Acromioclavicular and sternoclavicular joint injuries in contact sports: a narrative review of conservative and surgical treatments

Introduction

Acromioclavicular (AC) joint sprains are a common musculoskeletal injury, accounting for between 3% to 9% of all injuries to the shoulder girdle (1,2). With respect to the contact athlete, AC joint injuries have been reported to account for up to 50% of shoulder injuries (3). Most injuries occur due to a direct blow or direct fall onto the superior aspect of the shoulder with the arm adducted, predisposing contact athletes in particular to these injuries (3,4). While most of these injuries can be treated in a non-operative fashion, including many Rockwood Type III AC joint injuries, higher grade injuries can require surgical stabilization in order to minimize symptomatic instability (1,2,5,6). Surgery in general consists of rigid fixation versus non-rigid ligamentous reconstruction versus coracoclavicular suspension, but there is little consensus regarding a single superior treatment modality (2,6,7).

Sternoclavicular (SC) joint injuries occur at the medial end of the clavicle and are much less common than AC joint injuries (8). SC joint injuries account for roughly 3% of shoulder injuries and <1% of instabilities (7). Given the rarity of these injuries, there is less consensus regarding non-operative vs surgical management of SC joint injuries (7,9). Biomechanically, the SC joint can only dislocate anteriorly or posteriorly, with posterior dislocations requiring reduction due to the proximity of surrounding neurovascular structures (7-9).

Contact athletes, defined as athletes participating in hockey, football, rugby, or lacrosse, are particularly at risk for AC and SC joint injuries due to their injury mechanisms (3,7). The purpose of this narrative review is to determine the current role for conservative and surgical treatment of AC and SC joint injuries in the contact athlete. In doing so, the authors sought to answer the following questions: (I) how do the rates of return to play compare between nonoperative and operative management of AC joint separation in an athletic population? (II) How do the rates of return to play compare between nonoperative and operative management of SC joint dislocation in an athletic population? We present this article in accordance with the Narrative Review reporting checklist (available at https://aoj.amegroups.com/article/view/10.21037/aoj-25-19/rc).

Methods

The authors conducted a comprehensive review of PubMed and MEDLINE on January 30th, 2025, to identify all studies that evaluated AC and SC joint injuries in an athletic population between 2010 to the present (Table 1, Figure 1, Table S1). Three authors (A.J.M., R.J.B., Jeremy M. Adelstein) independently screened all articles and organized pertinent articles into two categories. The first category consisted of clinical trials (randomized, cohort, case-series and/or case-control) reporting on the success of non-operative and/or operative treatment of AC or SC joint injuries in an athletic patient population. The second category consisted of clinical trials comparing nonoperative and/or operative treatment of AC or SC joint injuries within the general population. Articles were excluded if full text was not available in the English language, or if the article did not report on a clinical trial.

Figure 1 PRISMA 2020 flow diagram outlining identification, review and final inclusion of studies.

Articles were then divided into their respective anatomic location, consisting of articles reporting on AC joint sprain and articles reporting on SC joint dislocation. After considering the literature with regards to the athletic population, the general literature was then used as reference to help provide key insights for treating the contact athlete. In analyzing all articles, specific attention was paid to: nonoperative vs. operative management, type of operative management, rate of return to play, period of return to play and relevant clinical outcomes. When available, type of athlete, position, contact vs noncontact sport, and overhead vs non overhead sport was noted (Table 2).

For each article, all three reviewers independently evaluated the quality of included studies using the Methodological Index for Nonrandomized Studies (MINORS) tool (19). The tool grades non comparative studies from 0 to 16 and studies with a comparison group from 0 to 24 based on criteria related to study design, follow-up and outcomes. Higher scores indicate better study quality. The MINORS score of included studies was 12.4±2 for noncomparative studies and 17 for the comparison study (Table 2). Five total studies received scores of 11 (12,14,16-18). Among the studies receiving low scores, all received scores of 0 for unbiased assessment of the study endpoint, scores of 1 for length of follow-up sufficient to assess main endpoint and adverse events and scores of 0 for prospective calculation of study size based on statistical analysis.

In accordance with the above methodology, articles are presented with reference to joint injured (AC or SC), findings in an athletic population, and synthesis of the findings in athletes with a generalized patient population.

Key content and findings

AC joint sprains

Overall, the current literature with respect to the athletic population is extremely limited and heterogeneous. Of the six total studies focusing on athletes, two reported on ligament reconstruction with graft augmentation (10,12), two reported on tight-rope reconstruction (single or double) (11,13), one on clavicle hook plate (14), and one on generalized non-operative vs. operative management. In general, non-operative treatment of AC joint sprains in an athletic population was successful in a large majority of contact athletes (Tables 2,3) (11).

Roughly 98% of National Football League (NFL) athletes were managed without surgery. Rockwood Type I–III injuries were reported to have 3, 6, and 16 median days lost due to injury. Only three patients had Rockwood Type IV–VI injuries, with 29, 35 and 169 days lost for each athlete. It is not specified which injury corresponds with each time lost within this group. Of all NFL positions, Quarterbacks had the highest mean days of activity lost, at 17.3 days while linemen and linebackers had the lowest mean days of activity lost at 7.7 and 6.9 days, respectively (Table 3) (15).

Among athletes treated surgically for Rockwood Type III through V injuries, outcomes were also satisfactory. Median rate of return to sport ranged from 73% (13) to 100% and mean/median time to return ranged from 4–6 months in most cases (10,11,14). One study reported a 9.5-month median return to sport for overhead athletes compared to 4.5 months for non-overhead athletes, while another noted no correlation between radiographic appearance and clinical outcome (Table 3) (10).

When comparing the literature in athletes to the general population, several similar principles are seen. First, nonoperative management is often successful even in higher grade Rockwood Type V AC joint injuries when compared to both rigid and non-rigid fixation (20-22). Nonoperative groups had a quicker recovery of patient reported outcome measures, similar to improved long-term patient reported outcome measures and less long-term pain at the AC joint (20-22). Similar to the athletic population, radiographic appearance in these comparative studies did not correlate with clinical outcome (20-22).

When surgery is necessary, options reported in the general population include: suture reconstruction, rigid fixation with plates/screws/k-wire, reconstruction with graft augmentation, and non-rigid anatomic single, double and triple button repair (23-31). All treatment options do provide satisfactory outcomes with respect to reduction of the AC joint, but recent studies including randomized control trials and meta-analyses show lower pain scores and lower complication rates in non-rigid fixation when compared to rigid fixation (32-34). Despite these improvements, non-rigid reconstruction of the AC, coracoclavicular (CC), and combined ligaments do not restore baseline shoulder girdle kinematics (35). Furthermore, loss of radiographic reduction is cited as a common complication postoperatively despite type of fixation (34).

Given the above, several key principles can be applied to the contact athlete:

The vast majority of AC joint injuries, including Type V injuries, can be managed with an initial course of non-operative management (15,20-22). Even at the highest level of contact athletes seen in the NFL, 98% of players were not provided surgical treatment (15). Nonoperative management allows similar clinical outcomes, a shorter period of recovery and less overall complications when compared to both rigid and non-rigid fixation (20-22).

If surgery is required after failure of nonoperative management, treatment with anatomic non-rigid fixation with/without the use of graft appears to provide the highest rates of return to sport with the lowest rates of complication (10,14,34). In nearly all cases of surgery, normal shoulder kinematics will not fully normalize and loss of reduction is common (3,10,13).

Whether the treatment is nonoperative or operative, overall clinical progression of the athlete is most important factor in recovery (3,10,13,20-22). Anatomic radiographic appearance of the AC joint is commonly not achieved with either form of treatment, but little correlation exists between radiographic appearance and functional/pain scoring parameters. It is important to counsel the athlete on this prior to any form of treatment and to monitor their overall clinical status.

The success of return to previous level of activity is impacted most by overhead demand of sport and not by level of contact (11,15). Given this, appropriate consideration should be given to specific position of the contact athlete rather than the sport alone.

Considering the above principles, it is also important to understand complications from both operative and nonoperative intervention following AC joint sprains. Among patients treated non-operatively, the primary complication is persistent pain and inability to return to sport requiring surgery. Complication rates can be as low as 1.8% in professional athletes but are reported to be as high as 15% in higher grade sprains (15,22). With operative management, the primary complications are loss of reduction, persistent pain and hardware failure. Considering all complications in general, the rates are reported at up to 44% with loss of reduction being the most common complication (36). Other more rare complications seen on an individual basis within modern studies include fracture of the acromion or clavicle after drilling, neurovascular damage during surgery and surgical site infection (22,36,37).

SC joint dislocations

Literature pertaining to SC joint injuries in the contact athlete patient population is extremely limited. Two studies provided case reports on the nonoperative management of posterior SC joint dislocations in football and rugby (16,17). In both cases, athletes were able to successfully return to contact sport without complication following closed reduction (17) or physeal remodeling (16) with sling and gradual increase in activity. Time of return to sport was 8 weeks and 5 months for the two patients (16,17). Ingoe et al. specifically notes that surgical careful consideration should be given to having cardiothoracic surgery on standby for reductions with signs of major vessel involvement on imaging, or in some cases having interventional radiology preemptively place balloon catheters given anatomical high risk (17). One study reported on the operative treatment of anterior SC joint instability in 59 athletes following failure of nonoperative management (18). Within the study, all patients successfully returned to sport following hamstring reconstruction of the SC joint. However, only 45% of overhead athletes returned to their preinjury level of sport compared to 81% of non-overhead athletes (Tables 2,4) (18).

When comparing this study to recent literature, a few key findings are seen. In general, outcomes following surgical treatment of SC joint dislocation is satisfactory with plate fixation, rigid stabilization with k-wires, tension cable, and non-rigid fixation (33,38-40). While rare with fewer than 125 cases reported in the literature, vascular complication in the form of upper-extremity deep vein thrombosis, cardiac tamponade, and even cerebrovascular accident can happen with posterior SC joint dislocations and/or reductions (41-43). Overall rate of cardiothoracic intervention is around 0.76% and is higher in the presence of polytrauma and/or with symptoms of neurovascular compromise (44).

Due to the limited nature of the literature, recommendations for the contact athlete are as follows:

Closed reduction and non-operative management appears to allow for a safe return to contact sport within 2–6 months, but this is based on an extremely small sample size (16,17).

If nonoperative management fails, surgical fixation of the SC joint is reasonable, but patients should be counseled that there is a high rate of not returning to the pre-injury level of sport due to limited anterior and overhead arm positioning (18).

Similar to AC joint injuries, return to previous level of activity seems to depend less on contact level and more on overhead sport demand (18). Clinical progression and decision for return to sport will depend on position requirements.

Risk of cardiothoracic and/or interventional radiology intervention is low at less than 1%, but side effects can be devastating and life threatening including cerebrovascular accident and cardiac tamponade (41-43). Careful consideration should be given to getting cardiothoracic surgery and/or interventional radiology involved especially in athletes presenting with neurovascular symptoms (44).

Similar to AC joint sprains, consideration of complications is important in treatment of SC joint injuries. The most common complications cited are poor-cosmesis and redislocation, cited at rates of between 21–100% (45). Based on the narrative review at present, risk of neurovascular injury is overall low, although some studies do cite rates as high as 30% when including tracheal and esophageal injury (45). While the authors feel that contemporary data supports overall low rates of serious complications, these should still be discussed with each patient.

Limitations

The results of this study must be interpreted within the constraints of its limitations. Most of the studies included in this review were of lower level of evidence with most studies being level IV or V and only one level II (prospective) study. In addition to this, the studies overall present a low number of total cases, especially pertinent with the SC joint injury data presented. While the search terms were made to specifically capture treatment within an athletic population, the terms may not have been broad enough to capture all the studies evaluating AC and SC joint injuries in contact sports, contributing to the low number of studies and cases reported.

Heterogeneity amongst included studies exists and may further influence our findings. For example, studies had varying lengths of follow-up time which may evoke length-time bias when comparing return-to-sport times and other outcomes across studies. Further, although all these studies involve contact athletes, heterogeneity still exists as the studies still involve athletes of different sports and different levels of competitiveness. There also exists heterogeneity in the surgical techniques used as some athletes with AC joint treatment methods varied from graft reconstruction to tight-rope reconstruction to clavicular hook plates, which also limits our ability to make concrete comparisons between different study populations. Despite these limitations, this study still provides a comprehensive review on return-to-play outcomes for conservative versus surgical management of AC and SC joint injuries in contact athletes. The above limitations reduce the overall strength of recommendations provided.

Conclusions

Contact athletes with AC and SC joint injuries should be trialed with a course of nonoperative management, even in higher grade injuries. Athletes should be appropriately counseled, with particular attention paid to positions requiring increased overhead demand. When surgery is required, non-rigid anatomic fixation allows for a high rate of return to sport with less complications compared to rigid fixation.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the Guest Editor (Justin W. Arner) for the series “Care of the Contact Athlete’s Shoulder” published in Annals of Joint. The article has undergone external peer review.

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://aoj.amegroups.com/article/view/10.21037/aoj-25-19/rc

Peer Review File: Available at https://aoj.amegroups.com/article/view/10.21037/aoj-25-19/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://aoj.amegroups.com/article/view/10.21037/aoj-25-19/coif). The series “Care of the Contact Athlete’s Shoulder” was commissioned by the editorial office without any funding or sponsorship. J.E.V. reports receiving consulting fees from Arthrex and DePuy Synthes, a Johnson & Johnson company. J.G.C. reports receiving consulting fees from Smith & Nephew. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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