One of my patients in the clinic today was seeing me for the shoulder pain that he had been having for about a week. The pain started when he had fallen onto his shoulder while wrestling around with a couple of friends. He now had a rather pinpoint area of pain and decreased range of motion throughout his shoulder.
This is a common presentation. I hear this a lot. It’s classic for shoulder injuries.
Just having the description doesn’t give any doctor a very good clue about what is going on. Twenty different shoulder issues will have almost the same presentation. So despite him wanting me to do “chiropractic on his shoulder”, we weren’t there yet. That would have been irresponsible and perhaps even detrimental.
What this guy needed was an exam.
After the exam, it was quite apparent that this was a low-grade AC joint issue.
He was excited to know it wasn’t a surgical fix but he still needed to know more about it. He wasn’t even sure what “AC” meant nor where exactly it was.
Here’s the SportsDocDC version of an AC issue and how it all plays out in real life.
The AC stands for Acromnion/Clavicular joint. Look at the picture and notice how the clavicle (collar bone) comes up right next to the hook of the scapula (shoulder blade) at the top of the shoulder?
That’s the AC area. There is a ligament attaching those two bones to give you structural integrity. And as we all know, where there are ligaments, specifically at mobile joint areas (shoulder, ankle, wrist, etc.) there is potential for sprains.
A sprain is simply where a ligament is injured. I often explain it as a “run” similar to what you’d see in pantyhose, socks, tights, or athletic wraps.
There are different levels of sprains.
Traditionally grades 1, 2, and 3 sprain.
Classification with these grades of sprains helps Healthcare professionals and Sports Medicine teams concisely relate information. For example:
Think of a grade 1 sprain as a classic basketball “sprained ankle.” One of those where you roll your ankle and whither in pain on the basketball court or soccer field and by the time the trainer and your mom get out there to access you, it is already feeling a little bit better. Sometimes you can kind of bounce back and get into the game and other times it may take a few days. Overall it is the lowest grade of injury and the body responds very well and does what it does and heals you up.
Grade 2 is a little bit more severe. These are almost always still non-surgical but the ligament has a bit more damage. When I explain Chiropractic to people I will always tell them, “If you have a sprain, it is very good for me to get in there and move the joints back in the right positions and make the right movement so these ligaments have the best opportunity to heal up in the right position. However, I cannot control your biology. Grade 2 sprains just take time to get better.”
These are classic sprain injuries and common to athletics and can take anywhere from a week to 4 to 5 weeks depending on the severity.
Grade 3 sprains are complete tears. A full rupture of the ligament. Think of an ACL tear in an athlete that requires surgery.
So have this idea in mind as we get into AC joint injuries.
First, a quick review and reminder.
Partially torn ligaments are sprains.
As part of the sports med. team, realize that we can call the same injury either of those terms- A partially torn ligament or a sprain. In my lectures when I talk to athletic trainers, coaches, and Sports Medicine doctors I bring this up a lot. Yes, a partially torn ligament sounds more severe, it’s medical, it gets the point across but, it is also much scarier. It is just as easy to tell an athlete, “It is a sprain” and set their psychology towards the healing. You can’t believe how many times in my career I’ve had somebody come in and tell me, “I have a partial tear in my rotator.”
My first thought is, “Somebody wasn’t paying attention or somebody had a poor doctor that didn’t take the time to explain stuff correctly. There’s more than one thing wrong with just that statement.” Followed immediately by my second thought, “ Dude you are 40 years old and this happened in high school. It’s not partially torn anymore. It is either healed up or scar tissue.”
The main point is, to stop making it scary. Athletes HATE scary.
See, the thing is, what we say as practitioners, matters. You can take the same injury and make it something that the patient is going to recover from or you can be scary and use a bunch of 50 Cent words and the poor athlete has to carry this with him like a backpack full of bricks for the rest of his life as his burden to bear.
Let’s just go with “sprain.” This is a sports med page after all and I want you as the athlete to get it in your head “YOU WILL RECOVER FROM THIS!” Heck, a lot of times in the office I just call an AC joint issue.
Things have changed a lot in the last few years and with the AC joint separation, there are multi-levels of classifications of the injury. So as you see in the picture, it’s not just 1-3 here. I want you to be modern so I included the newest ways of looking at this, but you understand better now so be sure to figure out if you have the Old grade three or the New grade three if you get to that point. Feel free to take this article out and ask!
Grade 1: Low-intensity and there is no permanent displacement that is obvious to the naked eye. There is no big step sign on the shoulder.
Grade 2: This is more severe and you will surely see a small “step sign” where the joint has become a bit displaced. This is one of the more common ones I see and typically the moms of the younger athletes are very concerned because it, in essence, is a small disfigurement. I have kids of my own, any sort of disfigurement is terrifying as a parent. What I tend to tell the kids that have these issues is
that most likely that small step sign isn’t going to go away. It may get a little bit smaller as some of the edema and swelling goes down but many athletes still have the bump. In my opinion, this just doesn’t create any permanent damage. In fact, it might even make your traps look a little bit bigger. ( why not spread a little bit of positivity when we can?)
Grade 3 sprains are even more serious. And typically require Surgical Intervention. These are a “sprung clavicle” and are outside of my scope of practice
Treatment for these goes very well and I think there are a lot of different practitioners that can help you if you are suffering from one of the non-surgical classifications.
First, any shoulder issue will almost always have a reaction of the pec muscle locking down as a stabilization response. This puts the shoulder in a position similar to what a shoulder sling from the 1980s and 90s would look like. The brain just likes the shoulder in that position because it tends to take a lot of the pain away. So look for a tight pec muscle. Helping to relax this specifically the subclavius muscle directly underneath the collarbone helps set the scene for a response.
You might not be able to do this with stretching because the pain through the AC joint is too severe so I like some of the Tools, Tak Balls, hands-on myofascial release, etc.
This tends to be well received from the patient because it is not in the direct area of pain.
We have been having a lot of success with cupping however not in the standard, “ I’m going to leave a giant hickey on your body” sense. the copy that I’ve seen the most success with is just lifting the superficial layer of skin. If this works, it works nearly immediately and is a good clue that RockTape 2 creating some decompression at the area would also be successful and is something they can take with them on the road.
In the case of my last patient, the muscle work throughout his pec and trap caused him some pain but gave him a better range of motion. The second I put on the RockTape, the pain was almost 75% better.
If there’s inflammation in the area I don’t start any exercises right away. I want the inflammation gone so I tend to use ice just over the shoulder at the area of pain for the first few days until the inflammation is gone.
In any case, hopefully, now you understand a little bit more about the AC joint as far as anatomy, how to treat it, and what to expect with a low-grade sprain to this area.