Shoulder patho AC separation/sprain

Question 1

Shoulder separation (aka AC separation or sprain)

Answer 1

• This is the sprain or rupture and possible displacement of the AC joint
• The structures involved are the AC joint capsule and ligaments, and the coracoclavicular complex – trapezoid and conoid ligaments

Question 2

Etiology:

Answer 2

• Direct trauma – downward force applied on top of AC joint

- Fall landing on the AC joint or FOOSH

Question 3

Signs & symptoms:

Answer 3

Grade I
- damage to AC joint (ligaments and joint capsule) with no clavicular displacement
- Coracoclavicular complex intact
- Mild inflammation
Grade II
- Disruption to the AC joint (ligaments and joint capsule)
- Subluxation of the clavicle (partial or incomplete dislocation) : mild step deformity
- Some damage to the coracoclavicular complex
- More inflammation and edema
Grade III
- Rupture of the AC and CCC ligaments
- Severe step deformity (clavicle rides superior to acromion)
- Severe inflammation
- Medical intervention needed
Generally:
- Step deformity observed with grade II and III
- Muscle spasm and guarding
- Holding pattern – IR and AD of shoulder, elbow flexed and hand rests against opposite shoulder. Other hand supports
- PROM = pain with ER, IR, horizontal AD, AB
- AROM = limited and guarding, pain may or may not be present
- RROM = painful and weak

Question 4

Special tests:

Answer 4

Acromioclavicular shear test –test the integrity of AC joint

Question 5

Treatment planning:

Answer 5

Acute:
- First 3-4 weeks the guest is usually immobilized
- Position for comfort and stability
- Reduce pain, decrease SNS firing, decrease edema, maintain local circulation and address compensatory structures with general Swedish, petrissage and MLD techniques. Ice if needed
Subacute:
- As per acute stage
- Reduce but do not remove protective muscles spasm (MTP’s)
- Maintain available ROM (PROM)
- Prevent disuse atrophy (Isometric contractions)
- Late subacute – prevent excess adhesion formation – begin cross-fibre frictions
Chronic:
- As per subacute
- Cross fibre frictions to prevent adhesions and maintain mobility between structures
- Reduce hypertonicity
- Restore ROM and strength

Question 6

Precautions and contraindications:

Answer 6

• As per general orthopedic treatment
• In the acute stage, testing or challenging beyond available AROM should be avoided to prevent further damage
• If the AC joint has not been surgically reduced, joint play should be avoided in an unstable joint or until after surgical reduction

Question 7

REMEX & homecare:

Answer 7

• Gradually increase range
• Strengthen muscles crossing the joint to help with stability
• Re-educate proprioception
• Encourage activity to help prevent fibrosis and hypomobility