Coming Back From Shoulder Separation

By Dev K. Mishra, M.D., President, Sideline Sports Doc, Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

  • A “shoulder separation” is a different injury than a shoulder dislocation
  • The shoulder separation involves a sprain to the ligaments of a joint at the point of the shoulder near the end of the collarbone
  • We will often see these injuries when a player is tackled or falls to the ground on the point of the shoulder, with the arm at the player’s side
  • Most shoulder separations from sports injuries can successfully be treated without surgery

I’ve written recently about shoulder dislocation, a serious condition in which the ball portion of the shoulder (humerus) becomes completely dislodged from the socket. This week we’ll discuss a shoulder separation, another common shoulder injury. But first let’s clear up some terminology to avoid confusion.

A separated shoulder refers to an injury to the ligaments of the acromioclavicular joint (commonly known as the AC joint), which is the joint between the end of your collarbone and the upper part of your shoulder blade. It’s located near the point of the shoulder.

Most shoulder separations occur during some type of hard fall or contact, such as a quarterback being tackled on to his shoulder, or a cyclist falling and landing on his shoulder. When I see a hard fall to the ground I’ll be suspicious for either a shoulder separation or a broken collarbone if the athlete fell with the arm tucked in to the side, and I’m suspicious for a shoulder dislocation if the athlete fell on to the outstretched hand.

There are six types of shoulder separations. Types 1 and 2 are the most common ones we see in sports injuries and are treated without surgery. Type 3 injuries are also reasonably common, and most of these are treated without surgery (although there is some debate about early repair for the throwing shoulder of an elite athlete…). Types 4-6 are not seen very often in sports injuries and these will require surgery. I refer to these as “types” although some surgeons will call these “grades”.

  • Type 1 – The ligaments have a mild sprain without a tear.
  • Type 2 – The AC ligament tears, leading to a partial separation.
  • Type 3 – The AC ligament and other associated ligaments tear, leading to a complete separation.
  • Types 4-6 – These are complete separations, serious injuries often requiring urgent surgery. I have seen one type 4 separation in a D1 quarterback during my 23-year career.

Here are typical return to play times for the common types:

  • Type 1: You can usually return to play 2-3 weeks after the injury, depending on your sport and position. You should be comfortable, with full motion, normal strength, and ability to do sport specific motions. Treatment includes rest and anti-inflammatory medication.
  • Types 2 and 3: A Type 2 injury takes about 3-4 weeks to fully heal, and a type 3 injury takes about six to eight weeks to heal. We’ll almost always treat these without surgery, and we’ll use the same return to play criteria as indicated above for the Type 1 injury. If you’re in a collision sport (such as football) I’ll usually recommend you return to play with an AC joint pad to minimize the chance of another injury.

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Monitoring Training Metrics on Elite Athletes; Clavicle Fractures; Concussion & Youth Football Participation

Episode 17.24 with Hosts Steve Kashul and Dr. Brian Cole. Broadcasting on ESPN Chicago 1000 WMVP-AM Radio, Saturdays from 8:30 to 9:00 AM/c.

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Segment One (01:23): Dr. Kevin Sprouse from Podium Sports Medicine describes the key elements in monitoring the unique biomechanical and physiologic variables widely applicable to any level of athlete who wishes to ensure that they are optimizing their overall health and performance.

Dr. Kevin Sprouse is a Knoxville native, now working with elite athletes and active individuals around the world. Trained and certified in both Emergency Medicine and Sports Medicine, he obtained his Bachelor’s degree in Exercise Science at Wake Forest University before attending medical school at the Virginia College of Osteopathic Medicine at Virginia Tech.

He then completed his Emergency Medicine residency in New York City, where he was elected Chief Resident. Following residency, he attained a fellowship in Sports Medicine at the Steadman Hawkins Clinic in Greenville, SC.

The focus of his academic interests and practice has been the care of the endurance athlete, as well how exercise, diet, and movement effect the health and well-being of all active individuals. His patients have included professional and Olympic cyclists, runners and triathletes, and he now brings his experience and expertise in this field to Podium Sports Medicine.

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Segment Two (11:40): Dr. Cole and Steve talk about the causes, treatment and recovery for Clavicle Fractures.

A clavicle fracture is a break in the collarbone, one of the main bones in the shoulder. This type of fracture is fairly common—accounting for about 5 percent of all adult fractures. Most clavicle fractures occur when a fall onto the shoulder or an outstretched arm puts enough pressure on the bone that it snaps or breaks. A broken collarbone can be very painful and can make it hard to move your arm.

Most clavicle fractures can be treated by wearing a sling to keep the arm and shoulder from moving while the bone heals. With some clavicle fractures, however, the pieces of bone move far out of place when the injury occurs. For these more complicated fractures, surgery may be needed to realign the collarbone.

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Segment Three (17:00): Coach Paul O’Toole, Commissioner of the St. Raphael Youth Football Program in Naperville IL, talks with Dr. Cole and Steve about the decrease of football enrollment due to risk of concussion; technique, program and protocol changes to make the game safer for young players; addition of trainers onsite at all games.

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Related article: Counsel patients, parents on concussion risks in football

PITCH SMART RECOMMENDATIONS FOR YOUTH BASEBALL

By Dev K. Mishra, M.D., President, Sideline Sports Doc, Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

  • Young pitchers are at risk for arm injuries due to a number of factors, and pitching while fatigued is perhaps the biggest risk for injury
  • MLB’s Pitch Smart guidelines are designed to reduce injury risk while still allowing for the competitive development of the young player.
  • Parents, coaches, and league administrators would be wise to implement the Pitch Smart recommendations for their pitchers

As spring and summer baseball is ramping up, I’d like to remind our readers of a terrific Grant Lewisresource for the young pitcher- MLB’s Pitch Smart guidelines. I’ve written about pitch counts, the “100 inning rule”, and pitching injuries in several other blog posts but it is worth pointing out some of the reasons why we should revisit this topic. Pitch Smart is an effort by Major League Baseball to critically evaluate factors responsible for injury risk to young pitchers and then create guidelines to minimize that risk. Pitch Smart is partnered with many of the brightest minds in sports health for throwers and has produced a set of recommendations based on evidence and experience.

The result of their effort is a set of age appropriate recommendations designed to keep young pitchers as healthy as possible.

We’ve definitely made progress in recognizing and putting in place recommendations to reduce injury risk, but as the website points out we still have some work to do. For example, a survey of youth pitchers published in 2014 showed that of the pitchers responding to the survey many were engaging in behaviors that risk the health of their arms:

  • 45% pitched in a league without pitch counts or limits
  • 5% pitched on consecutive days
  • 4% pitched on multiple teams with overlapping seasons
  • 2% pitched competitive baseball for more than 8 months per year

Those published statistics are a few years old and hopefully we’ve made some progress in this area thanks to the efforts of Pitch Smart and others.

Take a look at the age-specific guidelines. They are divided into 5 age groups. For example, in the 15-18 year group which would cover most of our high school aged athletes some of the key recommendations are:

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Players can begin using breaking pitches after developing consistent fastball and changeup

  • Do not exceed 100 combined innings pitched in any 12 month period
  • Take at least 4 months off from competitive pitching every year, including at least 2-3 continuous months off from all overhead throwing
  • Make sure to properly warm up before pitching
  • Set and follow pitch-count limits and required rest periods
  • Avoid playing for multiple teams at the same time
  • Avoid playing catcher while not pitching
  • Players should not pitch in multiple games on the same day
  • Make sure to follow guidelines across leagues, tournaments and showcases
  • Monitor for other signs of fatigue
  • A pitcher remaining in the game, but moving to a different position, can return as a pitcher anytime in the remainder of the game, but only once per game
  • No pitcher should appear in a game as a pitcher for three consecutive days, regardless of pitch counts

In my opinion, Pitch Smart’s recommendations are another example of much neededSideLineSportsDoc changes designed to keep young players playing longer and healthier. These are recommendations rather than rules, but if you are a league administrator I’d urge your league to have a close look at these recommendations and adopt them for your players.