SHOULDER SEPARATION – PART 2: TREATMENT OPTIONS
Please see Part 1 for anatomy and injury classification
Nonsurgical management is the treatment of choice for grades I and II AC separations. This consists of wearing a sling for 1-2 weeks, at which time patients with grade I injuries can return to full activities as pain allows. Grade II injuries often require physical therapy and avoidance of sports and heavy lifting for at least 6 weeks. Persistent pain is often minimal in the short-term, although up to 50% of grade I and II injuries develop pain, impaired function, and AC joint arthritis down the road.1,2
Treatment of grade III injuries is controversial. Some patients with these injuries can be successfully treated without surgery. In these cases, patients wear a sling for up to 4 weeks and undergo physical therapy with avoidance of sports and heavy lifting for at least 2-3 months. Although most patients do well with this protocol, there is a subset of patients who seek surgery at a later time due to persistent pain and dysfunction. Several studies have shown that those patients who undergo surgery, after not succeeding with a three-month trial of therapy first, do not do as well as patients who have surgery right away.3,4 Furthermore, AC separations classified as grade III and higher are much more likely to have sustained additional surgically-relevant injuries in the shoulder. A recent study found that 48% of patients with grade III-V AC joint injuries had additional pathology that required arthroscopic treatment.7 It is for this reason that considering surgery is a reasonable option for patients who have a grade III AC separation and who are at a greater risk of functional disability (e.g. overhead workers, heavy laborers, athletes, etc).3,5,6 Surgery may also be considered in those patients with grade III AC separations who fail conservative treatment first and in all cases of grade IV, V, and VI AC separations.
Surgical management of AC separations consists of correcting the deformity and stabilizing the clavicle, thereby restoring its normal anatomic relationship to the scapula. The type of fixation used to hold the clavicle depends on how long the injury has been present, the patient’s size, and desired activities. The procedure is performed as an outpatient surgery and, depending on the above-mentioned factors, can be performed either arthroscopically via several “poke-hole” incisions with a single 2 cm incision over the AC joint or in an open fashion, requiring a single 5-6 cm incision. If the procedure is performed arthroscopically, then a thorough evaluation of the shoulder structures within and above the joint is undertaken and any additional pathology is treated, as necessary. Possible fixation constructs include various methods of attaching permanent sutures, typically with the use of several small drill holes, small metal buttons, and a tendon graft.
At the time of surgery, the patient’s AC joint is closely evaluated. Given that 50% of patients with these injuries develop painful AC joint arthritis down the road, if there are any findings consistent with AC joint arthritis, then a small wafer of bone (<1 cm) will be removed from the end of the clavicle. This additional procedure is called a distal clavicle excision or Mumford procedure.
Following the surgery, a sling is worn for the first 6 weeks. Formal physical therapy begins immediately and continues for at least 3 months. Patients may return to low-intensity sports and activities at 4 months and contact sports at 6 months.
Summary:
Grades I-II:
- These are more minor AC separations that maintain a significant degree of stability, do not typically result in a visible deformity, and often lead in minimal discomfort in the short-term.
Grades III-VI:
- These are more severe injuries with a higher degree of instability and deformity, leading to greater pain and disability.
- Additional shoulder injuries often occur simultaneously (e.g. labral tears).
Visit an orthopedic surgeon if any of the following are present:
- A visible deformity
- Mechanical symptoms (e.g. clicking/popping sensations)
- Weakness with shoulder/arm movements
- Severe shoulder pain limiting motion
- Pain that is failing to improve
1. Bergfeld JA, Andrish JT, Clancy WG: Evaluation of the acromioclavicular joint following first- and second-degree sprains. Am J Sports Med 1978;6:153- 159.
2. Mikek M. Long-term shoulder function after type I and II acromioclavicular joint disruption. Am J Sports Med. 2008;36:2147– 50.
3. Weinstein DM, McCann PD, McIlveen SJ, et al. Surgical treatment of complete acromioclavicular dislocations. Am J Sports Med. 1995;23:324–31.
4. Rolf O, Hann von Weyhern A, Ewers A, et al. Acromioclavicular dislocation Rockwood III-V: Results of early vs delayed surgical treatment. Arch Orthop Trauma Surg. 2008;128:1153–7.
5. Larsen E, Bjerg-Nielsen A, Christensen P. Conservative or surgical treatment of acromioclavicular dislocation. A prospective, con- trolled, randomized study. J Bone Joint Surg Am. 1986;68:552–5.
6. Bannister GC, Wallace WA, Stableforth PG, Hutson MA. The management of acute acromioclavicular dislocation. A random- ized prospective controlled trial. J Bone Joint Surg Br. 1989;71:848–50.
7. Boileau P, Gastaud O, Wilson A, Trojani C, Bronsard N. All-Arthroscopic Reconstruction of Severe Chronic Acromioclavicular Joint Dislocations. Arthroscopy. 2019 May;35(5):1324-1335.
If you are experiencing shoulder separation or would like to learn more don’t hesitate to reach out.
Nels Sampatacos, MD
Orthopedic Surgeon and Sports Medicine Specialist
