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.
Sheryl Black
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.
Ryan
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.
craig castanet, d.c.
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.
Brandon
Hello dr. Luks… I separated my shoulder 4 months ago, grade 2-3. Two doctors told me two different grades. I am still not able to do push-ups, dips, bench press, or any shoulder lift without pain. I waited the 4 months before I tried to lift. Before I was benching 315, deadlifting 500. I am now looking at surgery to try and rebuild the joint. I was told that I wouldn’t be able to strength train for 6 months after. If I have a successful surgery and build back up slow, do you think those numbers would be achievable again? It is a major reason I want to try and get it fixed. I am also a construction worker and work a lot overhead. I just don’t want to get the surgery and end up worse. I have researched a good surgeon, who claims he has 100% success rate. i am just confused if it will be worth it. Your opinion is greatly appreciated
Many people can make a full comeback after an AC Joint reconstruction. However, there are no experienced surgeons out there with 100% success rate :-( #truth
Mitchel
Hello Dr. Luks. I am 27 years old and a personal trainer. 10 days ago I had a snowboarding accident that resulted in a grade 3 AC separation (The Ortho Doc today explained another 2 millimeters would have put in at 300% making it a grade 5). I read quite a bit but don’t fully understand that just yet. I was in agony for about 5 days with extreme limitations and could only perform mandatory task but I made vast improvements in the last two days. I still have limited range of motion, mostly with forward flexion and opposite that (reaching for wallet type of motion) with acute pain if I try to reach beyond that. I felt that surgery was a given considering the limitations, obvious skin tenting, and my line of work/ lifestyle. Today my doctor confirmed that, although it wouldn’t be mandatory, he felt that a surgery would be my best treatment option. However, he proceeded to tell me that the success rate for a shoulder repair procedure is 50-60%, which seems incredibly low and requires 6-9 physical therapy. Following the surgery I would have to wear a sling for 6 weeks (only to remove for PT and showering). Some of what I read confirms this, some of it conflicts it. I would like ask for your opinion on what I was told today and to see if you have any recommendations for the best course of treatment. Thank you.
Hi Mitchel,
The success rate in the hands of those of us who perform this often enough is much higher than that. BUT .. not all Type IIIs need surgery. Only ones which remain “unstable”. Instability in this situation is tough to explain, it’s something we see on examination. Without examining you it would be hard to comment further.
Saad
Hello,I am 29 years old. I separated my shoulder two days ago. I have a grade 2 to 2 1/2 degree tear. I have a bump on my shoulder yesterday but today it has gone away. I can feel it, but no longer see it. My doctor said it’ll never be the same if I don’t get surgery done. Is this true? Can I try homeopathic remedies?
Not true …
Surgery as an initial treatment option is NOT recommended for Type 2 injuries. Most will do very well without surgery and return to sports.
Chuck
Hi Doc, I am 64. Last night, while playing racquetball, I hit the rear wall with my non-dominant, left shoulder/arm (similar to a hockey player hitting the boards). Immediate pain followed in the joint and upper arm… Not painful/no bump on top,but ROM and strength is poor. I should be sleeping right now, but …
Should I get an xray today? Naturally, rest is indicated. My doc doesn’t like me taking motrin due to kidney concerns, but that would usually be my first course of action @ 3×800 mg per day.
Thanks for an informative website!
Chuck
At 64 your concern is both an injury to the AC Joint as well as the rotator cuff. Best to have a good exam by a shoulder doctor sooner rather than later.
Good luck.
Robert
Hi I am now 6 months down the road since I injured my shoulder. I have a grade 3 and it is unstable as far as I can tell. I have gotten some strength back and have had good ROM the whole time sluggish at parts but able. I have strength but not all of my original and I still cant do any explosive movements. I am currently in the military and am quite active. Will surgery help me get closer to my original strength and will it allows me to get my explosive movements back.
Without examining you … all I can say is that it is possible. Just be careful who you have fix it.
Brett Ciabattini
Hey I separated my AC 4 weeks ago. The pain went away quickly but the bump never went away. I went back to skating a week and a half ago and everything has been going well. As long as I don’t fall on it the pain stays away. Just wondering when it’s going to go back into place and what I can do to make that happen faster
The bump will remain there no matter what… that is normal.
Mike Lombard
Yesterday 12-20-15 I caught an edge while public skating and crashed into the boards. Banged up both knees, a ding to the head but no cognitive/ consciousness issues and sustained Type III A/C Separation. Was not playing hockey at the time just public skate (i.e. no pads). Was taken by ambulance to the hospital; X-Rays were run. No breaks or fractures or chips. Surprisingly there is not much pain. Almost full rotation extension with moderate pain only when I tuck arms in close (putting on a shirt) or try to lift something any more than say 30 lbs.
Jacob
Hello, I separated my shoulder about 8 weeks ago during football. The doctors classified it between a 2nd and 3rd degree without need for surgery. I still am unable to throw a baseball at full speed and only feel pain when I’m throwing hard. If I continue with physical therapy will my shoulder ever be back to pitching form?
It is still in its healing phase … while there is no way to know for sure if you will be back to perfect … it is too early to decide that non-surgical treatment isn’t working
Richard
Hello, I separated my ac joint 3 years ago and it has bothered me ever since and recently was considering surgery. Can I do it? Will my shoulder be better after surgery?
Surgery for chronic AC Separations can be successful … like any procedure, there are successes … and a few failures.
Zach Hester
Hello sir,
I am a pitcher for my high school baseball team and when I’m not on the mound I’m at short stop. 2 weeks ago after throwing only 1 ball, when my arm reached the top point of my throw, I heard and felt a pop. Immediately following the pop my arm shot with intense pain, it dropped immediately to the ground. It has been 2 weeks since the incident and I still can but throw a single ball, or do anything at all with my shoulder. Every day I can feel the pain getting worse and my shoulder continuesly is in pain, agonizing pain. Even sitting still with no physical activity or movement. What is this? What should I do? Is something torn?
Zach .. you should see a shoulder specialist.