Shoulder Separations

One common shoulder injury that is frequently confused with a dislocation is the shoulder separation.  Many people believe them to be the same injury, but the two are completely different.

Shoulder separations refer to a disruption of the ligaments which hold the collarbone to the shoulder blade.  When these ligaments are ruptured, the collarbone rises out of place from the shoulder and “separates.”  Medically, this is referred to as an Acromio-Clavicular separation.  As the clavicle (collarbone) attaches to the acromion (side extension of the shoulder blade), it is held by three ligaments.  These ligaments stabilize the clavicle and hold it down toward the top of the chest.  Injury to these ligaments “springs” the collarbone upward from its normal position.

Run your hand along your collarbone; as the shoulder is approached, you will feel a small bump—this is the acromio- clavicular (A-C joint).  A-C separations usually occur from a direct force as one falls violently onto the point of the shoulder.  The shoulder is forced downward as the ligaments holding the collarbone tear.  The injury is common in contact sports, such as football, rugby, hockey, and lacrosse.  Football players who carry the ball, such as backs and ends, are more susceptible because their shoulders are directly hit when they are tackled.  However, the improvement and effectiveness of shoulder pads over the years has diminished the incidence of this injury in football in contrast to rugby where the occurrence rate remains higher.

A shoulder separation is quite painful, and the athlete is unable to lift his arm without discomfort.  The A-C joint is swollen and tender to touch.  Complete separations produce a prominent deformity with an enlarged “bump.”  If there is any doubt about the diagnosis, stress x-rays can be performed to confirm that the joint has separated.  The patient is asked to hold a heavy weight with the arm at the side.  The weight pulls the shoulder blade down, and the collarbone will displace upward.

Like many other orthopaedic injuries, A-C separations are categorized into three degrees of severity.  A first degree separation is merely a sprain without serious ligament damage.  The joint is tender and swollen, but there is no separation.  Treatment consists of ice applications and use of a sling for 3-7 days.  Athletics can later be resumed when the pain subsides, and full shoulder motion is restored.  Little rehabilitation is necessary, and the prognosis is excellent.

In the second degree separation, the injury is greater, and there is complete disruption of the ligaments which surround the A-C joint. However, the ligaments holding the collarbone to the shoulder blade are not torn, and consequently there is only minor displacement of the collarbone.  The A-C “bump” is more prominent, and the separation can be felt.  This injury is also treated with a sling, but immobilization is required for two to three weeks to allow the joint to heal.  During this period, gentle motion exercises are allowed to prevent shoulder stiffness.  Later, shoulder strengthening exercises are recommended.  The athlete can return to sports in four to six weeks if the pain has subsided, and if there is clinical evidence of healing.

third degree A-C separation represents a complete dislocation of the joint and rupture of all ligaments.  The collarbone displacement produces a large painful deformity.  The treatment of this injury is controversial.  Some orthopaedists believe that no treatment is necessary, and therefore no attempt is made to reduce the separation.  The rationale of this treatment is based on the belief that the separation does not really cause any permanent disability of the shoulder after the initial pain has subsided.  The patient rests with a sling for one to two weeks and later resumes activity when there is no longer any pain.  There is merit to this approach, as many patients regain useful function of their shoulder even with a permanent deformity.

The other school of thought is that the separation must be set and held either with a brace or by surgery.  The brace is a special sling with a pad which exerts pressure over the collarbone, pushing it down.  The sling could be effective, but it is very uncomfortable and must be worn constantly for six weeks.  Unfortunately, this treatment requires a rather stoical and reliable patient and, frequently, this treatment option is not practical.

Surgery consists of returning the collarbone to its normal position and holding it in place with a screw, pin, or wire.  The ruptured ligaments are also repaired.  The athlete will miss competition for approximately 12 weeks.

However, surgery may be performed in certain instances—depending on the severity of the displacement and individual requirements of the athlete relating to his sport.

Please note: these articles are for general information. They are not intended to serve as medical advice or treatment for a specific problem. Diagnosis and treatment of a problem can only be accomplished in person by a qualified physician.