As previously described, surgery is not the gold standard. I also think we should question whether 3 months is enough to reduce pain and increase function. When reading studies I often see that there is a further positive change in function and pain measures from months. In both Ketola et al. Therefore, I think we should consider extending the period with active exercises to a minimum of 6 months.
However, this does not imply that the patients will have to do supervised physiotherapy for 6 months, but I believe that they should do exercises up to 6 months and preferably continue doing some exercises or general movement, which includes their upper extremities. In this study the authors questions whether surgery will work, if physiotherapy does not. Eighteen patients in the active exercise group were not satisfied with the results and crossed over to surgery. These patients, did however sadly not improve with this intervention either.
So, which factors appears to increase the risk of persistent pain? There was also a negative correlation between satisfaction at work and the perception of pain. In a study from Dunn et al. There is to my knowledge, no consensus regarding this question in the literature and no optimal dose to apply to all patients, but it seems that exercises that includes resistance might be an important component.
To me this is not shocking, even though it used to annoy me when I was a student and had very little experience treating patients. One-size-fits-all models rarely works, when treating people with multidimensional problems like chronic shoulder pain. The best exercise is often the exercise that you do.
- Is it time for change with the management of chronic shoulder pain?.
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- Being Is Enough: Collective Self-Help for a Sustainable World.
- Ed on My Shoulder?
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If a patient with chronic shoulder pain presents with fear-avoidance behaviour, maybe we should start with providing pain neuroscience education and graded exposure to these exact movements and make use of cognition-targeted exercise therapy as described by Nijs et al. Higher pain self-efficacy has been shown to be associated with a positive outcome for patients with shoulder pain. In my opinion, we should therefore focus on knowledge translation and effective reassurance to build resilience and provide the patient with active coping strategies, using self-management strategies.
Findings from chronic low back pain research suggests that pain management and rehabilitation programs should specifically target pain self-efficacy as a key aspect of treatment. It has been shown that active exercises physiotherapy has a similar effect to surgery to a fraction of the cost for patients with subacromial pain.
- T.L. Moore (Author of Ed on My Shoulder);
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- The Two Moons of Rehnor Novella Collection I.
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It is time to move away from the purely pathoanatomical treatment, which in my opinion has been dominant in management of chronic shoulder pain. In a high quality RCT , a standardised manual therapy and home exercise program has not been shown to provide clinical important differences in comparison with a placebo intervention inactive ultrasound therapy and application of an inert gel.
Grades I-III are the most common. Grades IV-VI are very uncommon and are usually the result of a very high-energy injury such as one that might occur in a motor vehicle accident. Grades IV-VI are all treated surgically because of the severe disruption of all the ligamentous support for the arm and shoulder. The shoulder relies heavily on ligaments for support. Ligaments attach bone to bone and provide the "static" stability in a joint. Ligaments will alternately become tight and loose with normal motion. They keep the joint within the normal limits of movement.
Muscles and tendons work together in the shoulder to provide the "dynamic" stability of the shoulder. A bursa is a pillow-like sac filled with a small amount of fluid.
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Bursae plural reduce friction and allow smooth gliding between two firm structures, like bone and tendon or bone and muscle. There are over 50 bursae in the human body; the largest is the subacromial bursa under the acromion in the shoulder. The subacromial bursa and the subdeltoid bursa under the deltoid muscle are often considered as one structure. This bursa separates the rotator cuff and the deltoid muscle, from the acromion. After evaluating the history of the patient's injury the doctor will examine the shoulder area looking for signs of fracture or dislocation by comparing the overall position of the arm and shoulder to the uninjured side.
The AC joint itself is easily examined because it is located right under the skin. The doctor will gently feel the bones and soft tissue around the joint and between the acromion and clavicle. There may be a bump, tenderness or instability, which would suggest a joint separation. Crepitus noise as the bones move may indicate a fracture.
The doctor also evaluates the patient's range of motion and performs tests to isolate specific areas of pain and weakness. The treatment of an AC separation depends on the grade of the injury. The classification helps the physician choose the correct treatment approach. Grades I - III are usually treated non-operatively. The vast majority of patients will have a period of discomfort. Once this discomfort disappears, the shoulder is usually fully functional, although the patient may still have a minor cosmetic defect at the injury site. A discussion between the physician and patient should focus on the patient's expectations and possible return to sports.
Many surgeons prefer to first treat the AC separation conservatively. If grade III patients develop problems or do not heal properly surgical reconstruction is an option. Conservative and surgical treatment for grades I - III have essentially the same results after 1 year. Depending on the grade of injury, most patients heal within 2 to 3 months without surgical intervention. The patient is allowed to return to sports when there is full and painless range of motion, no more tenderness when the AC joint is touched, and manual traction does not cause pain.
This usually takes about 2 weeks for a grade I injury, 6 weeks for a grade II injury, and up to 12 weeks for a grade III injury. Surgery may be necessary for AC separations that do not respond well to non-operative treatment. If, after 2 to 3 months, pain continues in the AC joint with overhead activity or in contact sports, surgery may be necessary.
There are some physicians who offer early surgery for a select group of Grade III AC separations based upon the activities and demands these patients place upon the shoulder. A variety of surgical methods have been used to stabilize a separated AC joint. The surgical technique most often performed involves the reconstruction of the coracoclavicular ligaments and the excising removal of the distal shoulder end of the clavicle.
Distal clavicle resection without the repair of the ligaments may lead to excessive rotation of the scapula. Reconstruction studies show that the AC joint can be adequately stabilized by:. In a distal clavicle resection, about mm of the clavicle is removed through a two-inch incision above the joint. The AC ligament is then transferred from the bottom of the acromion into the cut end of the clavicle to replace the torn ligament. Complications of AC joint injuries are persistent instability of the shoulder girdle or residual pain with activity.
These complications can be present with either non-operative treatment or operative treatment. Failure of the acromioclavicular ligament and coracoclavicular ligaments to heal can lead to pain and a sense of instability with overhead activity. If the end of the clavicle remains unstable because of lack of scarring, contact sports or overhead tasks may be painful.
Other complications associated with the reconstruction of the AC or CC ligaments are related to hardware failure. Fixation of the clavicle to the coracoid process is difficult because of the rotation of the clavicle with all overhead activity. The screws used to fix these two bones together can pull out if the patient does not wear a sling after surgery as instructed.
Most surgeons today will securely fix the clavicle to the coracoid with dissolvable sutures or with a screw that is removed at about three months. Patients with lower energy AC joint injuries that respond to conservative non-operative treatment can recover in as little as one week for a Grade I injury to an average of twelve weeks for a Grade III injury. Specific recovery programs following surgical reconstruction of the AC joint vary depending on the type of surgery performed.
General care recommendations include:. In fact the vast majority of AC separations do very well with conservative treatment of the symptoms.
Is it time for change with the management of chronic shoulder pain? — Pain-Ed
Usually the joint remains sore for two to six weeks and then full return to activity is the norm. Only unstable grade III injuries and high-energy AC separations, which are often the result of motor vehicle accidents, require surgery for full recovery. The clavicle will become stable in its newly elevated position, but without surgery the "bump" will remain. The joint will function normally and will not remain tender to touch or movement.
This minor cosmetic deformity will persist but will not interfere with overhead activities or participation in sports. An AC resection is a procedure in which the end of the clavicle is removed and the acromioclavicular ligament in reattached into the end of the clavicle to replace the ligament torn during injury. Once the initial injury has healed and the clavicle has regained stability from scar tissue there is no functional loss with an AC resection.
AC Separation
In the rare instance that the AC joint remains painful after a separation, but does not require stabilization, an AC resection is very effective in relieving pain without sacrificing function. If, however, the clavicle is unstable at the time of resection, a full reconstruction of the coracoclavicular ligaments is necessary to maintain the stability of the upper extremity.
Most athletes in contact sports have had a low energy AC separation at some time in their careers. Except for the slight deformity that remains, there is no clinical significance to a healed AC separation. Occasionally high-energy AC separations that have disruption of the AC and CC ligaments will require surgery, but these injuries are usually apparent early on with a correct X-ray evaluation. Rockwood and Green Textbook of Fractures for a complete description of AC injuries and their classification.
Acromioclavicular Joint Injuries in Athletes. Principles and Practice of Orthopaedic Sports Medicine. Lippincott Williams and Wilkins; Biomechanics of the Shoulder. Care of the Young Athlete. Schenck, Jr, RC ed. Athletic Training and Sports Medicine. American Academy of Orthopaedic Surgeons; Overview An acromioclavicular joint separation , or AC separation , is a very frequent injury among physically active people.
What does the inside of the shoulder look like? What is an AC joint separation? Simple AC injuries are classified in three grades ranging from a mild dislocation to a complete separation: What are the signs and symptoms of an AC joint separation? There may be tenderness at the joint when touched.