Distal Clavicle Excision (Mumford Procedure)

Distal Clavicle Excision (DCE), commonly known as the Mumford procedure, is a surgical treatment used to address pain and dysfunction caused by acromioclavicular (AC) joint osteoarthritis. Initially described by Mumford and Gurd in 1941 as an open surgical technique, DCE has since evolved with the advancement of arthroscopic techniques, which are now commonly preferred for their reduced invasiveness and quicker recovery.

How Common It Is and Who Gets It? (Epidemiology)

AC joint osteoarthritis is commonly seen in athletes, particularly weightlifters and those who engage in repetitive overhead activities. It is also prevalent in older individuals as a result of degenerative changes in the joint. DCE is often recommended for patients who have not found relief from conservative treatments such as physical therapy, anti-inflammatory medications, or corticosteroid injections.

Why It Happens – Causes (Etiology and Pathophysiology)

The acromioclavicular joint is the small joint where the clavicle (collarbone) meets the acromion (part of the scapula). Over time or due to repetitive stress—particularly in weightlifters, athletes, and elderly individuals—the cartilage in this joint can wear down, resulting in osteoarthritis. Symptoms include pain during overhead activities, tenderness over the joint, and limited shoulder motion. When conservative treatments fail, surgical intervention may be necessary to relieve the symptoms.

How the Body Part Normally Works? (Relevant Anatomy)

The AC joint is a key structure in shoulder movement, allowing for the clavicle to connect with the scapula. It helps stabilize the shoulder during overhead and arm-above-head motions. As the cartilage in the joint wears away due to arthritis, the bones can rub together, causing pain and reduced movement. The goal of DCE is to remove the end of the clavicle that is causing the pain while preserving as much of the joint’s function as possible.

What You Might Feel – Symptoms (Clinical Presentation)

Symptoms of AC joint osteoarthritis include localized pain at the top of the shoulder, tenderness over the joint, and pain that worsens with overhead motions or lifting. Limited shoulder range of motion, particularly when reaching overhead or across the body, is also common. Chronic pain that persists despite conservative treatment may indicate the need for surgery.

How Doctors Find the Problem? (Diagnosis and Imaging)

The diagnosis of AC joint osteoarthritis begins with a physical examination, where tenderness over the joint and pain during specific movements can help localize the issue. Imaging studies such as X-rays, MRIs, or CT scans are used to assess the extent of cartilage damage and bone changes in the AC joint. These images help guide surgical planning for procedures like DCE.

Classification

AC joint osteoarthritis is classified based on the severity of cartilage loss and bone damage. In mild cases, conservative treatment may suffice, but in more advanced cases where the joint surfaces have been worn away, surgery like DCE may be necessary.

Other Problems That Can Feel Similar (Differential Diagnosis)

Other shoulder conditions that can cause similar symptoms include rotator cuff tears, labral tears, and shoulder impingement syndrome. Accurate diagnosis requires distinguishing these conditions using imaging and clinical tests.

Treatment Options

Non-Surgical Care

• Physical therapy to strengthen the shoulder and improve joint function
• Anti-inflammatory medications or corticosteroid injections to manage pain
• Activity modification to avoid exacerbating the pain

Surgical Care

• Distal clavicle excision (Mumford procedure), where the distal clavicle is removed to alleviate pain and restore function
• Arthroscopic DCE, a minimally invasive approach with smaller incisions and faster recovery times
• Open DCE may still be used in certain cases requiring greater surgical exposure

Recovery and What to Expect After Treatment

Recovery from DCE typically involves wearing a sling for the first 1 to 2 weeks to protect the shoulder. Physical therapy is essential to restore shoulder motion and strength, starting with gentle passive exercises and progressing to active strengthening. Most patients can return to daily activities within a few weeks, but full recovery, particularly for overhead movements, may take 3 to 6 months.

Possible Risks or Side Effects (Complications)

Complications are generally rare but can include infection, nerve injury, persistent shoulder pain, and stiffness. With the traditional open approach, there is also a risk of cosmetic concerns, such as visible scarring, or injury to surrounding tissues. In the arthroscopic technique, risks include over-resection or under-resection of the bone, leading to persistent pain or instability.

Long-Term Outlook (Prognosis)

The long-term prognosis for patients who undergo DCE is generally positive, with most experiencing significant pain relief and improved shoulder function. Arthroscopic techniques tend to result in quicker recovery and fewer complications compared to open surgery. However, some patients may experience minor residual pain or limited motion, particularly if the procedure does not fully address underlying instability.

Out-of-Pocket Cost

Medicare

CPT Code 23120 – Distal Clavicle Excision (Surgical Removal of the Distal End of the Clavicle for AC Joint Issues): $140.97

Medicare Part B typically covers 80% of the approved cost for this procedure once your annual deductible has been met, leaving you responsible for the remaining 20%. Supplemental Insurance plans such as Medigap, AARP, or Blue Cross Blue Shield generally cover that remaining 20%, minimizing or eliminating out-of-pocket expenses for Medicare-approved surgeries. These plans coordinate with Medicare to fill the coverage gap and reduce financial responsibility.

If you have Secondary Insurance, such as TRICARE, an Employer-Based Plan, or Veterans Health Administration coverage, it acts as a secondary payer. These plans typically cover any remaining coinsurance or small deductibles, which generally range from $100 to $300, depending on your plan and provider network.

Workers’ Compensation

If your distal clavicle excision is required due to a work-related injury or overuse condition, Workers’ Compensation will cover all associated medical expenses, including surgery, rehabilitation, and follow-up care. You will not have any out-of-pocket expenses, as the employer’s insurance carrier directly covers all approved treatments.

No-Fault Insurance

If your distal clavicle excision is needed due to an automobile accident, No-Fault Insurance will typically cover the total cost of your treatment, including surgery and postoperative care. The only potential out-of-pocket cost may be a small deductible or co-payment depending on your insurance policy.

Example

David Harris required distal clavicle excision (CPT 23120) to treat chronic AC joint pain. His estimated Medicare out-of-pocket cost was $140.97. Since David had supplemental insurance through Blue Cross Blue Shield, his remaining balance was fully covered, leaving him with no out-of-pocket expenses for the procedure.

Frequently Asked Questions (FAQ)

Q. What is a distal clavicle excision (Mumford procedure)?
A. It is a surgical procedure that involves removing the end portion of the clavicle (collarbone) to relieve pain and improve shoulder function, typically due to arthritis or impingement at the acromioclavicular (AC) joint.

Q. Why is the Mumford procedure performed?
A. It is performed to treat persistent shoulder pain caused by arthritis or injury at the AC joint when non-surgical treatments have failed.

Q. What causes the pain treated by distal clavicle excision?
A. The pain is usually caused by arthritis, osteolysis, or trauma leading to degeneration or instability of the AC joint.

Q. What are the symptoms of AC joint arthritis?
A. Symptoms include pain at the top of the shoulder, especially during overhead activity, weightlifting, or sleeping on the affected side.

Q. How is the diagnosis of AC joint arthritis made?
A. Diagnosis is based on physical examination, patient history, and imaging such as X-rays or MRI scans.

Q. What are the treatment options before surgery?
A. Non-surgical treatments include rest, ice, anti-inflammatory medications, corticosteroid injections, and physical therapy.

Q. When is surgery recommended for AC joint issues?
A. Surgery is recommended when conservative treatments fail to relieve symptoms and pain significantly affects daily life.

Q. What happens during a distal clavicle excision?
A. The surgeon removes 5 to 10 mm of the distal end of the clavicle to eliminate contact between the bones at the AC joint.

Q. Can the procedure be done arthroscopically?
A. Yes, the surgery can be performed arthroscopically using small incisions and a camera for guidance.

Q. What are the advantages of arthroscopic Mumford procedure?
A. Advantages include less postoperative pain, smaller incisions, faster recovery, and less tissue damage.

Q. How long does the surgery take?
A. The procedure typically takes less than an hour to perform.

Q. What type of anesthesia is used?
A. The procedure is usually performed under general anesthesia or regional nerve block.

Q. What is the expected recovery time?
A. Recovery generally takes a few weeks to a few months depending on individual factors and rehabilitation progress.

Q. What is the rehabilitation process like?
A. Rehabilitation includes a brief period of rest followed by physical therapy focusing on restoring range of motion and strength.

Q. When can patients return to work or sports?
A. Most patients return to desk jobs within a few days and sports or heavy labor within a few months, depending on their healing progress.

Q. Are there any risks associated with the procedure?
A. Risks include infection, stiffness, continued pain, and damage to surrounding tissues, although complications are rare.

Q. What is the success rate of the Mumford procedure?
A. The procedure has a high success rate with most patients experiencing significant pain relief and return to function.

Summary and Takeaway

Distal clavicle excision (Mumford procedure) offers an effective solution for patients with acromioclavicular joint arthritis who have not found relief from conservative treatments. With advances in arthroscopic techniques, the procedure provides quicker recovery times, less postoperative pain, and a lower risk of complications compared to traditional open surgery. For patients with severe AC joint pain and limited function, this procedure can offer significant improvements in both pain relief and shoulder mobility.

Clinical Insight & Recent Findings

A recent study evaluated the use of ultrasound-guided techniques combined with a cannulated dilator system to improve the precision of arthroscopic distal clavicle excision (DCE) for patients with acromioclavicular (AC) joint pathologies.

The study found that this method provided more reliable joint localization and decreased the risk of iatrogenic damage compared to traditional techniques, which rely solely on visual and palpation-based guidance. By using ultrasound to guide the placement of a needle and dilator, the procedure allowed for more accurate and efficient resection, with reduced complications such as over-resection or instability in the AC joint.

The authors concluded that this approach, while requiring additional equipment and a learning curve, offers significant advantages in surgical efficiency and safety. (“Study on arthroscopic distal clavicle excision – see PubMed.”)

Who Performs This Treatment? (Specialists and Team Involved)

Orthopedic surgeons specializing in shoulder procedures typically perform distal clavicle excision. A rehabilitation team, including physical therapists, plays an important role in postoperative recovery and helping patients regain shoulder function.

When to See a Specialist?

If you have persistent shoulder pain, particularly with overhead movements or lifting, that has not improved with conservative treatments, you should see a specialist to discuss surgical options like DCE.

When to Go to the Emergency Room?

Seek emergency care if you experience severe shoulder pain following a traumatic injury or if you develop signs of infection, such as fever or redness at the surgical site.

What Recovery Really Looks Like?

Post-surgery, recovery involves wearing a sling for a few weeks, followed by a structured rehabilitation program to restore mobility and strength. Most patients can return to daily activities within a few weeks, but overhead motions may require additional time for full recovery.

What Happens If You Ignore It?

Ignoring AC joint arthritis can lead to continued pain, limited function, and worsening of shoulder motion. Over time, this can affect daily activities and may necessitate more invasive surgery.

How to Prevent It?

Maintaining shoulder health through strength training, proper lifting techniques, and avoiding repetitive overhead motions can help prevent the progression of AC joint arthritis.

Nutrition and Bone or Joint Health

A diet rich in calcium, vitamin D, and omega-3 fatty acids supports joint health and reduces inflammation. This may help manage arthritis symptoms and support recovery after surgery.

Activity and Lifestyle Modifications

To prevent further strain on the shoulder joint, focus on shoulder stability exercises and avoid repetitive overhead activities that may exacerbate AC joint arthritis.