Sports injuries are a normal process of athletic development. It is important to understand that injuries always occur and they must be taken care of by health care professionals.
Among contact sports, AC joint injuries comprise of about half of all shoulder related injures. The sports most likely to cause AC joint separations are football, soccer, hockey, rugby, and skiing. The most common method of an AC joint separation is falling directly onto the AC joint and/or with the shoulder in an internal and abducted position. In addition, it is important to rule out any concomitant injuries of the glenohumeral joint (shoulder joint) which can simultaneously occur with AC separation injuries. The road to recovery depends on the degree of the injury, a sprain to a full out dislocation warrants good clinical judgement and reasoning to return the athlete back to sport. Here is a brief review of things to consider when recovering from an AC joint separation.
Anatomy and Classification
To understand the level of therapy needed to repair an AC separation, it is important to understand the anatomy and the medical classification of an AC joint separation. The AC joint is a small articular joint that links the shoulder girdle to the axial skeleton. It is made up of one small joint (AC), and both the AC ligament and the CC (coracoclavicular) ligaments which attach the shoulder girdle to the clavicle (collar bone).
There are 6 classifications, types 1-3 are the most common, whereas types 4-6 are less common and involve a very high degree of impact, and often require surgery consultation. Type 1 involves a sprain of the AC joint with the AC ligament and CC ligaments kept intact. Type 2 involves a subluxation of the AC joint with disruptions of the AC ligament, with a step deformity seen. Type 3 involves both the CC and AC ligaments fully disrupted and a larger step deformity is seen at the AC joint.
Clinical Presentation and Management
Upon initial presentation to the doctor’s office, the patient typically presents supporting their elbow from beneath the injured shoulder using their opposing hand. It is important to recognize shortness of breath as this can lead to a lung injury as well. Abrasions, swelling, bruising may be present on the prominence of the clavicle near the shoulder girdle. Physical exam will include tenderness over the AC joint with minimal range of motion due to discomfort. Orthopedic testing for the AC joint include: cross arm adduction and loading of the AC joint, which will increase pain and localize shoulder pain to the AC joint. These tests are especially useful in patients with type I and II (minor) injuries in which visible or palpable deformity may not be present. Then a shoulder exam will be performed to rule out other injuries to the shoulder capsule. The doctor may decide to send the patient for X-rays of the shoulder and the AC joint.
AC joint separation management includes acute and sub-acute care with a graduated return to play protocol. Acute and sub-acute management should be focused to relieve the patient from pain, reduce swelling, and mobilization.
Usually the first week of care may require the athlete to wear a cloth sling to prevent movement as the ligaments heal. During active rehabilitation, certain therapeutic modalities can be used to reduce pain and swelling such as electrotherapy and electro-acupuncture, and to help reduce excessive motion the therapist may use athletic taping of the AC joint. In addition, thoracic manipulation can help improve thoracic spine movement, which has been evidenced to help with shoulder mobility.
Usually, after about 3-4 visits (2-3 weeks) of sub-acute management, therapeutic exercises can be added which include light mobility exercise and progressive resistant exercises usually with a frequency of 2 visits per week.
After about 4 weeks of care, a proprioceptive exercise program should be added to improve stability and strength. After about 4-5 weeks of rehabilitation exercises and conservative therapy, pain should subside, and a general exercise program for the athlete should begin which includes upper body strengthening and plyometric exercises. The athlete would be monitored as he/she progresses through their exercise program monthly until they are cleared to return to sport. It is important for the athlete to follow up with their medical provider as they transition week to week, and month to month.
Overall it is important to have comprehensive conservative management when addressing AC joint separations as they can be complex and lead to many limitations as the athlete matures if not properly cleared. The therapist should always evaluate the athlete for contaminant shoulder injuries It is important to at least consult with your medical provider when you suspect an AC injury.
Dr. Nourus Yacoub, DC
Medical Director and Chiropractor
Royal Chiropractic and Sports Injury Clinic
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