AC Separations are a relatively common cause of shoulder pain and deformity. An AC Separation, also called a Shoulder Separation is a different injury then a Shoulder Dislocation. Most AC separations occur from a hard fall onto the point of your shoulder. AC separations cause significant pain on the top of your shoulder. Some of you might notice a bump has formed. Our thoughts on who might benefit from AC separation surgery is evolving and changing. See you video discussion below where Dr Jeff Berg and I discuss treatment strategies for the most common types of AC separations.
What is the AC Joint?
The AC Joint represents the region where your clavicle (or collar bone) meets your scapula (or shoulder blade). The two bones are held together by many strong ligaments.
The AC joint is commonly injured as a result of a blow to the side or top of your shoulder. For a hockey player that means hitting the shoulder hard against the boards. For others it means a fall directly onto the side or the top of the shoulder.
Types of AC Joint Separations
In mild AC Separations there will be pain on top of the shoulder, and perhaps mild swelling. Mild AC separations are either grade I or II. Both of them will not require surgery. You will be very tender over a small area on the top of your shoulder. Moving the shoulder will be very difficult due to pain on top of the shoulder. With a Type I or Type II AC separation there should not be a significant deformity noted.
In more severe AC separations, where more of the ligament supports are torn, you will have severe pain on top of the shoulder and you will now notice a deformity is present. The most common severe type of AC separation is a grade III injury. You will see a bump on top of your shoulder. It might be a small bump, or it could be a rather large and disturbing bump.
When you have an AC separation the ligaments which connect the collar bone to the scapula have torn. The deformity or bump following a shoulder separation occurs because the scapula (and arm) drops down. Most people mistakenly believe that the collar bone popped up.
Is Surgery Necessary for an AC Separation?
Most AC separations can be effectively managed without the need for surgery. Most of the recent literature shows no difference between surgically treated AC separations and non-surgically treated separations.
We grade AC or Shoulder separations by how far the collarbone is from the scapula. The further the distance, the higher the grade. Most surgeons used to only rely on the grade of the shoulder separation to determine whether or not surgery was necessary. Things have changed. Surgery for all Type III AC separations is no longer recommended.
One caveat … We now know that there are “stable” AC separations, and there are “unstable” AC separations (read on) .
Considerations before surgery for an AC Joint or a Shoulder Separation:
- The severity or grade of your injury
- We must also consider the “stability” of the clavicle (see below)
- IS it your dominant arm?
- what sports you are involved with?
- and if any other injuries exist.
An unstable Type 3 AC separation means that even after a 3 week period of rest, every time you move your shoulder you feel, and see the end of the collar bone moving, and that leads to pain, as well as poor function. If you are an overhead athlete with an unstable AC separation your performance and endurance will suffer.
A stable ACJ Separation means that you do not feel the clavicle moving around significantly as you move the arm. It also means that within a few weeks after your shoulder separation you are comfortable and after rehabilitation your function is good.
IF you have an unstable Type III (or greater) AC separation, your dominant arm is involved and you are an overhead athlete then surgery is typically advised to repair the AC Joint, and to repair the ligaments of the AC Joint. During the surgery we bring the shoulder back up to meet the clavicle and then we reconstruct or repair the ligaments around the AC Joint to protect it from future injury and restore your level of function.
Recovery From an AC Separation
The recovery from an AC separation will depend on the grade of the injury and whether or not surgery was necessary. If surgery is not necessary then an athlete might be able to return to the field in 6-8 weeks. If surgery is necessary then the recovery is much longer, somewhere on the order of 4-6 months to allow the new ligaments to heal.
Bottom Line: For ACJ separations, you want to follow a short period of rest with a course of rehabilitation. After a few weeks (3-4) you will know whether or not your AC separation will be stable and your function has been restored… or you will know if you are not tolerating the instability, pain and loss of function (non-coper). In the later situation where you are not coping well or tolerating the injury and loss of function, then you can consider surgery for your AC separation as a reasonable option.
Great website doc. Thanks. The AC joint queries and answers are extremely helpful. After reading about some bad surgical outcomes, it’s encouraging to know that surgery isn’t indicated, solely on the basis of grading- at least for grade 3 injuries. Thanks again.
Hello Dr. Luks, I seperated my shoulder the Fall of 2011 and I went to a doctor about it a year later and decided not to have a surgery. I recently just went back to the doctor because 3 and a half years later, it still bothers me and I feel like it effects my elbow and my whole arm when I throw a ball or use it. I guess I should tell you that I am really active and I’m always playing in men’s sports leagues whether it is flag football, basketball, or softball. My recent visit to the doctor, he confirmed that it is a grade 3 injury and we spoke about surgical options. My question is after 4 and a half years, with it still bothering me, would it be possible to heal without surgery or are those ligaments destroyed to the point where surgery would be the best option? it doesn’t hurt me all the time but it will hurt me from time to time without doing anything on it. It usually hurts me when I throw a football or softball and not just the ac area but a lot of pain throughout the whole arm. I also feel like it has effected my elbow because that has started to hurt over the years and I never had a problem with it before I injured my shoulder. I guess I’m really just asking if you personally believe it could still heal without surgery or would surgery be the best option? Thank you.
Hi – thanks for all this information. I am 40 years old and was a New Zealand representative mountainbiker in my younger days. At age 20 I separated my shoulder with a bike crash (not sure what grade) and the hospital gave me conservative treatment, taping it down, with a sling and recommending against surgery as it was often not successful.
I have always experienced discomfort in the joint (my dominant arm) and it noticeably protrudes with my arm hanging lower than the other. The muscle pain in the surrounding areas is what really bothers me though. I get knotted and painful muscles around my scapula. Every couple of weeks after hard work with the arm the muscles in my neck and upper back on that side get really tight and I have constant pain until I can get massage therapy to settle it down. I am worried about further degeneration and osteoarthritis in the joint and wondering what you think the success rate for corrective surgery would be after 20 years. I appreciate your help! Thanks.