Injury of the Week - Shoulder Separation (AC Joint Sprain)

Medically referred to as an acromialclavicular or AC joint separation, a “Shoulder Separation” occurs when the ligaments that hold the clavicle (collar bone) and acromion (top of the shoulder blade) (pictured below) are injured by a direct blow or a fall on the point of the shoulder with outstretched hand.  The force of the blow or fall can cause the ligaments which hold the joint together to tear. 

 

When you separate your shoulder it is difficult, if not impossible, to move your arm and shoulder without a good deal of pain. Lying on your side at night is almost impossible, and reaching your injured arm over to scratch your ear on the opposite side can be excruciating.  Proper management is important for recovery. 

A shoulder separation is graded from mild to severe as Type I –Type VI respectively based on the severity of the ligament damage and degree of instability in the joint.  

The injuries have been medically classified into 6 categories.  Allman* lists Type I-III and Rockwood ** classified the most severe cases as Type III-VI:

• Type I This is the most common injury encountered. Only a mild force is needed to sustain such an injury. The acromioclavicular ligament is sprained with an intact coracoclavicular ligament. The acromioclavicular joint remains stable and symptoms resolve in 7-10 days. This injury has an excellent prognosis.
• Type II The coracoclavicular ligaments are sprained; however, the acromioclavicular ligaments are ruptured. Most players can return to their sport within three weeks. There is anecdotal evidence to suggest that steroid injections into the acromioclavicular joint speed up the resolution of symptoms, but this practice is not universal.
• Type III The acromioclavicular joint capsule and coracoclavicular ligaments are completely disrupted. The coracoclavicular interspace is 25-100% greater than the normal shoulder.
• Type IV This is a type III injury with avulsion of the coracoclavicular ligament from the clavicle, with the distal clavicle displaced posteriorly into or through the trapezius.
• Type V This is type III but with exaggeration of the vertical displacement of the clavicle from the scapula-coracoclavicular interspace 100-300% greater than the normal side, with the clavicle in a subcutaneous position.
• Type VI This is a rare injury. This is type III with inferior dislocation of the lateral end of the clavicle below the coracoid.

Treatment for Separate Shoulder:

Initially, rest, ice and nonsteroidal anti-inflammatory drugs (NSAID’s) are immediately required.  If pain is present immobilization in a sling is necessary.  Otherwise, range of motion exercises can be introduced as tolerated.  Return to full activity can begin when pain and strength permit however, the area should be properly padded for protection. 

Generally, if managed properly, Type I and II sprains heal without complications within 10 days however pain may be present intermittently.  Cortisone injections may be used to help athletes with inflammation.  Rehabilitation includes taping for stabilization, range of motion exercises, strengthening, and later, progressive resistance exercises.

Type III injuries are generally treated conservatively and non-surgically.  Immobilization in a sling for 2-4 weeks is followed by range of motion and strengthening exercises.  Surgery may be recommended at this stage for those athletes performing repetitive, high weight lifting and possibly for thin persons with prominent lateral ends of the clavicles.  Return to sports may take 10-12 weeks. 

***Severe Type IV-VI injuries are rare and require surgery to repair.  Immobilization can be as long as 4-6 weeks.  Generally patients can use their arm for daily functional activities but are restricted from actively bringing their arm forward and up or away from their bodies.  Pushing, pulling or carrying more than 5lbs is also prohibited.  Complete return to sport generally takes 6 months. 

Role of Massage Therapy in AC Joint Sprain

Massage to the surrounding arm and shoulder muscles can alleviate compensating pain patterns for a period of time while the shoulder is healing.  Focus to the area should not exceed a 15-20 minute period.**** In general, massage can provide a feeling of increased relaxation and stress relief which can prove helpful when dealing with sharp pain.    

*Allman FL Jr. ‘Fractures and ligamentous injuries of the clavicle and its articulation.’ J Bone Joint Surg Am 1967; 49:774- 784.

**Rockwood CA Jr, Williams GR, Young CD. ‘Injuries of the Acromioclavicular Joint.’ In CA Rockwood Jr, et al (eds), Fractures in Adults. Philadelphia: Lippincott-Raven, 1996; 1341-1431.

***Anderson MA, Hall SU, Martin MA.  Sports Injury Management. 2000; 294-296.

**** Benjamin Ben. “Acromio-clavicular Joint and Ligament Injuries.” Massage & Bodywork Magazine;  April/May 2005.