Acromio-clavicular jointInstability

Conservative rehabilitationand post operative rehabilitation

AC joint injuriesOne of the most common injuries in athletes/

sports. 9% of injuries affecting the shoulder girdle (Mazzoca 2008).

More common in young men.Male/Female ratio 10/1.Associated glenohumeral injuries. SLAP tear.Severity depends on the extent of

ligamentous /soft tissue disruption.Rehabilitation is an important part of care for

these patients , conservative or post-op.

CausesFall onto the point of

the shoulder e.g. Spear tackle, motor bike injuries

Direct blow/contact with a hard surface.

Whiplash injury to the shoulder. Effect of seatbelt. (Wallace et al 1998,levy et al 2002)

SEQUENCE OF STRUCTURES AFFECTED A/C Joint ligaments and capsule torn. Coraco-clavicular ligaments torn. Tear of coraco humeral ligaments. Delto trapezio fascia. Results in a loss of the suspensory support of the shoulder girdle and the shoulder

drops downwards. Tossy and Rockwood classification (1998)

DiagnosisClinical signs and symptoms:Acute(all grades) Injury mechanism. Sudden pain. Worse lying on side. Cradling arm. Step Deformity/bump. (Type 3

injury) Swelling/bruising+. Disability. Aggravated by movement. Clavicle and acromium

tenderness.-X-Rays:-Diagnose any associated clavicle #-Weighted views?-AP, 10° tilt, Axillary views.

Diagnosis (cont)Sub acute (lower grades) Injury mechanism. Pain lying on side. Pain moving the arm across the body. Pain on overhead activities Pain on lifting. Pain pulling and pushing Swelling and stiffness after activity Morning stiffness-AC joint stress test-X-rays/ MRI scan/?CT scan- Dynamic US cross arm manoeuvre (Peetrons 2007 . J clinical

US)

Aims of Physiotherapy & Conservative Management

Reduce pain and inflammation: Ice, Anti inflammatories, Acupuncture, Electrotherapy etc. Protect the shoulder: Supports: Figure 8, Sling, Neoprene, Taping techniques (k tape/strapping)Early Rehab Normalise joint range. -Start exercises when no pain at rest. Arm by the side. (Cote-et al 2009).-Weighted pendulum exercises. Relieve pressure on cuff tendons.

-ROM exercises: Care with internal rot, cross adduction and HBB (stresses the A/C joint)

N.B. -All movement exercises must be relatively pain free and well controlled. -If 1 week of no improvement in ROM for grade 2 injury. Consider concomitant

diagnosis.

Aims of Physiotherapy & Conservative Management Improve scapula alignment and control. CKC exercises e.g. Scapula clock, T’s and Y’s, scapula pro and retraction off the wall.N.B. For grade 2 injuries. Start immediate exercises to dynamically stabilise the A/C joint. Upper limb proprioceptive exercises. Progressive Strengthening exercises: -Avoid pain and fatigue. -Progress to open chain exercises.e.g. Prone horizontal extension and Abduction in external rotation.

Normalise muscle lengths. Address the whole kinetic chain. Improve technique and function e.g. lifting and overhead activities.

Return to SportReturn to Sport:-Load bearing exercises.-Plyometrics.Pain free task examples• Landing sideways against a wall.• Landing on the arm (simulated fall).• Landing against the wall with an outstretched arm.• Throw and catch a ball in awkward positions.• Completing 1 or 2 contact training sessions.Protective equipment to be considered. (Shoulder

pads)

Conservative protocol (Gladstone 1997)Phase 1: Pain relief & protection (3-10 day

immobilisation).Phase 2: ROM and early isotonic strengthening.Phase3: Advanced strengthening and dynamic

A/C joint stability strengthening.Phase 4: Sports specific training.

Research of conservative management of AC joint injuries. Bjerneld et al (1983) 5 year follow up study of acute acromio clavicular

separation.Conservative treatment (partial separation): No=37-24 Excellent results-13 GoodConservative treatment (complete separation):No=37-7 Excellent-26 Good-3 UnsatisfactoryNB Unable to qualify conservative treatment other than minimal

immobilisation and rehabilitation.?Lower grade injuries respond better in the long term than higher grade

injuries to conservative treatment.

Research of conservative management of AC joint injuries.Fremerey et al 2001Compared grade 3-5 Rockwood AC joint treatmentsConservative physiotherapy vs Surgical (Weaver

Dunn)Similar results in both groups at follow up 6.3 yearsMore severe patients faired as well as less severe

injuriesDeformity persisting did not affect outcome of pain,

strength and function (Constant Murley score)Post traumatic OA occurred with patients with AC

joint healed in partial dislocation.

Research of conservative management of AC joint injuries.Reid et al 2012A/C joint separation grades 1-3 conservative care. Review of literature .Anatomy, AC jt biomechanics, injury mechanisms,

rehabilitation.Development of best practice required. Little evidence as to what constitutes conservative care.24 articles identified. No RCT’s.Conservative management is the main recommendation

for grades 1-3Well constructed RCT’s need to be carried out.

(Ceccarelli 2008, Reid 2012)

PrognosisGrade 1 and 2 separation• Most symptoms subside within 7-10 days of injury• 52% remain asymptomatic after 6.3 years. N=33 (Mouhsine

et al 2003)• Average constant score at 6.3 years 82. (Mouhsine et al 2003)• Yet 27% of type 1 and 2 injuries require surgery after

26months!! (Mouhsine et al 2003)• Radiographic AC joint changes 70% • Osteolysis 6%• Laxity 33%• Painful clicking on press up 30% grade 1 and 42% (Bergfeld

1978)• Major pain and instability forcing sports to be given up was

9% for grade 1 and 42% for grade 2 injuries. (Shaw et al 2003)

PrognosisGrade 3 separations• 6-12 week trial prior to decision of surgery. (Cote et al 2008)• Management decision based on hand dominance, occupation, heavy labour,

sports, risk of re-injury and scapulothoracic dysfunction.Meta analysis of 1176 patients of conservative and operative

treatment:( Augustus D, Mazzocca et al 2007) • 88% satisfied with operative RX vs 87% with non-operative treatment. (Larsen and Hede 2003). Similar results: • Persistent symptoms in 8% operative group and 10% non operative group.

• Complications: Operative vs Non operative treatmentFurther surgery 59% Vs 6%Infection 6% vs 1%Deformity 3%vs 37%• Pain and ROM not significantly affected. (Augustus et al 2007)

• (Schegel et al 2001). 20% sub optimal outcome and 17% decrease in bench press strength.

Discussion (Conservative Treatment).-Are we managing low grade injury effectively?-Can we identify the Grade I/II patients who will have

problems later on?-Is standardisation of physiotherapy care possible?(Set a

gold standard of care). Immobilisation period post injury.Physiotherapy for the grade of injury.Exercise progression. Return to contact sport.-Problem with milestones? Clinicians critical thinking lost.-Lack of RCT’s in conservative care of AC joint

dislocations.

Lancashire Teaching Hospitals physiotherapy protocol.Week Rehabilitation

Operation to 2 weeks

Advice and educationElbow hand wrist AROMAAROM flexion and abduction to 90 degrees for 2/52Full lateral/ medial rotation30% isometric cuff exercise

2-6 weeks No loading beyond 5kg up to week6.Removal of sling (2/52).Start AROM to full range.Address dynamic scapula controlProgress cuff strength rehabilitationAddress kinetic chain and core stabilityCorrect abnormal movement patterns

6 weeks+ Start resistive strengthMay include deltoid rehabilitationProgress dynamic functional activityShoulder Class.

Milestones 80% AROM by 6/52.Full AROM by 12/52.Normal cuff and deltoid activity by 12/52.Non contact sports 3/12.Contact sports 4/52

Nottingham ProtocolPhase(week)

Rehabilitation

InpatientPhase 1(week 0-2)

AROM - Hand and elbow.Sling management, sleep positions and early home function.2 week physiotherapy FU.Surgical FU.

Early OutpatientPhase 2(week 2-6)

AROM- Shoulder flexion to 90. - ER and IR, resisted as tolerated.Early ADL advice.Movement re-education as required.Closed and open chain work.

Phase 3Intermediate Outpatient(week 6-8)

AROM through rangeScapular stability and motor movements as requiredIncrease rotator cuff workCorrect and modify ergonomics as necessary

Phase 4Late Outpatient

Rotator cuff and scapula stability work (open Chain)Sports specific drillsFunctional work progressionsAdvice with regards to ongoing care

Milestones Avoid heavy lifting 6 weeksFull AAROM and AROM 6-8 weeksReturn to work/functional independence 6-8 weeksComplete strengthening 6-8 weeksReturn to contact sports 12 weeks

Problems!!Complications Actions

InfectionRe-rupture of ligamentsLoosening of screwNerve damagePersistent painStiffness

Surgical reviewInvestigationsChange physiotherapy

strategy: Hydrotherapy/ Pain management modalities.

Further surgery

Surgiligament Complications.(Last 3 years case-note data)

N=300

0.5

1

1.5

2

2.5

3

2

1 1

3

ScrewScarROMSurgery

Rehabilitation after anatomic acromio clavicular joint reconstruction AACRBrace 6-8 weeks!Avoid cross adduction ,HBB, internal

rotation.Closed kinetic chain exercises at 8/52

(scapula & shoulder).Gradual incline.Isotonic exercises at 12/52.Kinetic chain involved.

Discussion (Post-Op)Patients respond very well to surgery. Can we

review milestones and create a fast track rehabilitation protocol?

Physiotherapy treatment post-op: More evidence is required for different surgical techniques e.g. Weaver Dunn, Tightrope, AACR, Surgiligament.

Rehabilitation to sport? Clarity in guidelines required.

What is the effect of (early) rehabilitation on the screw?

How do we implement a 5kg lifting limit?