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Clinical Pearl

Evaluation and Management of Grade III Acromioclavicular Joint Separations

Vincent, Kevin R. MD, PhD, FACSM, CAQSM; Vincent, Heather K. PhD, FACSM

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Current Sports Medicine Reports: November 2018 - Volume 17 - Issue 11 - p 358-359
doi: 10.1249/JSR.0000000000000530
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Acromioclavicular (AC) joint separations are common in sports medicine clinics. Acromioclavicular joint separations are classified into five categories, known as the Rockwood classification system (1) (Fig. 1). The treatment strategies for grades I, II, IV, and V are straightforward (2). Considerable controversy exists with the appropriate treatment of grade III separations, however. Grade III separations are characterized by a 25% to 100% displacement of the clavicle relative to the uninvolved side and a complete rupture of the acromioclavicular and coracoclavicular ligaments. Data support both surgical and nonoperative management (3). Beitzel et al. (4) reported in a statement from the ISAKOS Upper Extremity Committee that a more specific classification system for grade III injures was needed to improve the clinical approach; grade III was separated into “IIIa” and “IIIb” subclassifications. Grade IIIa was defined as a stable AC joint without overriding of the clavicle on the cross-body adduction X-ray view (Fig. 2A). Class IIIb was defined by overriding of the clavicle during cross-body adduction, scapular dysfunction, and lack of response to therapy (4) (Fig. 2B).

Figure 1
Figure 1:
Rockwood classification system for acromioclavicular (AC) separations.
Figure 2
Figure 2:
A-B, Posterior overriding clavicle with cross-arm adduction test X-ray views (A). Overriding clavicle on cross-arm shoulder adduction test (B). (Reprinted from Beitzel K, Mazzocca AD, Bak K, et al. ISAKOS Upper Extremity Committee Consensus Statement on the Need for Diversification of the Rockwood Classification for Acromioclavicular Joint Injuries. Arthroscopy. 2014; 30:271–8. Copyright © 2014 Elsevier Science. Used with permission).

Based on this new classification system, Petri et al. (5) measured physical function and pain in individuals over an average of 3.3 years. A total of 70.3% were successfully treated nonoperatively and 29.7% required surgery. At follow-up, there were no differences between groups for pain or physical function. Importantly, delaying surgery to pursue a trial of nonoperative treatment did not affect the ultimate outcome. Thus, conservative care can be pursued before surgery without compromising the outcome. Based on this work, the following treatment pathway was recommended:

Treatment PEARL

  • Early pain control with sling immobilization (0 to 3 wk). Do not perform cross-arm adduction test during this phase (phase I) due to pain limiting test performance.
  • Based on pain, perform cross arm adduction test between 3 and 6 wk postinjury.
  • If there is persistent pain, posterior overriding of the clavicle and scapular dysfunction, surgical management is suggested.
  • If there is normal clavicular and scapular motion during the cross-arm adduction test, continue by pursuing phases II and III of rehabilitation protocol (6).
  • If pain or residual dysfunction persists despite conservative care, surgical management can by pursued without compromising long-term outcomes.


1. Williams G, Nguyen V, Rockwood C. Classification and radiographic analysis of acromioclavicular dislocations. Appl. Radiol. 1989; 18:29–34.
2. Pogorzelski J, Fritz EM, Godin JA, et al. Nonoperative treatment of five common shoulder injuries: a critical analysis. Obere Extremität. 2018; 13:89–97.
3. Canadian Orthopaedic Trauma Society. Multicenter randomized clinical trial of nonoperative versus operative treatment of acute acromio-clavicular joint dislocation. J. Orthop. Trauma. 2015; 29:479–87.
4. Beitzel K, Mazzocca AD, Bak K, et al. ISAKOS Upper Extremity Committee Consensus Statement on the Need for Diversification of the Rockwood Classification for Acromioclavicular Joint Injuries. Arthroscopy. 2014; 30:271–8.
5. Petri M, Warth RJ, Greenspoon JA, et al. Clinical results after conservative management for grade III acromioclavicular joint injuries: does eventual surgery affect overall outcomes? Arthroscopy. 2016; 32:740–6.
6. Gladstone JN, Wilk KE, Andrews JR. Decision making: operative versus nonoperative treatment of acromioclavicular joint injuries. Clin. Sports Med. 1997; 5:78–87.
Copyright © 2018 by the American College of Sports Medicine