What is a separated shoulder (AC Joint separation)?

Dr. Timothy Hamby of Tri-State Orthopaedics helps us understand Shoulder Separatation (aka AC joint separation)

What is a Separated Shoulder?

Separated shoulder, is also known as AC joint separation.  This injury is a result of falling directly on the shoulder or a direct blow to the shoulder.   This injury occurs in 9-12% of shoulder injuries. Here is all you need to know about recognizing AC joint separation and its treatment.  

Understanding the anatomy.

Three bones form the shoulder joint: the humerus (upper arm bone), scapula (shoulder blade) and clavicle (collarbone).  The AC joint, which stands for acromioclavicular joint, is where the clavicle meets the highest portion of the scapula, known as the acromion, and is held together by ligaments known as the acromioclavicalar (AC) ligament and coracoclavicular (CC) ligament.

Who gets AC joint separation?

This most often occurs in men in their 20’s who participate in contact sports like football, hockey and wrestling.  However, it can occur in anyone with a traumatic injury to the shoulder.

What causes AC joint separation?

AC separations often occur from falling directly onto the shoulder.  The force of falling on the shoulder injures the ligaments that connect the clavicle and acromion, by either a sprain (stretch) of the ligament or tear.  The force of the fall determines the severity of the injury. When the ligaments torn the clavicle separates from the acromion, the clavicle will then elevate and the acromion will then drop due to the weight of the arm.  This results in a bump over the top of the shoulder.

AC separations can also occur from indirect injury like falling onto outstretched arm or falling onto your elbow pushing the humeral head into the acromion injuring the joint

What are the symptoms of AC joint separation?

Usually there is an injury resulting in pain in the shoulder and then one would notice a bump over the top of the shoulder.  There are grades to separation ranging from 1-6, with increasing in grade you can expect increase in pain and deformity. Patients will also experience pain and popping with overhead range of motion and cross body range of motion and might even experience lack of range of motion in these directions.  

What are the grades of AC joint separation?

Grade I or II/ Mild separation:  sprain of the AC ligament with no movement of the clavicle from the acromion.  This is the most common AC joint separation, occurring twice as often then higher grades.   

Grade III-IV/ Moderate separation: tearing of the AC ligament with sprains of the CC ligament.  There is significant noticeable elevation of the clavicle at this point.

Grade V-VI/ severe separation: complete tears of both the AC ligament and CC ligament resulting in obvious elevation of clavicle.  

How do you diagnosis of AC joint separation?

When seeing an orthopedic surgeon we can diagnose AC joint separation with history and physical exam.  History will most likely include direct injury to the shoulder. Most patients on physical exam will be tender to palpation over the AC joint with a possible elevated clavicle.  X-ray is used to confirm diagnosis and determine the grade of separation, which will also help rule out any other possible injury to the shoulder like fracture of the humerus, scapula or clavicle.  There is a specific x- ray technique used to for AC joint injury and normally both AC joints will be imaged for comparison.

Treatment of AC joint separation.

Treatment depends on your grade or severity of separation.  

Grade I and II:   This is a mild injury so treatment is usually conservative and patients recover quickly.  You will start with rest, ice, NSAIDs and possible sling for comfort. Physical therapy is started for range of motion and strengthening fairly quickly.  

Grade III:   This is a moderate injury to the AC joint.  Treatment for this is more controversial. Some experts recommend non-operative treatment with rest, ice, sling and NSAIDs.  If your pain persists or deformity is concerning surgery could be considered. Other experts recommend surgery for athletes or laborers for Grade III separations.  The surgery is discussed further below. Grade III separation takes a total of 6-12 weeks to fully heal before returning to sport or heavy overhead work.

Grade IV, V, VI: This is the severe injury to the AC joint.  These usually require surgical treatment, either open or arthroscopic procedures.    Some chronic injuries require use of a graft to reconstruct the ligaments that are torn.  The purpose of surgery is to realign the clavicle to the acromion. Surgical patients are placed in a sling for six weeks with no overhead activity.   After six weeks the sling is removed and patients start physical therapy for range of motion and strengthening. Total healing time for this severity of injury can be up to 6 months.  

If you or a loved one is experiencing shoulder pain, contact Dr. Timothy Hamby at Tri-state Orthopaedics.  Contact information is below along with a link to schedule an appointment.

Tri-State Orthopaedics Scheduling:  812.477.1558

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All You Need to Know About Frozen Shoulder

Adhesive Capsulitis, also known as Frozen Shoulder, is a common cause of pain in the shoulder.   It effects up to 5% of adults. Here is all you will need to know about recognizing adhesive capsulitis and how to treat it.

Understanding the shoulder.

The shoulder joint is made up of three bones:  

The humerus (long bone in the upper arm), the clavicle (collar bone) and scapula (the shoulder blade) with connective tissues that make up your shoulder capsule.  Inside this capsule is synovial fluid which is a fluid that lubricates the bones and connective tissue.

Who gets adhesive capsulitis?

Most commonly adhesive capsulitis occurs in 40-60 year olds and more often women.  People with diabetes or thyroid conditions are at increased risk of getting adhesive capsulitis.   Other medical conditions increase your risk of adhesive capsulitis as well, like stroke and Parkinson disease.  

You can also get secondary adhesive capsulitis which occurs after shoulder injuries like rotator cuff tears, proximal humerus fractures or shoulder surgery.   

What causes adhesive capsulitis?  

While the cause is not fully understood, a common thought is inflammation in the shoulder joint capsule which then leads to the development of adhesion and fibrosis in the synovial lining.  This causes the shoulder joint to thicken and contract leading to restricted range of motion.

What are the symptoms of adhesive capsulitis?

Most experience a stiff and painful shoulder.  They will have trouble reaching overhead and behind the back.   With this pain some patients will experience weakness in the joint, as well.  

What are the stages of adhesive capsulitis?

1st stage / Freezing: diffuse, severe and disabling pain in the shoulder with increasing stiffness. This phase can last 2-9 months.  

2nd stage / Frozen: stiffness and severe loss of shoulder motion but pain is gradually decreasing.  This phase lasts 4-12 months

3rd stage / Thawing: recovery with gradual return of motion.  This can take 5 to 24 months.

Adhesive capsulitis affects only one shoulder at a time and can resolve on its own in two to three years or longer.   Due to the significant impact of joint function and discomfort caused by adhesive capsulitis most people seek treatment to drastically reduce the length of time for recovery.

How do you diagnosis adhesive capsulitis?

When seeing an orthopedic surgeon we can diagnose adhesive capsulitis with a physical exam.  Most patients present with pain and significantly reduced active and passive range of motion.  X-rays are beneficial to rule out other shoulder conditions like shoulder osteoarthritis which can mimic symptoms of adhesive capsulitis.  We can use Musculoskeletal ultrasound to see thickening of the joint capsule, increased fluid in the joint and rule out any rotator cuff tear.  

What is the treatment of adhesive capuslitis?

First step:  

  • Prednisone
  • Cortisone injection
  • Physical therapy

Nonsteroidal anti-inflammatory drugs (NSAIDs), prednisone dose pack or shoulder joint injection with corticosteroid and physical therapy.  The NAIDs or steroid and prednisone dose pack will decrease the inflammation in the joint and physical therapy is to break up the adhesions that have formed to get full range of motion back.   This treatment is given 3-4 weeks to work.

Second step:

If there is no improvement or minimal improvement with the first step, the next course of action is a closed manipulation by an orthopedic surgeon.  This is an outpatient procedure; the orthopedic surgeon moves your shoulder through full range of motion to break up the adhesions and then injects the shoulder with a steroid.  After the procedure physical therapy is prescribed to prevent the adhesions from reoccurring.

If you or a loved one is experiencing shoulder pain, contact Dr. Timothy Hamby at Tristate Orthopaedics.  Contact information is below along with a link to schedule an appointment.

Please call to schedule an appointment:  812.477.1558

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