Shoulder Separation: Treatment Options

Shoulder Separation: Treatment Options

Treatment of shoulder separation will take into consideration many factors, including the patient's symptoms, their activity level, along with the severity of the injury. When assessing severity of shoulder separation, surgeons rely on a classification system that considers which soft tissue structures surrounding the acromioclavicular, AC, joint are injured, along with the amount of separation between the tip of the shoulder blade, the acromion, and the tip of the collarbone, the clavicle, as seen on x-rays.

For this discussion, we will group these injury types into mild, moderate, and severe. For a mild AC joint injury, the AC ligament connecting the two bones may be sprained or torn. Patients may experience tenderness at the joint, and there may or may not be a small bump seen on the skin. On x-rays, the acromion and clavicle may appear normal, or the clavicle may be slightly elevated in comparison to the acromion.

For a moderate AC joint injury, not only is the AC ligament torn, but the other supporting ligaments called the coracoclavicular ligaments, or CC ligaments for short, have also torn. These ligaments normally help stabilize the collarbone to the bone below, the coracoid. A patient will notice a bump on the top of their shoulder.

In severe AC joint injury, both AC and CC ligaments are torn in addition to other soft tissue structures. The collarbone can then displace into abnormal positions and potentially disrupt nerve structures in this area.

Mild AC joint injuries are very common, and for treatment, nonsurgical management is generally recommended. This includes ice, rest, gentle motion exercises, and activity modification, for which duration will vary based on symptoms.

For severe separations, surgery is recommended to reduce the AC joint back to its normal location. Moderate AC joint injuries can be treated either with or without surgery. The surgeon will discuss the risks and benefits of each option and tailor the treatment plan to the individual patient.

Many patients with moderate injuries will get better with nonsurgical treatment. Generally, those who are more active in sports, have a labor-intensive job, or have not seen improvement with nonsurgical measures are recommended for surgical intervention.

Historically, there have been many ways to address an AC joint separation with surgery, but with advanced technology, more minimally invasive approaches have come into favor. Using the assistance of a small camera and instruments referred to as arthroscopic surgery, along with a smaller open incision.

In the operating room, patients are positioned in a seated semi-reclined position called the beach chair position, which allows the surgeon to have access to the entire shoulder joint. The goal of surgery for shoulder separation is to reduce the collarbone back in line with the acromion and hold it there.

If the injury was recent, surgeons accomplish this goal using a suture-based implant with metal buttons connecting the collarbone to the bony projection called the coracoid. If the injury happened a while ago, in addition to the suture and metal button-based implant, the surgeon would add a soft tissue graft and wrap it around these two bones.

With either technique, the goal remains the same: to help reconstruct the CC ligaments that were torn and stabilize the collarbone back down in line with the acromion to reduce the AC joint. The surgeon will take x-rays during the surgery to ensure that this goal has been achieved.

After surgery, rehabilitation will involve keeping the affected arm in a sling for a period of time to protect the shoulder, as guided by the surgeon and physical therapist. Range of motion exercises are gradually introduced. Eventually, the sling is discontinued, and strengthening exercises can begin to help facilitate the patient's return to their daily activities.