Background and Etiology
The shoulder is formed by three bones, the upper arm (humerus), collar bone (clavicle), and the shoulder blade (scapula). At the top of the shoulder there is a protective arch formed by the inferior aspect of the acromion and coracoid process of the scapula with the coracoacromial ligament spanning between them. This arch overlies the head of the humerus and is called the coracoacromial arch.
The shoulder blade (scapula) and collar bone (clavicle) are joined together at the tip of the shoulder. This is called the acromioclavicular joint. The superior and inferior acromioclavicular ligaments and coracoclavicular ligament hold together the two ends of the scapula and clavicle. In a shoulder separation, these ligaments are partially or completely torn. There are six levels of shoulder separation that vary based on the severity of the injury.
Type 1: the acromioclavicular ligament is partially torn, but the coracoclavicular ligament is intact.
Type 2: the acromioclavicular ligament is completely torn, and the coracoclavicular ligament is intact or partially torn. The collarbone is partially separated from the acromion.
Type 3: the acromioclavicular ligament and coracoclavicular ligament are completely torn. The collar bone and acromion are completely separated.
Types 4 through 6: are more severe and involve the tearing of muscle in addition to the joint separation.
A shoulder separation usually occurs due to a direct injury or blow to the top of the shoulder (for example, from football, hockey or other high contact sports) or a fall onto an outstretched arm (FOOSH injury).
- Immediate pain at the time of injury
- Tenderness of the acromioclavicular joint
- Swelling and bruising
- Pain that limits movement
- Possible bump or step down deformity where the acromion is separated from the clavicle.
The treatment for a shoulder separation will depend on the severity of the injury and what type of separation (1-6) you have.
Type 1-2: separations are usually placed in a sling to reduce pain and support the injury site. Early physical therapy is initiated to prevent a frozen shoulder, improve range of motion and initiate light strengthening.
Type 3: separations are sometimes treated with surgery, while in other cases a sling and therapy can be successful. Evidence shows that a nonsurgical approach to these injuries is just as effective as surgery. Individuals who participate in over head sporting activities or laborers who perform heavy lifting may benefit from surgery.
Type 4-6: separations should be evaluated for surgery by a trained professional.
Physical Therapy treatment following a shoulder separation will depend on the severity of the injury. If surgery is not required, treatment will be focused on restoration of shoulder motion near the end of the shoulder immobilization period. It is important to get the shoulder moving while protecting the acromioclavicular joint to avoid a frozen shoulder.
As the pain subsides, strengthening exercises should be initiated to prevent muscle weakness and atrophy. Physical therapy following surgery for a shoulder separation will be delayed, but will have the same goals and purpose. Common interventions in the treatment of a shoulder separation include:
- Manual Therapeutic Technique (MTT): hands on care including mobilization, soft tissue massage and manual stretching to regain mobility and range of motion of the shoulder while protecting the acromioclavicular joint.
- Therapeutic Exercises (TE) to regain range of motion and strengthen the shoulder and surrounding joints. Rotator cuff and shoulder strengthening exercises to dynamically depress and stabilize the humeral head and prevent it from irritating the acromioclavicular joint. Strengthening of the trapezius and deltoid muscles to support the acromioclavicular joint should also be initiated.
- Neuromuscular re-education to begin retraining the upper extremity and the person overall to use the involved upper extremity in daily activities. Scapular and shoulder stabilization exercises to improve stability of shoulder and support the acromioclavicular joint may also be initiated.
- Modalities including the use of ultrasound, electrical stimulation, ice, cold laser and others to decrease pain at the shoulder.
- Home program that includes stretching and strengthening exercises as well as instructions to help restore motion and strength of the shoulder girdle.
- Initially, medical management of the separated shoulder should focus on reducing the inflammation and pain, and resting the joint.
- Application of ice to reduce inflammation
- Anti-inflammatory medications and pain medication to help reduce inflammation and pain.
- Use of a sling to immobilize the shoulder
- Initiation of early physical therapy
- In the case of severe separations, surgery may be required to regain full motion and function.
Prognosis
Patients with simple separations typically do well, especially when the ligaments are not badly damaged. More severe cases that require surgery take longer to recover but most people do recover full function in a short period of time.
