Treating shoulder separations

Apr 1 2009

While low-level shoulder separations can commonly be treated nonsurgically and high-level injuries often require surgery, a literature review published in the April 2009 issue of the Journal of the American Academy of Orthopaedic Surgeons (JAAOS) finds that many surgeons still disagree on the best course of treatment for those injuries that fall in between.

• Shoulder separations, clinically known as acromioclavicular joint injuries, represent nearly half of all athletic shoulder injuries.
• These injuries result from a fall onto the tip of the shoulder with the arm tucked in toward the body.

"Shoulder separation" is not a truly accurate term for this type of injury, which is not a separation of the shoulder joint itself, but rather a disruption or dislocation of the acromioclavicular joint (also called the AC joint), where the collarbone (clavicle) meets the highest point of the shoulder blade (acromion).

If the force of the fall is severe enough, the ligaments attaching to the underside of the clavicle may also be torn. The severity or "type" of injury is classified by the amount and direction of joint separation seen on x-rays. If the underside of the clavicle is torn, it is referred to as a major injury. Signs and symptoms of AC joint injuries range from a minor deformity and mild pain, to a very painful, severe deformity. However, even more serious separations can often be treated successfully with proper attention.

"AC joint injuries are not benign and should not be ignored," says Ryan Simovitch, MD, orthopaedic surgeon specializing in the shoulder, Palm Beach Orthopaedic Institute, Palm Beach Gardens, Florida. "Nonsurgical treatment does not mean you can neglect the injury. Many patients who follow appropriate treatment and a rehabilitation program can have clinical success without surgery. At the same time, surgery has an important role in high grade injuries."

Nonsurgical options – which help treat the injury and manage pain for minor sprains (clinically called type I and II AC joint injuries) of the shoulder ligaments include:

• slings
• cold packs
• over-the-counter pain and anti-inflammatory medications

Sometimes, other types of supports may be used to help lessen AC joint motion and reduce pain. Surgery is almost always recommended for major or high level injuries (also called type IV, V, and VI injuries), as well as less serious injuries that do not respond to nonsurgical treatment. Both surgical and nonsurgical types of treatment must include rehabilitation to restore and rebuild the patient's motion, strength, and flexibility.

The treatment of the mid level injuries (type III) remains controversial, with nonsurgical treatment favored in most instances and surgical reconstruction of the acromioclavicular joint reserved for cases in which the joint demonstrates persistent instability.

"Nearly 50 years after the initial papers describing type III acromioclavicular joint injuries, there is still a lack of consensus on the best treatment for them," Simovitch says. "So far, most studies do not show a significant difference in outcomes between nonsurgically and surgically treated patients with this type of injury. Also, while most orthopaedic surgeons agree that type IV and higher injuries should be treated surgically, we haven't reached a consensus on which surgical technique is best. Over the years, however, arthroscopic and open treatment options for AC joint reconstruction have made significant advances."

Although the issue has not been fully researched, the study authors suggest that certain patients with Type III injuries, such as heavy laborers and athletes who perform frequent overhead motions, might benefit more from surgical reconstruction.