Acromioclavicular Joint Separation
If you live on the Front Range of Colorado you probably know at least a few mountain bikers, if you are not one yourself. And if you talk to mountain bikers about their injuries you will start to see a trend: lots of collarbone injuries. Falling over the handlebars -- a right of passage among mountain bikers -- is a common culprit for collarbone injuries. The most common collarbone injury amongst mountain bikers is an AC joint separation.
AC joint separation occurs most commonly when a downward force is placed on the shoulder or upper arm, tractioning the arm from the body (including the clavicle). This occurs in biking with a crash onto the shoulder, or in football when a player takes a strong hit to the top of the shoulder. The joint at the end of the clavicle -- the acromioclavicular joint -- takes the most stress in this injury and the ligaments that hold the joint in place can tear.
Degree of Injury
AC joint separations are graded from I to VI depending on the type and severity of separation. In a Grade I sprain, the ligaments are minimally torn and normal activity can usually resume painfree within a few weeks. Grade II includes more ligament tearing and can result in a small bump deformity on the top of the shoulder, but usually heals within two months without functional deficit. Grade III sprains involve a complete tear of the ligaments and visible “step deformity” over the top of the shoulder. The “piano key sign” occurs with this grade of separation where you can push down on the raised collarbone and it will pop back up like a piano key. Grade III injuries can be treated surgically, especially if someone is concerned with their physical appearance, however, functional outcomes are roughly equal between those who undergo surgery or not. Grade IV-VI AC joint separations are rare, but more serious, and require surgery.
So what can you do if you separate your AC joint? In the short term you want to let it heal without injuring it again. Icing it is likely beneficial for at least the first week and taping over the joint with kinesiotape or a more rigid tape can help give a feeling of stability for a few months. Avoiding high contact sports until it’s completely healed will help prevent a worsening of the joint separation. As it starts to feel pain free, the strengthening phase begins. Because of the separation of the joint and tearing or stretching of ligaments, the shoulder joint will be inherently less stable; using muscular strength to support the AC joint becomes more important. Strengthening exercises include rotator cuff, shoulder blade, upper trap (top of shoulder), and chest strengthening to provide support all around the joint. A physical therapist can guide this strengthening phase over the course of a few weeks to a few months, depending on the severity of injury
As a rule of thumb, if there is a visible bump on the shoulder more than a quarter inch and/or pain lasting more than 2 weeks it is advised to get the injury evaluated by a physician or physical therapist to help grade the injury and guide recovery. If pain is severe or the separation is more than a half an inch then immediate medical attention is advised as surgical treatment for this injury, if needed, can be time sensitive.
What is a tendon
A tendon is a strong rope like structure that attaches a muscle to a bone. A common example of a tendon is the Achilles, which attaches your gastrocnemius and soleus muscles to your calcaneus or heel bone. Tendons are an essential part in allowing our bodies to move. They help transfer forces from our muscles (when contracted/tighten) to the bones they attach to, which leads to movement of that bone/body part. Often, they will attach from a large muscle such as your bicep to a small single point on a bone. Therefore, they must be made of strong material as they often undergo strong force transfers
(tendons are known to have one of the highest tensile strengths of any soft tissue in the body).
Anatomy of a Tendon
Tendons are made of dense fibrous connective tissue that is made up of mostly collagen fibers (structural proteins). These fibers are found in very tightly wound bundles throughout the tendon. This collagen and bundling make them very strong and resistant to tears. Another important aspect of tendon anatomy is that they do not receive as much blood as the muscles and bones that they attach to. This is because they have a lower density of blood vessels (reason for their white color). This is an important factor when it comes to tendon injuries. While tendons are strong and resistant to injury they do occur and can be classified into 4 categories: tendinitis, tendinosis, tendon tear and tendon rupture.
The medical definition of the suffix “itis” is inflammation, so the term tendinitis translates to
“inflammation of a tendon.” This is often more of an acute injury (short-term) and is associated with
swelling around the tendon and pain when that tendon is used (contracted by muscle). This
inflammation and pain is caused by micro-tears in the tendon that occur when there is a force applied
that is too heavy and or to sudden applied on that tendon. The treatment goal for tendinitis is to reduce
inflammation. This can be done in a number of ways, starting with RICE (rest, ice, compression, and
elevation), anti-inflammatory medications, and physical therapy techniques including soft tissue
mobilization. Recovery time varies between days-6 weeks.
This term refers to degeneration of a tendons collagen fibers often caused by chronic overuse (longer
periods of time). This degeneration of collagen fibers can lead to loss of fiber continuity, causing
decreased overall tendon strength. These are often seen when a tendon is injured and not given the
appropriate time to rest and recover. Because tendinosis is a chronic issue, there is no tendon
inflammation/swelling present, so the treatment goals are different. Primary treatment goals are to
inhibit the cycle of injury (or tendon overuse) and to optimize normal collagen production and
maturation so that the tendon regains normal tensile strength. To do this we must determine what is
causing the repetitive injury by looking at ergonomics, biomechanics, etc. Once this is determined we
can use support (braces, tape, etc.) to help reduce forces on the tendon and allow for appropriate
healing. Light stretching while minimizing pain is crucial to limit shortening of muscles and maintain
flexibility. Eccentric strengthening and loading the tissue without pain is essential to help with collagen
production and improve collagen alignment. Treatment time can vary from 6-10 weeks (if caught early)
all the way up to 3-6 months.
If you are having any tendon pain (most commonly in heel, elbow, shoulder, knee) please give us a call.
We can help evaluate this pain and determine the underlying cause then come up with a plan to get you
back on track!
A common question that I get from patients is, “Should I use ice or heat?” My immediate response is always, “It depends.” The debate of whether to use ice or heat depends on numerous factors, including the type of injury/ailment and the chronicity of the injury (i.e. time since injury onset). I will take this time to discuss the indications and contraindications for ice and heat, based on both the current research and my clinical expertise.
October is National Physical Therapy month, so I thought I’d take this opportunity to write a series of informative articles on physical therapy- what is it, how long has it been around, who can benefit from it, etc. It only makes sense, that the first in this series should go back to the beginning of physical therapy to provide a brief history of how we got to where we are today!
Bob Cranny, PT