ACJ injury presentation for the NWULG, May 2014, by Andrew Gardner

1. Conservative rehabilitation
and post operative rehabilitation

2. AC joint injuries
 One 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.

3. Causes
 Fall 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)

4. 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)

5. Diagnosis
Clinical 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.

6. 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)

7. 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.

8. 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.

9. Return to Sport
 Return 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)

10. 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.

11. 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 Good
Conservative treatment (complete separation):
No=37
-7 Excellent
-26 Good
-3 Unsatisfactory
NB 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.

12. Research of conservative management of AC joint
injuries.
Fremerey et al 2001
 Compared grade 3-5 Rockwood AC joint treatments
 Conservative physiotherapy vs Surgical (Weaver Dunn)
 Similar results in both groups at follow up 6.3 years
 More severe patients faired as well as less severe injuries
 Deformity 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.

13. Research of conservative management of AC joint
injuries.
Reid et al 2012
 A/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 1-3
 Well constructed RCT’s need to be carried out. (Ceccarelli
2008, Reid 2012)

14. Prognosis
Grade 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)

15. Prognosis
Grade 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 treatment
Further 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.

16. 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.

17. Lancashire Teaching Hospitals physiotherapy protocol.
Week Rehabilitation
Operation to 2
weeks
Advice and education
Elbow hand wrist AROM
AAROM flexion and abduction to 90 degrees for 2/52
Full lateral/ medial rotation
30% 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 control
Progress cuff strength rehabilitation
Address kinetic chain and core stability
Correct abnormal movement patterns
6 weeks+ Start resistive strength
May include deltoid rehabilitation
Progress dynamic functional activity
Shoulder 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

18. Nottingham Protocol
Phase
(week)
Rehabilitation
Inpatient
Phase 1
(week 0-2)
AROM - Hand and elbow.
Sling management, sleep positions and early home function.
2 week physiotherapy FU.
Surgical FU.
Early
Outpatient
Phase 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 3
Intermediate
Outpatient
(week 6-8)
AROM through range
Scapular stability and motor movements as required
Increase rotator cuff work
Correct and modify ergonomics as necessary
Phase 4
Late
Outpatient
Rotator cuff and scapula stability work (open Chain)
Sports specific drills
Functional work progressions
Advice with regards to ongoing care
Milestones Avoid heavy lifting 6 weeks
Full AAROM and AROM 6-8 weeks
Return to work/functional independence 6-8 weeks
Complete strengthening 6-8 weeks
Return to contact sports 12 weeks

19. Problems!!
Complications Actions
 Infection
 Re-rupture of ligaments
 Loosening of screw
 Nerve damage
 Persistent pain
 Stiffness
 Surgical review
 Investigations
 Change physiotherapy
strategy: Hydrotherapy/ Pain
management modalities.
 Further surgery

20. Surgiligament Complications.
(Last 3 years case-note data)
0
0.5
1
1.5
2
2.5
3
N=30
2
1 1
3
Screw
Scar
ROM
Surgery

21. Rehabilitation after anatomic acromio clavicular joint
reconstruction AACR
 Brace 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.

22. 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?