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

This week I’ll offer up some pre-World Cup injury recovery info, inspired by Egypt/Liverpool brilliant playmaker Mo Salah. There’s been much speculation about the nature of Salah’s recent shoulder injury, and I haven’t been able to find a clear diagnosis in publicly available sources. But if I had to guess (and this is a pure guess), given the way the injury occurred and the evaluation from the physician in the accompanying photo, I’d say he likely sustained a shoulder separation.

First, let’s look at some confusing terminology.

I’ve written previously 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.

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 player 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.Logo

Whether Salah will play is still speculative but most media reports indicate him as “probable”. When it comes time to lacing up the cleats for a possibly once-in-a-lifetime event with the eyes of the country on him, my guess is that he’ll find a way to work his magic from game 1.

Athletico’s Overhead Athlete Program

Matt Gauthier, PT, DPT, SCS from Athletico Physical Therapy talks with Steve and Dr. Cole about the unique characteristics of the Overhead Athlete, types of overhead throwing injuries: causes, prevention and treatment.

There’s more to throwing than just the motion of your arm.  There’s actually a whole science dedicated to it-and Athletico offers a comprehensive approach. Our team of physical therapists, occupational therapists, certified athletic trainers, and physical therapy assistants combine their expertise in throwing analysis with slow-motion video analysis to enhance performance and help prevent injuries.

Matt Gauthier specializes in the treatment of high-level athletes, and is the most passionate about treating shoulder and knee injuries. He is the head of Athletico’s Overhead Athlete Program,  and is a member of the USOC physical therapy volunteer program. As a sports specialist, he has experience treating athletic injuries at the youth, high school, college, professional, and Olympic levels.

From head to toe, swimmers must kick the injuries and pain to get to the top

By Julie Gardner for ATI Physical Therapy

From head to toe, swimmers must kick the injuries and pain to get to the top

While many probably consider swimming a relatively safe sport, injuries can still put these athletes in hot water.  Katie Varnado, ATC from the ATI Sports Medicine department knows about swimming injuries first hand from her work with these athletes.  Here’s what Katie has to say…

What injuries are common…

  • Swimmer’s Shoulder:  The shoulder is the joint most commonly injured, and may include rotator cuff impingement, biceps tendinitis and shoulder instability.  All can result from overuse, fatigue and weakness, especially when proper techniques are not used.
  • Swimmer’s Knee:  This injury occurs during the breaststroke because of the “whip kick,” which places all of the force of the kick on the outside of the knee. The inner ligament of the knee, called the medial collateral ligament, is put under stress.
  • Other Lower Body Injuries: Breaststrokers may experience pain from inflammation of the hip tendons. Lower back disk problems or spondylolisis, a stress fracture in the vertebrae of the spine, may be caused by the dolphin kick.

Prevention…

Katie recommends these tips to help prevent injury. In addition to stretching, there are specific things a diver can do to help ward off a repetitive injury:

  • Understand and focus on proper stroke techniques
  • Lessen repetitive strokes that are causing the  overuse injury
  • Perform core strengthening and cross-training exercises as part of pre and early season routines
  • Be sure to warm-up and cool down after activity and use periods of rest to recover
  • Focus efforts on rotator cuff and scapular strengthening for most shoulder injuries,  and pelvic and hip strengthening exercises for hip and knee injuries
  • Speak with a sports medicine professional or athletic trainer if you have questions  about injuries, exercises and  prevention

Rotator Cuff Repair For Young Athletes: An Uncommon Operation With Excellent Results

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

Key Points:

  • Rotator cuff tears requiring surgery are uncommon in young athletes
  • Surgery typically leads to excellent function and very high return to sports at the same level or higher, although overhead athletes may need to change positions

The rotator cuff is a term used to describe a group of four tendons at the top of the shoulder responsible for movement and stability of the shoulder joint. We’ll typically see rotator cuff tears in older athletes. In young athletes the most common issue with the rotator cuff is an overuse tendonitis, and occasionally a partial tear. A complete detachment of the rotator cuff from the bone is very uncommon in young athletes, but it can happen. When a detachment happens it will require surgery for the young person to have the best chance of full function. Fortunately surgery can lead to excellent results.

At the James Andrews sports medicine center in Birmingham, Alabama, they have quite a bit of experience with rotator cuff tears. In this published study, they report on 2-year follow up of young athletes with rotator cuff tears who underwent surgical repair. Attesting to the rarity of this problem, in an 8 year period at this very high volume clinic they identified 32 athletes (28 boys and 4 girls) with an average age 16 years.

Each athlete played at least 1 sport, and 27 athletes had no shoulder issues prior to the start of their pain. Twenty-nine of the 32 tears resulted from a traumatic event.

The athletes all had surgery at the Andrews Center. Overall, 25 patients (93%) returned to the same level of play or higher. Among overhead athletes, 13 (93%) were able to return to the same level of play, but 8 (57%) had to change positions.

Surgery for rotator cuff tears can lead to excellent outcomes in young athletes, but what we find from these results is that overhead athletes could have difficulties returning to the same position after surgery.Logo

If you’re a young athlete with a complete detachment of the rotator cuff you’ll likely need surgery to best restore shoulder function for sports as well as other activities. These uncommon injuries would best be managed by a physician with substantial experience in treating shoulder injuries.