I must’ve been a bad boy this year, because for Christmas, Santa got me a Type 3 Separated Shoulder. I took a poor fall during randori (free sparring) at judo practice two weeks ago and landed on my left shoulder. Snap, crackle and pop! I’m OK now, but the AC and CC ligaments are smoked, and the clavicle sticks out, proudly disconnected from the scapula.
After a few hospital visits, I was surprised to hear that the injury isn’t as bad as it sounds, and there are two ways forward that lead to similar results:
- Non-operative: rest and physiotherapy.
- Operative: surgery, rest and physiotherapy.
Within the medical community, there is no consensus in which of the above is best, so from my point of view as a patient, it’s a Choose Your Own Adventure. I had a few days to make up my mind about which way to go, during which I spent more time reading about this than I’d like to admit. This post is my attempt to salvage that time and produce a summary of what I found. A secondary goal is to get this stuff out of my system, so I can concentrate on other parts of my life for the time being.
There are several people documenting their shoulder separation journeys on YouTube. I won’t be joining them, but watching the videos was helpful for me, so I’ll list them here:
- Operative path: the author posted videos before the op, as well as 1, 4, 9, 26 and 79 days after.
- Operative path: this is actually a Type 5 (significantly worse than a Type 3). Had initial surgery to fix it, and then revision surgery after the first failed. Now contemplating surgery for the third time.
- Operative path: in Russian. Operated immediately after injury, but the surgery failed, now contemplating revision. Also keeps a huge shoulder separation-related playlist, mostly in Russian, here.
- Non-operative path: starts at 3 days after injury. The videos in the playlist are a bit out of order, but still useful.
- Non-operative path: A single video 3 months after injury, but still helpful.
- Non-operative path: Tracks progress since 2013. Recently reported major complications several years after injury, now contemplating surgery.
Reading through this thread on an MTB forum was quite helpful, too.
Now the heavy artillery: here are some relevant medical articles I skimmed through.
- Treatment of acute grade III acromioclavicular dislocation: a lack of evidence: A survey of existing literature comparing operative and non-operative approaches. Reports similar results for both approaches, with a greater risk of complications for the surgery group.
- Acromioclavicular Joint Separations Grades I-III A Review of the Literature and Development of Best Practice Guidelines: A survey focusing on the non-operative path and the different physiotherapy protocols commonly used.
- Nonoperative treatment of acute, grade III acromioclavicular dislocation in judo competing athletes: abstract in English, paper in Polish. Tracks 14 judo athletes over several years. Would be good to read a translation of the full paper, but the summary reports results of the vast majority of subjects as good.
- Acromioclavicular third degree dislocation: surgical treatment in acute cases: reports slightly better results in the operative group.
- Is conservative treatment still defensible in grade III acromioclavicular dislocation? Are there predictive factors of poor outcome?: advocates non-operative treatment as the first option.
- Treatment of Grade III Acromioclavicular Separations in Professional Baseball Pitchers: favors nonoperative management.
- Rehabilitation of Acromioclavicular Joint Separations: Operative and Nonoperative Considerations: 16 pages of shoulder separation goodness.
- Return-to-activity after anatomical reconstruction of acute high-grade acromioclavicular separation
There are many methods of performing surgery, and they differ significantly. Here’s an overview and some more details:
- Weaver-Dunn: this may be the first ever method, documented in 1970
- Bosworth: uses a screw to fix the clavicle to the clavicle, sutures together the ends of the torn ligaments, and then removes the screw after 8 weeks of immobilization.
- Hook plate fixation: seems similar to Bosworth, but uses a hook plate instead of a screw. Sounds like the hook plate stays in for longer, around 8 to 12 months.
- Continuous Loop Double Endobutton: new technique that replaces the CC ligament with thread. Not sure what it does about the AC ligament.
My summary is below. There are two phases: acute (up to 3 weeks after injury) and chronic (more than 3 weeks after). During the acute phase, if you reconnect the ligaments early, the body’s natural healing processes may help in their recovery.
- Faster return to ADL (activities of daily life)
- Altered mechanics of shoulder AC joint. No AC/CC ligaments, the body will have to compensate. Risk of scapular diskinesis.
- Risk of complications requiring subsequent surgery. This surgery will be in the chronic phase, so success rates may be lower than in the acute phase, depending on the type of surgery.
- Visible deformity in the shoulder area due to the detached scapula (intensity varies from person to person). Mostly cosmetic.
- Partially (or fully, in the acute case) restore the biomechanics of the shoulder AC joint.
- Full recovery may be possible if operated acutely (within 3 weeks of the injury).
- Fix the clavicle to the scapula, remove bump. Mostly cosmetic.
- Later return to ADL (activities of daily life)
- Results may not be significantly better than the non-operative path
- No gold standard: lack of consensus of what type of surgery is best
- Greater initial risk and discomfort
- Financial cost
I picked the non-operative path. That’s all from me.
Oh, and Merry Christmas!