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A fall onto your shoulder, a heavy tackle or even repetitive gym training can all cause problems with the acromioclavicular joint (AC joint) – the small joint at the top of the shoulder where the collarbone meets the shoulder blade.
Some AC joint injuries cause little more than temporary pain and settle well with time and physiotherapy. Others result in a very noticeable lump at the top of the shoulder, persistent instability or difficulty returning to sport.
Understandably, one of the first questions patients often ask is: ‘will I need surgery?’
The answer depends on the type and severity of the injury, but surgery is certainly not inevitable.
London Bridge Orthopaedics upper limb surgeon Mr Simon Owen-Johnstone recently joined Complete Physio clinical director and specialist physiotherapist Chris Myers to discuss AC joint injuries, their diagnosis and the point at which surgical treatment should be considered.
The AC joint sits at the top of your shoulder, where the outer end of the clavicle – your collarbone – meets the acromion, which forms part of the shoulder blade.
Although it is a relatively small joint, it plays an important role in the overall movement of the shoulder girdle.
AC joint problems broadly fall into two groups.
The first is atraumatic or overuse AC joint pain. This is commonly seen in people who regularly lift weights, particularly those doing a lot of bench pressing and overhead work.
The second is an acute traumatic AC joint injury, usually caused by falling directly onto the outside of the shoulder.
These two problems can involve the same joint, but their treatment can be quite different.
AC joint pain is often remarkably well localised.
As Simon explains:
“They point with one finger to the end of the collarbone.”
Patients may experience pain:
With a more significant traumatic injury, there may also be swelling and an obvious bump or prominence at the end of the collarbone.
Not every painful AC joint has been dislocated.
Repetitive loading can irritate the joint and its surrounding tissues without one identifiable injury. This is particularly common in people doing frequent or heavy upper-body training.
Possible causes include inflammation of the joint capsule, degeneration within the joint and distal clavicle osteolysis, an overuse-related bony change affecting the outer end of the collarbone.
Treatment usually begins conservatively.
This doesn’t necessarily mean stopping the gym completely. Instead, it may mean temporarily reducing the particular loads and movements that are repeatedly irritating the joint.
As Chris Myers explains in the podcast:
“You don’t need to stop going to the gym, but you do need to modify for a period of time.”
Simon also highlights that biological recovery frequently takes longer than patients expect:
“Anything biological doesn’t take a month, it takes more like three months.”
Repeatedly resting until the pain improves and then immediately returning to the same heavy loading is one reason symptoms can recur.
Diagnosis starts with listening carefully to how the problem developed and examining the shoulder.
Localised tenderness directly over the AC joint combined with pain during movements such as cross-body adduction can strongly suggest that the AC joint is the source of symptoms.
Imaging requirements depend on the circumstances.
Following a significant traumatic injury, X-rays are particularly important. They can exclude fractures and assess the relationship between the clavicle and acromion, helping to classify an AC joint separation.
An MRI may occasionally be required if the diagnosis remains unclear or another significant shoulder injury is suspected.
Musculoskeletal ultrasound can provide additional information about the AC joint, particularly where symptoms are persistent or the clinical diagnosis is uncertain.
Because the AC joint is superficial, ultrasound can visualise the joint and surrounding soft tissues in real time.
Depending on the pathology, it may demonstrate joint or capsular swelling, synovial change, capsular thickening, degenerative bony changes and abnormalities affecting the superficial AC ligaments and surrounding tissues.
Ultrasound also has the advantage of being dynamic: the joint can be assessed during movement, which may help identify abnormal movement or instability.
However, ultrasound doesn’t replace X-ray assessment following significant trauma. Instead, the different imaging techniques provide complementary information.
Ultrasound can also be used to guide a diagnostic local anaesthetic or corticosteroid injection accurately into the small AC joint when appropriate.
For persistent inflammatory AC joint pain that hasn’t responded adequately to activity modification and rehabilitation, a corticosteroid injection may be considered.
This can reduce pain and inflammation and potentially create a window in which rehabilitation can progress more effectively.
However, Simon and Chris are both clear that injection isn’t a long-term substitute for addressing the underlying loading problem.
As Chris explains, the problem can be that an effective injection makes the patient feel so good that they immediately return to exactly the same heavy training that aggravated the joint in the first place.
Repeated injections are therefore not usually the ideal long-term strategy.
The aim should be to combine symptom control with appropriate rehabilitation and a gradual return to load.
Traumatic AC joint injuries commonly occur when someone falls directly onto the point of their shoulder.
Simon frequently sees them following:
Rather than fracturing the bone, the force can damage the ligaments responsible for maintaining the relationship between the clavicle and shoulder blade.
The severity of that ligament damage determines the grade of injury.
The Rockwood classification is commonly used to describe traumatic AC joint separations.
A Grade I injury is essentially an AC joint sprain. The normal relationship between the bones is maintained, although the joint can be extremely painful.
These injuries are normally managed without surgery.
Treatment may include pain relief, temporary activity modification and physiotherapy, followed by progressive return to normal activity.
In a Grade II injury, there is more significant damage to the AC joint ligaments, but the deeper coracoclavicular ligaments remain intact.
A sling can be used initially for comfort, followed by progressive movement and physiotherapy.
Again, surgery is rarely necessary.
Grade III injuries are where decision-making becomes more interesting.
Both the AC and coracoclavicular ligaments have been disrupted and the end of the collarbone becomes more prominent.
The traditional approach has been to manage many Grade III injuries without surgery – and there is good evidence to support this.
Recent systematic reviews have found that conservative treatment can produce comparable long-term functional outcomes to surgery for many Grade III injuries.
But that doesn’t mean every Grade III injury behaves in the same way.
Simon explains:
“My experience is that some injuries clearly require surgery and some aren’t so clear – it is always a joint decision between the patient, surgeon and physio”
Some patients regain excellent function, have little or no pain and aren’t particularly concerned by the residual bump.
Others experience persistent symptoms. The shoulder may feel unstable, clunk or catch when lifting, or simply feel mechanically “wrong”.
This is where an individual discussion with a shoulder surgeon becomes important.
There isn’t one correct answer for every patient.
Simon has been treating these injuries for many years and is very clear that patient preference and function need to form part of the decision.
Asked what he would do if he personally sustained a Grade III AC joint injury, he replied:
“I wouldn’t have an operation. I’d wait and try rehab first.”
The advantage of waiting is that many patients will discover they don’t need surgery at all.
The disadvantage is that a patient may spend several months rehabilitating the shoulder before deciding that the residual instability, pain or functional limitation isn’t acceptable. If they then undergo surgery, there is another postoperative rehabilitation period to complete.
Current research reflects this uncertainty. Surgery can provide better anatomical reduction, but studies have not consistently demonstrated superior long-term functional outcomes for all Grade III injuries.
The decision therefore needs to take into account factors such as:
As Simon puts it:
“It’s all patient choice; we provide the information and support to help patients make an informed choice”
Higher-grade AC joint injuries involve greater displacement and disruption of the surrounding soft tissues.
A Grade IV injury involves posterior displacement of the clavicle, while Grade V injuries involve more extensive soft-tissue disruption and significant displacement.
These injuries are more likely to require surgical treatment than Grade I – III injuries, although every patient still requires individual assessment.
Evidence comparing surgery and non-operative treatment across higher-grade AC joint injuries remains mixed, reinforcing the importance of specialist assessment rather than treating the X-ray alone.
There are several techniques for stabilising a significantly disrupted AC joint.
Simon describes his preferred technique as using a strong synthetic ligament that passes around the coracoid and clavicle to restore their relationship.
The reconstruction initially provides mechanical stability while healing and scar tissue develop around it.
As Simon describes it, the implant acts rather like a temporary scaffold around which the body can heal.
Surgery can produce very good results in appropriately selected patients, but it is important to recognise that it isn’t an instant solution.
This is particularly important for active patients considering surgery.
Following AC joint stabilisation, Simon advises patients that healing takes approximately three months, with strict restrictions on heavier lifting during this initial period.
Feeling good doesn’t necessarily mean the reconstruction has fully healed.
This is why physiotherapy is such an important part of postoperative care.
As Simon says:
“Everyone who has a shoulder operation needs physio.”
Physiotherapy helps maintain appropriate movement, progressively restore strength and guide the patient through each stage of rehabilitation without overloading the reconstruction too early.
The eventual aim is to rebuild towards normal daily activity, work, gym training and sport.
One of the most important messages from Simon’s discussion with Chris is that physiotherapy and surgery shouldn’t be viewed as competing treatments.
For many patients, rehabilitation is the treatment.
For others, physiotherapy is used initially to establish whether surgery is actually necessary.
And when an operation is required, rehabilitation becomes essential to achieving the best possible functional result afterwards.
This philosophy is central to Simon’s practice at London Bridge Orthopaedics. His approach is to consider non-operative treatment first where appropriate, while providing surgical options when persistent pain, instability or the severity of an injury means that conservative management is unlikely to provide the result the patient needs.
If you have sustained an AC joint injury and aren’t sure whether it requires surgery, assessment by an experienced shoulder specialist can help establish the grade of injury, identify any associated damage and discuss the advantages and disadvantages of both conservative and surgical treatment.
You can find out more about Mr Simon Owen-Johnstone and his upper limb practice at London Bridge Orthopaedics or explore the LBO Shoulder & Elbow service.
The article accompanies Simon’s discussion with specialist physiotherapist Chris Myers. You can also find out more about Chris Myers at Complete Physio and physiotherapy and sports injury rehabilitation at Complete Physio.
Yes. Most Grade I and II AC joint injuries are treated without surgery, and many Grade III injuries can also recover successfully with physiotherapy and progressive rehabilitation.
The decision depends on the severity of the injury and whether pain, instability or functional problems persist.
Research supports non-operative management as a reasonable first-line approach for many Grade III injuries.
Milder injuries may feel substantially better within several weeks, but ligament and soft-tissue healing takes longer.
Simon advises patients to think in terms of approximately three months for biological healing, particularly following a more significant injury.
Returning to heavy gym training or contact sport may take longer and should be guided by pain, movement, strength and function rather than time alone.
Not necessarily. Many Grade III injuries have good long-term outcomes without surgery. However, surgery may be considered when there is persistent pain, instability, clunking, difficulty returning to sport or work, or when the patient remains unhappy with the function or appearance of the shoulder.
Current research supports individualised decision-making rather than routinely operating on all Grade III injuries.
A prominent end of the collarbone can remain after a significant AC joint separation, even when the shoulder has recovered well functionally.
For many people this causes no significant problem. Surgery is not normally recommended purely because an X-ray or shoulder looks abnormal; symptoms, stability, function and the patient’s priorities are more important.
Yes, in most cases, but returning to heavy pressing or overhead exercise should be gradual. Lower-body and non-provocative exercise can often continue much earlier.
Following AC joint reconstruction surgery, lifting restrictions are considerably more important while the repair heals, and rehabilitation should be guided by the surgical and physiotherapy team.
Many AC joint injuries don’t require surgical treatment and will recover with appropriate conservative management.
However, some more significant injuries can leave persistent pain, instability, clicking or difficulty with heavy lifting and sport.
If symptoms remain despite rehabilitation, specialist assessment can determine whether further imaging or surgical treatment should be considered.
1. Xie, C., Fan, S., Chen, L. et al. (2024). Comparative efficacy of operative versus conservative treatment for Rockwood type III acromioclavicular joint dislocation: a systematic review and meta-analysis of randomized controlled trials. BMC Musculoskeletal Disorders, 25, 960.
Read the full paper
2. Lameire, D.L. et al. (2026). Outcomes after operative versus nonoperative management of Type III to V acromioclavicular joint dislocations: a systematic review and meta-analysis of randomized controlled trials. Orthopaedic Journal of Sports Medicine.
Read the full paper
3. Pogorzelski, J. et al. (2017). The acutely injured acromioclavicular joint – which imaging modalities should be used for accurate diagnosis? A systematic review. BMC Musculoskeletal Disorders, 18, 515.
Read the full paper
4. Adra, M., Mohamed Haroon, A., Milchem, H. et al. (2024). Operative versus nonoperative management of high-grade acromioclavicular injuries: a systematic review and meta-analysis. Cureus, 16(12), e76682.
View the paper on PubMed
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