior deltoid in the front, the middle deltoid on the side, and the posterior deltoid in the back of the shoulder. These muscle fibers can be trained by e.g. reaching straight up in front with the arm, out to the side, and back and out, using free weights or e.g. a weight pulley apparatus. If there is additional weakness of the rotator cuff and stabilizing scapular (shoulder blade) muscles, these must be addressed before training the deltoid aggressively, in order to prevent abnormal shoulder mechanics and problems such as shoulder impingement.

I wish you all a wonderful Thanksgiving Holiday!

Best wishes,

Gunnar

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