Medical Imaging Analysis Report

1. Imaging Findings

Based on the right shoulder X-ray and MRI images provided by the patient, the main findings are as follows:

• X-ray (shoulder joint anteroposterior view): The relationship between the humeral head and the acromion appears generally normal, with no obvious fracture line noted. However, an increased acromioclavicular joint (ACJ) space is observed, measuring approximately 8.52 mm (normal range about 1–3 mm), suggesting a notable joint space widening. The coracoclavicular (CC) distance measures about 12.8 mm (normal range approximately 11–13 mm), on the upper limit of normal.
• MRI sequences: In the region of the AC joint, there is an abnormal signal of the joint capsule and part of the ligament structure, with possible local edema and high signal on T2-weighted images, indicating ligament damage or tearing. The surrounding soft tissues (e.g., areas of deltoid and trapezius attachments) show certain traction signal changes, consistent with post-traumatic soft tissue involvement.

2. Possible Diagnoses

Based on the above imaging findings and the history of trauma (right shoulder pain after injury), the potential diagnoses include:

1. Acromioclavicular (AC) Joint Injury (AC Joint Separation): Most common when direct or indirect force leads to damage of the acromioclavicular or coracoclavicular ligaments. Per Rockwood classification, it can range from partial ligament tears to complete tears.
2. Distal Clavicle Fracture or Occult Fracture Line: If overlap on the plain X-ray is significant or the fracture line is very subtle, it may be missed on routine X-ray films. However, there is no clear evidence of a fracture line on the current images.
3. Other Soft Tissue Injuries Around the Shoulder: Such as rotator cuff tendon or labral injuries. However, from the MRI images, the primary abnormal findings are around the AC joint, and there is no significant indication of a major rotator cuff tear.

3. Final Diagnosis

Considering the patient’s trauma history, clinical symptoms, and imaging characteristics (significant AC joint widening, coracoclavicular distance at the high normal value, and MRI suggesting partial or complete ligament tears), the most likely diagnosis is: AC joint injury, Rockwood Classification Grade II (complete or nearly complete tear of the AC ligament, partial tear of the CC ligament, with clavicle displacement not exceeding 50%).

Since the coracoclavicular distance remains within the upper normal limit (12.8 mm) without a clear increase beyond normal, and there is no marked superior displacement of the clavicle, Grade II injury features appear to be more fitting.

4. Treatment Plan and Rehabilitation Program

4.1 Treatment Strategies

• Conservative Treatment: For Rockwood Grades I–II AC joint injuries, conservative management is usually preferred. This includes:
  • Shoulder sling or fixation to reduce stress
  • Oral or topical non-steroidal anti-inflammatory drugs (NSAIDs) to alleviate pain and inflammation
  • Cold therapy and physical modalities to control acute inflammatory response
• Surgical Treatment: If subsequent evaluation reveals severe ligament damage or conservative treatment is unsatisfactory, surgical reconstruction or ligament repair may be considered. However, for Grade II injuries, prognosis is generally good with conservative management.

4.2 Rehabilitation and Exercise Prescription

Rehabilitation should follow a gradual, individualized approach (the FITT-VP principle) to protect the injured area and progressively restore joint function and muscle strength:

1. Acute Phase (1–2 weeks)
   • Frequency: Carry out simple movements or protective exercises 2–3 times per day.
   • Intensity: Minimize weight-bearing on the shoulder. Perform hand or finger movements in a sling to promote circulation.
   • Time: Each session lasts about 5–10 minutes, depending on pain level.
   • Type: Primarily isometric contractions, posture maintenance, and gentle pendulum exercises.
   • Volume: Total daily exercise time of approximately 15–30 minutes.
   • Progression: Once pain subsides, reduce sling usage and gradually increase shoulder joint range of motion.
2. Recovery Phase (2–6 weeks)
   • Frequency: Rehabilitation exercises 3–4 times per week.
   • Intensity: Gradually increase active range of motion exercises for the shoulder, starting mild resistance exercises (e.g., light resistance band work).
   • Time: Each session for about 15–20 minutes, focusing on flexibility and joint mobilization.
   • Type: Progress from passive to active shoulder movements, combined with endurance training for peri-shoulder muscles.
   • Volume: Increase the total training volume by about 10–20% weekly as shoulder stability improves.
   • Progression: Gradually transition to resistance exercises, enhancing shoulder muscle strength and dynamic stability.
3. Consolidation Phase (After 6 weeks)
   • Frequency: 3–5 times per week.
   • Intensity: Use moderate resistance (e.g., higher-grade resistance bands or small dumbbells) for shoulder muscle strengthening.
   • Time: 20–30 minutes per session, including warm-up and cool-down.
   • Type: Incorporate functional movements, such as overhead activities, shoulder abduction, and rotational exercises to meet daily activity demands.
   • Volume: Increase training intensity and frequency as endurance and stability improve.
   • Progression: Ultimately aim to restore normal shoulder range of motion, strength, and stability.

If the patient has compromised bone quality or reduced cardiopulmonary function, they should increase training volume cautiously under the supervision of a professional rehabilitation therapist or physician, while closely monitoring for adverse effects. In case of significant pain or discomfort during exercise, the program should be adjusted promptly.

Disclaimer

This report is a reference analysis based on the current imaging and medical history and does not replace in-person consultations or the opinions of professional physicians. If symptoms worsen or there is any uncertainty, please seek medical attention promptly.