AC Joint Injury

What to expect when you’re not expecting, an acromioclavicular (AC) joint injury.

Shoulder separations are among the most common type of injuries in sports. Not to be confused with a dislocation, a shoulder separation involves the Acromioclavicular (AC) ligament, and sometimes the Coracoclavicular (CC) ligament, whereas a dislocation refers to the humerus (upper arm) and the ball and socket glenohumeral joint. Unfortunately with a shoulder separation there’s nothing that can be done to a ligament to fuse it back together if completely tore through outside of surgery.  However there are therapies that may be beneficial to help the healing process of a partial tear and heal the muscles around the joint. In order to understand the limitations that this type of injury presents and to provide an approximate recovery timeline, this article summarizes an injury that I personally endured and documented.

Upon examination by several qualified physicians, my diagnosis was a grade 2 to 3 AC separation. I’ll get to the levels of severity in a minute after some anatomical background. The Acromioclavicular (AC) joint is comprised of your AC process (a bony prominence on the top of the scapula), the clavicle (which serves as a linkage between your rib cage and the shoulder joint), and the AC ligament. The coracoclavicular joint is comprised of the clavicle, the coracoid process and the connecting conoid and trapezoid ligaments.

See figure below:

Netter, 2016

There are varying grades of shoulder separation that range from grade 1 to grade 6.

  • Grade 1: A slight tearing of the AC joint, but not all the way through.
  • Grade 2: The AC joint is tore all the way through, but the two others that attach to the corocoid process are intact, or partially tore.
  • Grade 3: All three of the aforementioned ligaments that attach to the clavicle are torn all the way through.
  • Grade 4- 6: Are all more severe versions of a grade 3, which will likely require surgery to repair.  

Though one may not need to know the exact details and names of things, it may be beneficial to learn some of these basics to help conceptualize the types of movements that could delay the healing process. As a shoulder separation may appear as if the arm is slightly drooped, it’s more than the clavicle has floated upwards creating a bony prominence. The taller the bony prominence, the more severe (or complete) the separation is. The only way to know with certainty is to obtain an MRI. Knowing the severity on the front end would be beneficial, but some simple range of motion tests, paired with a visual examination by a physician, might be all the info that is needed to rule out the need for surgical repair. Without further delay let’s dive into the recovery process.

Days 0-2:

The first two days of this type of injury can be summarized by an increased level of inflammation, a severely decreased range of motion (at least not without pain), and ultimately learning the limitations of daily life. Pain level 3 at rest, as high as level 7-8 when performing tasks such as closing a car door, picking up a light object, and most painful of all, putting on or taking off a shirt. Overall, motion or lifting the arm in the frontal plane or overhead may be painful and seemingly not possible. You may also experience a knocking or clunking feeling with certain movements potentially indicating a complete tear.

Recommendations:

  • No biking, running or abrupt athletic movements.
  • No lifting with the left arm, as well as limited lifting with the right arm (those forces transfer over across the body and cause pain!)
  • 600-800 mg Ibuprofin 2-3x/ day. No more than 2400 per day.
  • Immobilize with a sling for the first couple days.
  • RICE- Rest. Ice. Compress. Elevate. However the last two don’t really apply. 7-8 minutes of icing at a time. Several times per day.

Day 3-7:

The first week will be quite telling how severe your injury is…if there is any doubt.

By the third day, the swelling should be down and you may regain some range of motion but likely still with pain. During this time you may place your left hand on the steering wheel but not for turning corners. By the end of the week, you might have close to full range of motion, but not without some pain. On the fourth day post injury, I obtained an x ray to make sure there were no breaks. Featured below is my X-ray compared to a normal shoulder X-ray.

Normal AC Joint

Abnormal AC Joint

In the photo above: Notice the cervical vertebrae appear to be out of alignment? That issue also had to be addressed through chiropractic and massage.

Recommendations:

Many therapies started here to get the ball rolling on the healing process. Although the sling is a typical recommendation, kinesio-tape will provide the same function and allow you to use your arm a little to avoid being awkward in social situations. Ultimately this will keep the clavicle in better alignment to the AC process, more-so than a sling will.

Continue Ibuprofin. 400-600 mg, 2-3 times daily.  Also, This is a great time for supplementation! Because the joint was compromised, so were the length-tension relationships of all the muscles that surround the joint. To help those heal, extra protein, specifically a branch chain amino acid supplement, should be beneficial. Other supplements such as collagen, glucosamine, and omega-3 fatty acids in the form of fish or flaxseed oil could really improve the recovery process.

Supportive kinesio taping. Retape every 1-2 days as the tape stretches and it just feels good to have it off for a bit.

A video demonstration of the taping can be seen here.

Day 8-14:

Hopefully the soreness should be decreasing and range of motion should be increasing (slowly) on a daily basis, however, expect to continue to wake up to dull soreness and inability to roll over or prop yourself up without discomfort. During this time period many of things that hurt to do before, like opening up a car door, reaching to the upper shelf, etc. should start to become doable or less bothersome. By the end of the first two weeks, You may be ready for some stretching and/ or progressively moving the extremity through range of motion exercises. One of the hardest motions to do may be the outward extension of the arm in the prone position. See photo below:

Recommendations:

To keep the cardiovascular system active, get the legs moving! Running may be jarring, but if tolerated well, it’s a great way to maintain fitness. Still no outside biking, but indoor biking should be ok. The reason why outdoor biking is not a good idea is simple, the unpredictable. Your brain is wired to use that extremity to balance, lean on, and even catch yourself if you fall for whatever reason. Doing so could set you back and substantially delay recovery, so stick with indoor training workouts on a bike trainer or treadmill.

Days 15-30:

These two weeks of the recovery process can be summarized by a little progress on a daily basis in terms of range of motion and pain. Once the joint becomes more mobile, and you’ve felt comfortable doing more things, doesn’t mean you are clear to do all things. It may feel 95% better but any heavy lifting or even repetitive light load lifting could really set it back.

Recommendations:

Instead of doing dry land exercises, it may be useful to warm up the muscles in the hot tube and do water weight or range of motion exercises in the pool. Starting with no resistance and just moving the arms in the pool is a great place to start. The hardest thing to do will be a swimming stroke, or circular rotation of the humerus, long bone of the arm, but refrain from doing too much circular rotation. Instead performing frontal, lateral, and transverse raises to shoulder height with arm will help to regain strength without excessively pushing on the joint. The first week of these exercises work up from 10 reps up to 15 reps of 3-4 types of exercises, 1-2 sets each as tolerated.

The second week progress very slowly. NOTE: If your injury is more severe, these exercises may not be good to start yet. Overall, the focus should be on very light resistance and improving range of motion, NOT testing the strength of the joint with weight. Continue all other therapies including heat, ibuprofen as needed, Tiger balm, massage and chiropractic, just make sure that massage does not disturb or aggravate the joint. In terms of outdoors exercise: like all other activities, do only as long as tolerated without pain. very minor discomfort is ok but not beyond the level that is reached in daily activities.

Day 30-45:

By the 30th day, things will be feeling pretty dang good and you may feel like it’s’ time to get back after it. If you can bunny hop on a bike without discomfort, you’re good to ride trails and no matter what your doctor says, I’ve cleared you to ride! (with the exception that you don’t fall). If there is minor discomfort with any activity, back it down a notch, speed, or level or whatever you are doing and do not push through any pain. the healing process is like recovery between workouts multiplied by 20; it just takes time and doing the right things

In summary

Be patient with the healing process and after the first few days, start to move the arm as your range of motion allows. Do some icing the first few days paired with ibuprofen to reduce inflammation. It is extremely wise to immobile the AC process and I would recommend the use of tape to do so. Taping acts like extra supportive muscle tendon tissue if applied properly. Beyond that, If a particular motion is painful, stop doing it. Aching seems to be the normal with this type of injury so embrace that fact and do what you can to let the joint heal and gradually increase the range of motion. Another highly useful therapy was the use of heated therapy after the first several days to a week and this may certainly continue for as long as needed. Eventually if any deconditioning took place, it will be wise to strengthen the muscles of the joint very progressively. All tolled, not the worst injury to incur, not by far, but still one that takes patience and the right therapeutic approach to overcome and

For more information and guidance on overcoming an injury, regaining fitness, or any of the info presented, feel free to contact me at gharrison@source-e.net.

About the Author: Grant Harrison grew up competing in a variety of sports including college football, competitive soccer and hockey. Since then things have switched all things cycling- in multiple disciplines to boot. His extensive Master’s education in Human Performance gives him a solid background in all things athlete-related. He’s focused on the delicate balance between pyschological skills, coaching, nutrition, and athlete performance. In addition to coaching services, he also offers one-on-one nutrition consultations. Learn more about Grant or sign up for a nutrition consultation with him. 

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