Working Diagnosis:
Dynamic abutment of the acromion and clavicle with post-surgical acromioclavicular joint edema due to acromioclavicular joint osteoarthritis

Treatment:
The patient underwent an orthopedic surgical evaluation and ultimately chose to undergo an arthroscopic right shoulder revision with open distal clavicle excision. During surgery, acromioclavicular joint arthritis and several millimeters of the distal clavicle were removed, preventing further abutment of the distal clavicle against the medial acromion with cross body adduction.

Outcome:
Ten days after the surgery, upon follow up by phone call, the patient reported that he had no postoperative complications. He reported wearing a sling on the right upper extremity during the day and when sleeping. He was undergoing physical therapy twice a week and had been doing shoulder pendulum exercises at home. The patient reported severity of pain at follow-up was 2/10 and only required Tylenol as needed.

Author's Comments:
Arthroscopic excision of the distal clavicle is a common surgical procedure used in the treatment of acromioclavicular joint pathology and studies have shown great outcomes in 85-100% of patients. As sports medicine physicians, we must understand when post-surgical complications occur to diagnose them correctly and provide the best treatment. Dynamic ultrasound evaluation of a normal acromioclavicular joint with cross-arm maneuver should change the distance between the clavicle and acromion minimally (less than 1 mm). In this case, our dynamic ultrasound findings (approximately 4 mm change) was critical in securing a diagnosis as it showed how the acromioclavicular joint was being constantly aggravated with cross body adduction, causing edema and effusion.

Editor's Comments:
Dynamic ultrasound was the key to determining the next intervention in this patient who already had multiple surgeries. Ultrasound provides several advantages including low cost, dynamic evaluation, and no radiation exposure, which makes it an ideal imaging modality in this case.

References:
Strauss, Eric J. MD; Barker, Joseph U. MD; McGill, Kevin BA, MPH; Verma, Nikhil N. MD The Evaluation and Management of Failed Distal Clavicle Excision, Sports Medicine and Arthroscopy Review: September 2010 - Volume 18 - Issue 3 - p 213-219 doi: 10.1097/JSA.0b013e3181e892da
Docimo, Salvatore Jr et al. “Surgical treatment for acromioclavicular joint osteoarthritis: patient selection, surgical options, complications, and outcome.” Current reviews in musculoskeletal medicine vol. 1,2 (2008): 154-60. doi:10.1007/s12178-008-9024-5
Tytherleigh-Strong, Graham & Gill, Jasper & Sforza, Giuseppe & Copeland, Stephen & Levy, Ofer. (2001). Reossification and fusion across the acromioclavicular joint after arthroscopic acromioplasty and distal clavicle resection. Arthroscopy : the journal of arthroscopic & related surgery : official publication of the Arthroscopy Association of North America and the International Arthroscopy Association. 17. E36. 10.1053/jars.2001.26861.
Peetrons, P. and Bédard, J.P. (2007), Acromioclavicular joint injury: Enhanced technique of examination with dynamic maneuver. J. Clin. Ultrasound, 35: 262-267. https://doi.org/10.1002/icu.20339
Claes J. Petersson & Inga Redlund-Johnell (1983) Radiographic Joint Space in Normal Acromioclavicular Joints, Acta Orthopaedica Scandinavica, 54:3, 431-433, DOI: 10.3109/17453678308996596
Park J, Chai JW, Kim DH, Cha SW. Dynamic ultrasonography of the shoulder. Ultrasonography. 2018;37(3):190-199. doi:10.14366/usg.17055

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