Acromioclavicular joint dislocation — hook plate fixation

Adults after isolated hook plate fixation of an acute ACJ dislocation without additional ligament graft reconstruction. Before starting, review the operative report, fixation stability and the orthopaedic surgeon’s instructions. Ligament or capsular repair may require additional protection. Reconstruction for chronic instability, revision, a clavicular or acromial fracture, and concomitant rotator cuff or labral repair require a separate programme.

WHILE THE PLATE REMAINS: this protective programme limits forward elevation and abduction to a maximum of 90°, without forcing end range. Reaching 6 or 12 weeks does not remove this restriction. Motion above 90° and the resisted exercise shown on the poster require plate removal and the appropriate surgeon’s clearance.

Sling: the selected protective programme uses approximately 4 weeks of protection, usually weaning during weeks 4–6 after review. Remove it for approved exercises and hygiene with the arm supported. The surgeon determines any shorter or longer period.

Until plate removal and loading clearance: avoid lifting, carrying bags with the operated arm, pushing up from a chair, push-ups, planks, hanging and sports with a risk of falling. Do not pull on the arm or force stretches across the chest or behind the back.

Exercise gently, without sharp pain, painful catching or a mechanical block. Any mild discomfort should settle promptly, and symptoms should return to their pre-session level by the next day. Persistent worsening requires a reduced dose and reassessment.

The starting doses below are practical suggestions to individualise, rather than a regimen validated for every implant. Do not increase range, resistance and repetitions at the same time.

Plate removal is usually a planned second operation after ligament healing. Some studies performed removal around 3–4 months, whereas other series used longer intervals. A single best timing for all patients has not been established. [1–4]

Assessment for removal includes a clinical examination, radiographic assessment of maintained reduction and fixation, and implant-related symptoms. A radiograph alone does not demonstrate full ligament strength. The surgeon sets the removal date.

After surgery, document the removal date, ACJ stability, wound condition and new instructions. Separately specify permission for motion above 90°, resistance and weight bearing, and the next review. Secondary loss of reduction can also occur after plate removal. [5]

Sleep and rest

Lie on the back or uninjured side with the operated forearm supported; use a reclined position if needed for pain. Avoid lying on the operated shoulder while painful. Night-time sling use follows the prescription.

Dressing and hygiene

Use loose clothing. Put the operated arm into the sleeve first and take it out last. Support it during hygiene; avoid overhead or far-behind-the-back reaching while the plate remains.

Driving

Only when out of the sling, free of medication that impairs reactions, and able to safely control the steering wheel, gears and an emergency manoeuvre within the allowed range. Obtain surgeon clearance and meet insurer requirements; do not use the calendar alone.

Work and computer use

Computer work may resume gradually with the forearm supported, short sessions and no symptom flare. Manual work, carrying loads and overhead work require plate removal, strength progression and an assessment of job demands.

Walking and cycling

Walk in safe surroundings as tolerated. Use a stationary bike only if mounting, dismounting and exercising are safe without operated-arm support. Road or off-road cycling requires loading clearance and reduced fall risk.

Swimming, running and sport

Swimming requires a healed wound, plate removal and the necessary movement control. Introduce running and sport after assessing tolerance of arm movement, impact and fall risk. Contact sport and overhead weights require full functional progression and surgeon clearance.

Aim: protect the fixation, control pain and preserve movement of the distal arm.

• Use the sling as prescribed. Support the forearm when sitting and sleeping to avoid downward traction on the shoulder girdle.
• Move the fingers and wrist and gently bend and straighten the supported elbow. Keep the upper arm near the trunk; do not shrug.
• Passive or assisted shoulder motion requires the surgeon’s permission and the prescribed range. If the instructions are unclear, agree the range before starting; do not independently move beyond 90°.
• Postoperative review as prescribed, commonly around days 10–14: wound, sensation and circulation, sling tolerance and the plan for further mobilisation.

Progress when pain is controlled, there are no warning signs, elbow and hand movement is satisfactory and permitted shoulder motion has been clearly prescribed.

Aim: gradually restore motion without overloading the joint or aggravating hook contact with the acromion.

• Use passive and assisted exercises within the prescribed limits. Elevation and abduction must not exceed 90°; reaching 90° is not a mandatory goal at the expense of pain.
• In this programme, active shoulder motion and sling weaning usually begin only after review during weeks 4–6. Avoid shrugging or trunk leaning to increase range.
• Avoid external loads and weight bearing through the operated arm. The hand may assist with light tasks close to the trunk only within the permitted range.

Progress after surgeon review, with clinical stability, tolerance of the allowed range without increased next-day pain and no painful mechanical block.

Aim: maintain the allowed range and scapular control while the ligaments heal.

• Plate still present = the 90° limit still applies. Continue tolerated assisted movement and permitted active motion without aggressive mobilisation or stretching through pain.
• Practise gentle scapular alignment with the arms by the trunk. Avoid forceful squeezing of the shoulder blades, forced shoulder depression and weight training.
• Continue walking and safe lower-limb exercise without shoulder-girdle loading or arm support. Increasing arm activity requires a separate prescription; the band exercise on the poster belongs to the phase after plate removal.
• Plan a healing assessment and discussion of plate removal around week 12. Increasing subacromial pain or a mechanical block requires an earlier review.

Enter the next phase only after the plate has actually been removed, stability has been assessed and new motion and loading limits have been agreed. A calendar date alone is insufficient.

Aim: gradually restore functional range and strength while maintaining ACJ stability.

• The new postoperative instructions define motion and loading. Plate removal does not immediately authorise lifting, push-ups or contact sport.
• Once cleared, gradually increase passive, assisted and active motion, including above 90°. Stop for sharp pain, a new deformity or instability; do not force full range in a single session.
• Begin resisted exercise only after separate strengthening clearance and satisfactory motion tolerance. Start with light external rotation with the elbow close to the trunk; increase one parameter at a time.
• Then progress scapular and rotator cuff exercises, followed by work and sport tasks. Introduce weight bearing, overhead loads and activities with a fall risk only after clinical assessment.

Return to higher loads when there is no pain or instability, task-specific functional range has returned, scapular control is good, strength and endurance meet the task demands, symptoms do not worsen the next day and the surgeon has cleared progression.