SHOULDER SEPARATION (ACROMIOCLAVICULAR SPRAIN) Tom C. Haney, M.D. Team Physician Florida State University

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1 SHOULDER SEPARATION (ACROMIOCLAVICULAR SPRAIN) Tom C. Haney, M.D. Team Physician Florida State University Shoulder injuries in football are very common. Frequently, there is confusion between a shoulder dislocation and a shoulder separation. A shoulder dislocation is an injury during which the ball of the joint slips out of the socket. A shoulder separation is an injury to the small joint at the top of the shoulder called the acromioclavicular or AC joint. Although the AC joint can be dislocated, the injury is usually called a separation. ANATOMY The AC joint is formed by the end of the collarbone (clavicle) and a broad bone forming the top edge of the shoulder called the acromion, which is part of the shoulder blade. The soft tissue ligament which holds the joint together is called the acromioclavicular ligament. The joint is also supported by a second ligament which connects the clavicle to a small prominence, which is also part of the shoulder blade, called the coracoid process. This ligament is called the coracoclavicular ligament. The severity of the injuries to the acromioclavicular joint is determined by the extent to which these two ligaments are injured. ACROMION ACROMIOCLAVICULAR JOINT CORACOCLAVICULAR LIGAMENT ACROMIOCLAVICULAR CORACOID LIGAMENT PROCESS SHOULDER BLADE Figure 1 - The structures supporting the acromioclavicular joint. 1

2 THE INJURY The AC joint is usually injured by a direct blow to the tip of the shoulder when it strikes the ground. It frequently occurs when a running back, receiver or other athlete strikes the shoulder against the ground while the arm is at the athlete s side. Figure 2 - The usual mechanism of injury to the AC joint is direct impact to the tip of the shoulder. This injury forces the acromion of the shoulder down as the muscles of the neck tighten pulling the clavicle up. The direct blow causes enough stress to tear the ligaments that hold the joint together. DIAGNOSIS The acromioclavicular joint will always be painful immediately following the injury. There will be tenderness of the acromioclavicular joint. There may or may not be deformity of the joint depending on the severity of the separation. The severity of the shoulder separations can be described by various classifications. However, the most commonly used descriptions are grade I, grade II and grade III. When an AC separation is suspected, x-rays can be taken with a 10-pound weight suspended to each wrist of the athlete while the athlete is standing. The weights may spread apart the injured the AC joint while compared to the AC joint in the opposite shoulder. This helps to determine the severity of the injury. 2

3 MILD SPRAIN, GRADE I Figure 3A Milder AC separations are the result of partial tears to the acromioclavicular ligament. This is called a grade I sprain. The joint is tender and swollen, but not deformed. X-rays show no offset of the clavicle relative to the acromion. The treatment for mild sprains is restricted activities, ice, anti-inflammatory medications such as ibuprofen, and the use of a sling as needed. Most athletes can recover in one to three weeks with a mild sprain. Protective padding can be used following the sprain. MODERATE SPRAIN, GRADE II Figure 3B Moderate sprains of the AC joint occur when the acromioclavicular ligament is completely torn, as well as at least a partial tear of the coracoacromial ligament. X-rays reveal incomplete offset of the end of the clavicle relative to the acromion. However, 3

4 there is still some approximation of the clavicle with the acromion. This results in some deformity, more swelling, and increased pain. The treatment is restricted activities, ice, anti-inflammatory medications, and the use of a sling. Surgery is usually not necessary. Most athletes can recover within three to six weeks with a moderate separation. Protected padding is frequently used following this injury. If pain occurs later, arthroscopic surgery can be used to remove the end of the clavicle to relieve chronic symptoms. SEVERE SPRAIN, GRADE III Figure 3C Severe sprains occur when both ligaments holding the end of the clavicle are completely torn. This includes both the acromioclavicular ligament and the coracoclavicular ligament. X-rays show complete offset of the end of the clavicle from the acromion. Severe sprains result in marked deformity, more pain, and increased disability. Severe sprains can be treated with a special sling device which holds the clavicle down for two to four weeks to allow some healing, followed by the usual treatment for moderate sprains. Recovery time is usually six to twelve weeks. Some severe AC separations require surgery to repair the torn ligaments. Surgery is frequently needed in athletes with high demands on their shoulder such as quarterbacks, pitchers and other throwing athletes. Recovery from surgery usually takes at least twelve weeks. Regardless of the classification of the shoulder separation, some athletes return to action sooner than expected and still have satisfactory results. The trainers and team physicians can monitor the athlete s progress and return the athletes to action based on the degree of pain and motion, rather than absolute time standards. Most athletes return to full activities when the shoulder is nontender, has full motion, and is not painful when the arm is placed under traction. 4

5 ILLUSTRATIONS: Figure 2 From Rockwood, C. A., and Green, D. P. (Eds.), Fractures in Adults, 2 nd ed. Philadelphia, J. B. Lippincott, 1984 Figure 3A, 3B, 3C From Zarins, B., Andrews, J., and Carson, W., Injuries To The Throwing Arm, The United States Olympic Committee Sports Medicine Council, W. B. Saunders Company,

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