Ask Dr. Geier – Shoulder Separations

I hope everyone had a great weekend! It was beautiful here in Charleston, although it is starting to get hot. Quickly I want to congratulate two teams. The Academic Magnet High School girls’ soccer team won the state championship Friday. It is one of the high schools we cover, and the team has several former patients, so I could not happier for them. It is perennially one of the top academic schools in the United States, proving that it is possible to be smart and good at sports. Also, congratulations to the Lowcountry Highrollers All Stars. Despite a few injuries, our awesome roller derby team continued its undefeated season Saturday. It is great to work with these girls!

Next week’s Ask Dr. Geier column will be a little different, as I will describe a typical week for me at the request of a reader considering sports medicine and orthopaedic surgery as a career. Look out for that. Spoiler alert – I’m actually not that exciting, but it will still make for an interesting post.

As always, please keep in mind my disclaimer about not discussing specific medical advice online or by email.

David

Terry in Rochester, Indiana asks:

I have a type III shoulder separation since October 2010. I’m 47-year-old male who is very active in sports and active in mission trips that require rugged and heavy travel. I still have the same range of motion, but I lack the strength. At times when I use it during sports and piano, I experience pain.

1) Can you please tell me how many surgeries, for this injury, you have performed?
2) And what surgical technique do you use?

Thank you very much for your time and expertise. Terry

Surgery for shoulder separations (acromioclavicular joint separations, or AC separations) is actually not that common. I probably perform 5-10 of these surgeries each year, although they are among my favorite surgeries. The most common types of AC separations are the less severe ones, namely types I and II. They fortunately rarely require surgical treatment. Types V and VI, which are much more serious and usually require surgical treatment, are fairly uncommon. Type III AC separations, like the reader has, often do well with nonsurgical treatment. Even in athletic individuals, studies have shown fairly good outcomes with nonsurgical treatment for these injuries, so most sports medicine surgeons will at least offer and try nonoperative treatment for type III injuries first.

Notice the vertical separation between the end of the collarbone and tip of the shoulder blade on the right shoulder (left side of image). This is a type V AC separation, where there is more than 100% displacements at the joint.

A type III AC separation has a moderate amount of vertical instability of that joint. There is approximately 100% displacement between the end of the clavicle and the acromion. If surgical fixation is attempted, the surgeon uses a technique that reduces this vertical instability. Simply cutting off the end of the clavicle won’t change this instability. In the past, surgeons tried to take a ligament from one part of the shoulder and transfer it to the end of the clavicle to try to hold the end of the clavicle in position.

Newer techniques include implants that try to pull the clavicle down to the coracoid. I use a technique that takes a tendon, either from the patient himself or herself or from a donor. The tendon is looped under the coracoid and then passed through the end of the clavicle through two drill holes. It is anchored in the clavicle with absorbable screws in each drill hole, and then the tendon is sewn upon itself. The tendon reconstructs the ligaments that are torn in the injury, holding the end of the clavicle down in the appropriate position. Studies have shown that this technique, at least in simulated biomechanical studies, is among the strongest for stabilizing this joint. Readers who are considering surgery for AC separations should consult with their surgeons about the necessity of surgical treatment and the options for surgical fixation.

Have you suffered a shoulder separation? Did you have surgery for it, or did you let it heal on its own? Let me know about your experience!

19 Responses to Ask Dr. Geier – Shoulder Separations

  1. Terez Shelby says:

    I am a 37yr old woman who has fallen down the stairs, in result I now have an AC Separation type III. I am devastated to say the least!! I desperately desire surgery though my Orthopedic Surgeon keeps reminding me that most people “don’t” do it. Personally, I don’t care what MOST PEOPLE do, I would like to regain my sexy shoulders. My injury is fairly new, nearly 3-weeks old. I am due to return for a follow-up in a few weeks. Your enthusiasm in regards to AC Separation surgery excites me!! I would be extremely HAPPY if I could be under the care of a Dr. so confident and optimistic when it comes to this procedure.

    • drdavidgeier says:

      Yes, typically type III AC separations are treated nonoperatively, as the results of nonoperative treatment are pretty good, even in athletic individuals. Surgical reconstruction can improve the cosmetic appearance, although there is an incision, and it still occasionally appears larger than the opposite side. And it requires a fairly aggressive rehab of the shoulder after 3-6 weeks of immobilization. But in some people, surgery is a good option. I hope that helps. Please go to the Contact section to send more information if I can help further.

  2. cheryl says:

    I injured my shoulder in June 2010. AC separation III. Due to my active life style I chose to have the surgery. In late Febuary 2011 it failed. The pain was far worse from when I first had injured my shoulder. A 2nd surgery was performed in May 2011. Here I am now nearly 8 months later experiencing the worst pain of my life!! I still am unable to use my shoulder, cant sleep at night and needless to say the constant use of meds and pain killers has pretty much screwed up my stomach. Although I feel that surgery was my only option, I feel that I will end up regretting having the surgery for the rest of my life. I am going for yet another CT scan next week to find out why I am having so much pain. I never thought in a millions years I would end up this way. I used to work out every day and was a interior house painter for 15 years. Now, I sit home every day in the most unbelievable pain ever….I am losing my mind and honestly dont know what to do.

  3. Scott says:

    I just had 2 injections recently in my AC joint to try and relieve chronic pain from a old grade 2 AC seperation. My doctor want me to come back in 3 weeks for an MRI and possibly surgery if the pain in the AC joint does not let up. He talked about doing a distal clacical excision. My question is if this surgery relieves my pain will it also take care of the noticible prominence “bump” on the top of the shoulder also? I ask this only b/c I feel like I’d im going to have to go through surgery I would like to fix not only the pain but the deformity as well.

    • drdavidgeier says:

      In general, distal clavicle excision (removing about 1 cm from the end of the clavicle) does relieve most of the pain coming from AC joint arthritis and injuries. The “bump” that most people have after an AC separation is the prominent end of the clavicle. Removing part of it should improve the prominence for patients, even though it might still no be as flat as it was before they were originally injured.

  4. Mark says:

    Did both of my shoulders a little over 14 years ago. One is a type 3 and the other is a type 4. In both cases I think I was fortunate to get great doctors advise to not get surgery. Instead I spent two months in the pool for rehab progressing to breast stroke arms only, no feet. To this date I have no issues at all. Every doctor I have visited since tells my how smart it was not to get surgery as it leads to more complications down the road.

    • drdavidgeier says:

      There is no question that surgery to reconstruct the injured ligaments is a big one. Depending on the nature of the separation, some require surgery. Fortunately most of the mild ones, while painful, do well with nonoperative treatment and rehabilitation. Thanks for sharing your experience!

  5. Patrick K. says:

    hi doctor,
    i had a “button and pulley” operation on my left shoulder after a type 3 ac seperation 4 1/2 weeks ago.
    i have failed to ask my doctor the “right” questions at post-op visits, simply because i am relying on my own decisions, nutrition, and body to tell myself that im going to be alright. if i recieved the #5 fiberwire from arthrex corp., do you think that i will be able to wakeboard again?? its my true passion and i honestly exert more force wakeboarding than anything else in life. the force of pull on the handle used to be great, and i am so very curious if i will be able to participate in fun behind our boat ever again? this, of course, includes hardcore tubing and waterskiing!
    thank you doctor.

    • drdavidgeier says:

      Patrick, I can’t say specifically in your case. The goal with surgical repairs or reconstructions for AC separations is to get people back to all of the activities that they like to do. It takes a lot of work with therapy after surgery and a lot of time, but it often happens.

  6. Jeff says:

    I had an anatomical ac joint reconstruction with allograft 10 months ago, although my shoulder is much better than pre op, I am now having some pain around the coracoid…if I press firmly upon it I get a sharp pain throughout the shoulder.. What could this be? I’m scheduled for a ultrasound in 2 weeks..would this be of any use ? My age is 17 and I am healthy otherwise

    • drdavidgeier says:

      Sorry Jeff, I don’t know that I can really say without examining you. Your surgeon can probably determine the cause by physical exam and possibly x-rays or MRI.

  7. Timothy Edin says:

    I really like that you ask for peoples experiences and comments.

    Before talk about my injury, I would first like to say that I am and have been, very dismayed in general by the orthopedic community’s attitude towards separated shoulders. From the beginning I was treated like a petulant child who only cared about “looks”.

    In December of 2011 I had a grade 3 separation of my left shoulder. There was a massive 2 inch drop plus the “bump”. But not just a bump, my clavicle was (and still is) completely out of alignment with the clavicle now pushing into my back with a very noticeable up angle, approximately 25 degrees. Here I should note that I was told that the separation was “only a bad grade 2”. Later I have to come to find out I was lied to. It was a grade 3 at least, and most likely a 5. Reasoning was that I would want surgery and the doctor figured that it was fine like it was, and like you have mentioned, figured most separations “do ok on their own” according to the literature.

    I was told it was “normal” and that it would “heal” and “be fine”. It was not, and did not. I had a complete inability to move my left arm forward under load. As a hockey player I knew there was something wrong beyond what the sports doc told me. I was unable to shoot or stick handle up to nearly a year after the accident, I am left handed shot. As well, during this time my arm continued to droop badly. During this time all activity, physical and social, stopped. The continual fatigue and pain was too much. I lost 30 pounds of muscle; it was as if my body was in constant toxic shock.

    Finally after 10 months, a surgeon took my case on. I had the tightrope procedure with a tendon graft, clavicle top button with a toggle lock and suture material pulled tight to reduce the gap. Immediately there was improvement. In a week the pain was much less, even with the surgery pain. The fatigue left. Cosmetically however it is still messed up. As a body composition competitor, this is unacceptable. The deformity is massive and ends my current life. Even after surgery. Currently I have only 25% of the strength I had prior to the accident, despite full mobility. All contact sports are out, as is beach volleyball, and any other activity where my arm could sustain a hit.

    It has been a year since surgery and while it is a far improvement from what is was, I am still very disappointed with the aesthetics, it ends my competing. I do not have anywhere near the strength I once did, it is doubtful it will ever return. It is doubtful I will return to anywhere near my previous level of activity. In short, this injury was devastating to my life, and I really have not liked the “suck it up buttercup”, and “be a man attitude” I received.

    I read Terez Shelby’s comments and I have to agree with her attitude. For men, a large part of a males sexuality is how broad his shoulder are. I would like a surgeon to try explain to me how this is different than a woman who needs to have her breasts removed. A woman feels as that a large part of her sexuality is gone, and she is right. This is why doctors worked so hard to do something about it, now breast augmentation is standard to restore “cosmetic” appearance. Beyond a complete change in lifestyle, losing my shoulders meant losing my sexual appeal, and as a single male looking for a partner this is horrible, mentally debilitating. And there is no “just getting over it”. When a single woman looks at you and says “gross”, you know it, are aware of it “cosmetically”, and going to the beach, forget it. Nothing being a freak that people and kids point at, stare, and make comments constantly. I suggest any doctor with this attitude should have his shoulder badly separated and then talk to a male in this position. I was given the “a lot of hockey players have this” speach, like I was a 10 year old kid. I DON’T CARE IF THE ‘BIG BOYS” have it.

    I have reviewed the current literature on this injury, which after reviewing, I find is highly suspect in regards to the posts used to measure what acceptable means. Immediate surgery (acute) will be standard procedure in the next few years. Complete AC & CC ligament reconstruction using a tendon graft with tightrope and clavicle hookplate should be standard treatment now. Leaving the “bump” (it is not a bump, I do not appreciate the minimization of the injury by calling the entire injury a small bump) is professional folly. Leaving the injury means that almost all people will suffer daily and later life will have severe problems.

    I have decided to undergo surgery again (despite recovery time again … for a third time), this time with the hook plate to get my scapula up again and to get my clavicle back to at least semi-normal alignment. I do not expect miracles but it can, and will be better. I am disappointed I have had to do this all on my own.

  8. Arndt Manzel says:

    What Timothy says is so absolutely true – a man´s shoulder line is absolutely critical to his attractiveness. And a step deformity is not a cosmetic flaw, it´s a deformity (while a small scar is a cosmetic flaw that is well accepted). Acute stabilization using the tight rope technique should thus be a standard treatment. Why not reduce the ACJ with this relatively safe and minimally invasive technique? I was initially not informed about this option and now have to live with asymetrical shoulders for the rest of my life :(((

  9. paul says:

    I am a junior in high school who received a level 3 separation. I plan on playing college football and do not know whether surgery would be the right thing to do or to physical therapy. I still feel pain in my shoulder at times it is very painful. I do not know what to do?

    • drdavidgeier says:

      Difficult question. Typically Types I and II AC separations do well without surgery, and Types IV, V, and VI usually do require surgery. Some studies have shown good success rates with nonoperative treatment of Type III AC injuries even in athletes, but many athletes have surgery if they are limited by pain, stiffness, or weakness.

  10. Tony Minyard says:

    I had shoulder surgery on Sept 10th 2013, and it was a tear in the rotary cuff. However, I went to therapy and guess what happened the PT had me lift 25 pounds over my head. Now my shoulder is popping, clicking with great 9-10 pain level. I don’t have full range and now I have a bump on top of my shoulder. My doctor was angry, now I have to start over in therapy been to 45 sessions still hurts so the doc gave me a cortisone shot and now it hasn’t help at all. I think I might have to have surgery again?

  11. Douglas F Tomlinson says:

    Timothy Edin has said a lot of what I am feeeling. My Orthopaedic Surgeon was badgering me that he would be wrong to even suggest surgery. Now that I have the energy to look for an alternative, my time for normal healing processes will soon pass, which means much mor invasiv surgery. How can I locate a surgeon who does the surgery (with regularity and good results) to get an evaluation. The literature always refers to the surgery as “controversial” which means some clearly believe it is often the better course of action. I would like to at least discuss this with someone doing the Bosworth screw or the suture method. PS – I have above average upper body strength and never broken a bone in my life (and all my teeth) – I think I’m a good candidate for surgery.

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