Acromioclavicular joint is a part of shoulder joint. Shoulder joint is formed by three joint Glenohumeral joint, Acromioclavicular joint and Sternoclavicular joint. Disconnection of bones forming a joint is known as dislocation or separation. The disconnection of Glenohumeral joint is known as shoulder joint dislocation and disconnection of Acromioclavicular joint is known as shoulder separation or Acromioclavicular Joint Separation. The partial or complete separation of the clavicle from the acromion results in severe pain over shoulder joint and limited range of motion.
Classification Of Shoulder Separation Or Acromioclavicular Joint Separation
Shoulder Separation Or Acromioclavicular Joint Separation Is Divided Into The Following Categories:
Type-I Injury: In this type, the acromioclavicular ligament is incompletely torn but the coracoclavicular ligament is not damaged.
Type-II Injury: In this type, the acromioclavicular ligament is totally ruptured and the coracoclavicular ligament is either spared or incompletely ruptured.
Type-III Injury: In this type, both the acromioclavicular ligaments and the coracoclavicular ligaments are completely ruptured and the collarbone and acromion get totally separated.
Causes of Shoulder Separation Or Acromioclavicular Joint Separation
- Sports Injury– The contact sports often result in Shoulder separation or acromioclavicular joint separation. The partial or complete dislocation is caused by direct impact over the joint. The sporting activities, which may result in separation are as follows-
- Fall– Dislocation or separation of Acromioclavicular joint is rare following domestic fall. Fall from height resulting in direct impact over the joint may cause AC joint separation or shoulder separation. If the fall is of significant impact then the joint ligaments are torn or ruptured resulting in separation of the collarbone from the acromion.
- Work Accident– Direct impact of heavy object or fall from height often results in Shoulder separation or acromioclavicular joint separation.
- Automobile or Car Accident– Acromioclavicular joint separation results following head-on collision resulting in direct accelerating impact to the joint. Impact is caused by dashboard or steering wheel. Shoulder separation or acromioclavicular joint separation is usually caused by a trauma such as a fall directly on to the shoulder resulting in injuries to the ligaments surrounding the AC joint and thus destabilizing the joint.
Symptoms Of Shoulder Separation Or Acromioclavicular Joint Separation
- Pain– Joint separation can result in mild to severe pain and visible deformity. A good pain-free function of the shoulder is inversely proportional to the degree of deformity.
- Range of Motion– Shoulder joint is connected to Acromioclavicular joint. Movement of the shoulder joint is restricted because of pain and separation of the acromion and clavicle. The forward movement of the humerus and internal rotation of movement is limited because of protrusion of fragment segment.
- Swelling/Bruising– There is often bleeding in subcutaneous tissue following fracture, which may form hematoma or blood clot resulting in swelling. Bruising caused by blood under the skin follows skin discoloration.
- Joint Deformity– Possible visible deformity is observed over Acromioclavicular joint because of protrusion of dislocated bone and hematoma.
Diagnosis of Shoulder Separation Or Acromioclavicular Joint Separation
- Clinical Examination– Examination indicates deformity, skin discoloration and tenderness over the Acromioclavicular joint, which suggests possible separation of Acromioclavicular Joint.
- X-ray– Image study often follows clinical examination to confirm the clinical diagnosis. X-Ray will indicate the separation of the bone.
- MRI study is performed to evaluate the ligament injuries and also joint dislocation. 1
Treatment For Shoulder Separation Or Acromioclavicular Joint Separation
Treatment for Shoulder Separation or Acromioclavicular Joint Separation are basically conservative and surgical.
Nonsurgical Treatment For Shoulder Separation or Acromioclavicular Joint Separation:
- Cold Therapy or Cold Pack– Immediately following accident, ice or cold pack is applied for 15 to 30 minutes every 3 to 4 hours. Cold pack helps to reduce swelling and pain. Cold pack prevents bleeding and tissue edema.
- Immobilization– Immediately following accident, shoulder joint is immobilized until further investigation and image studies are performed. Shoulder joint is kept in sling for 4 to 6 weeks if surgical treatment is not necessary.
- NSAIDs– Inflammation and mild to moderate pain is treated with anti-inflammatory medications like Motrin and Naproxen.
- Opioids– Severe pain is treated with opioids like hydrocodone and oxycodone.
- Muscle Relaxants- Few patients may develop a muscle spasm resulting in increased pain. Muscle spasm is treated with muscle relaxants.
- Physical Therapy (PT)- Physical therapy is indicated during the treatment to prevent arm and shoulder muscle atrophy. Physical therapy is also indicated following surgery for rehabilitation.
Surgical Treatment For Shoulder Separation or Acromioclavicular Joint Separation:
- Joint Repair– Surgery includes combined Coracoclavicular and Acromioclavicular repair. The Acromioclavicular joint is stable following combined treatment. 2
- Arthroscopic Coracoclavicular (CC) Ligament Augmentation– The separated or dislocated joint function is improved by surgical augmentation of Coracoclavicular ligament. The surgery is performed using arthroscopy. 3
- Fixation Of Clavicle And Placement Of Biological Graft To Strengthen Ligament– The results were better when torn or rupture ligament is supported by biological graft.4
Exercises For Shoulder Separation Or Acromioclavicular Joint Separation
Pendulum Exercises: This is done when the shoulder has been immobilized for a period of time. These exercises can start immediately after there is complete healing of the ligaments and pain has calmed down. In this exercise, you need to swing the arm forwards, backwards, and sideways while lying or bent. Slowly increase the range of motion.
Front Shoulder Stretch: Place a forearm at a fixed point like a corner of a wall or a door and slowly turn away so as to stretch the front part of shoulder. Hold this position for about 20 and do it at least thrice.
External Rotation Stretch: In this exercise, you need to lie on the back with upper arm placed perpendicular to the body with the elbow bent such that the hand is pointing to the roof. Then with the use of assistance, rotate the arm at the shoulder such that the palm faces up. Hold this position for about half a minute. Now rest and repeat it again at least five times.
Internal Rotation: This exercise is exactly opposite to that of External Rotation. With the same starting position, try and pull the hand towards the stomach keeping the elbow by the side.
External Rotation: This exercise can be done by attaching the band to something and then holding the loose end with the upper arm and the elbow in a bent position. Now, try and pull the band such that the hand and forearm pull away from the body. Do this in sets of three with at least 10 repetitions.
Abduction Lateral Raise: Using resistance band, take the loose end in the hand and keeping the elbow absolutely straight, pull the hand upwards towards the level of the shoulder all the while maintaining good posture. Perform in sets of three with at least 10 repetitions.
1.MRI versus radiography of acromioclavicular joint dislocation.
Nemec U1, Oberleitner G, Nemec SF, Gruber M, Weber M, Czerny C, Krestan CR.
AJR Am J Roentgenol. 2011 Oct;197(4):968-73. doi: 10.2214/AJR.10.6378.
2.Management of acute acromioclavicular joint dislocations: current concepts.
Arch Orthop Trauma Surg. 2013 Jul;133(7):985-95.
3.Arthroscopic treatment of acute acromioclavicular joint dislocation by coracoclavicular ligament augmentation
Liu X1, Huangfu X, Zhao J.
Knee Surg Sports Traumatol Arthrosc. 2013 Dec 10.
4.Surgical treatment of chronic acromioclavicular dislocation with biologic graft vs synthetic ligament: a prospective randomized comparative study.
Fauci F1, Merolla G, Paladini P, Campi F, Porcellini G.
J Orthop Traumatol. 2013 Dec;14(4):283-90.
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