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.

Start ACL Injury Prevention Programs When The Players Are Young

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

Key Points:

  • The FIFA 11 injury prevention warmup program has been proven effective in reducing lower extremity injury rates in soccer players
  • Pre-adolescent and adolescent female players are at particular risk for ACL injury, possibly due to risky movement patterns
  • A recent study shows that the pre-adolescent group may benefit most from training with the FIFA 11 program, although all groups show improvements in their movement patterns
  • This study suggests that starting the FIFA 11 program as early as possible would be beneficial

I’ve written and spoken about how much I believe in the value of the FIFA 11 program to reduce ACL and lower extremity injury rates, and make better soccer players. In fact the value of the FIFA 11 has been demonstrated in other sports too. I honestly can’t see why any coach wouldn’t implement this program. It’s part of the regular warmup you’d be doing anyway, and it’s better for your players. Please do it.

ACL tears tend to happen more frequently in teenagers rather than in younger players. Does that mean you should wait until the players are teenagers to start the FIFA 11? This recently published study suggests that the younger players will have greater improvements in body mechanics than the teenagers. The key study result: start the FIFA 11 program in the younger age groups.

This study was recently published in the American Journal of Sports Medicine. In the study, the authors investigated improvement in movement patterns and mechanics in two groups of young players from an 8-week FIFA 11 training program. They had one age group of female soccer players aged 10-12 and another group of female players aged 14-18. In each age grouping there were “intervention” players who participated in FIFA 11 and “control” who did not.  To be clear, this study evaluated the improvements in movement patterns and did not follow the players out to see whether they had reduced injury rates.

Some movement patterns have been shown to be particularly risky for possible ACL tear or lower extremity injuries. For example, landing in a “knock kneed” position is a risky pattern, as is landing with the knee fully extended. The study authors found that the preadolescent 10-12 year old age group started off with more of the high risk injury patterns than the older players. And the younger players had greater improvements in their movement patterns after the 8-week training.

I spoke with study author Dr. Jason Dragoo, who is one of my practice partners at LogoStanford orthopedic surgery. “A few earlier studies suggested that intervention training programs might have a greater effect on athletes classified as ‘‘high risk’’ for ACL injury (meaning that they had poor movement techniques to start with) as compared with those classified as ‘‘low risk.’’ What we found is that preadolescent athletes not only display riskier movement patterns than adolescent athletes but also benefit more from participation in the FIFA 11 program.  I’d start this as early as you can.”

For More Information:

FIFA 11+ poster ages 13 and up

FIFA kids poster ages 7-12

Soccer stretches to always incorporate into your pre-game warm up from ATI

By: Brian Rog and Jen Robbins, MS, ATC for ATI Physical Therapy

Soccer stretches to always incorporate into your pre-game warm up from ATI

We all aim to be that bigger, faster and more conditioned athlete on the soccer field, but getting there requires a disciplined level of strength and endurance to keep up with the rapid speed and agility loads. A large fraction of your success falls heavily on your pre-game routine, which tends to be one of the most neglected aspects for many.

Before hitting the field and to help meet the physical demands of the sport, it’s important to properly stretch to limber up and activate the necessary muscle groups needed to withstand the strains from gameplay. Through stretching, the risk of injury is minimized, while flexibility is maximized.

As a result, you may also notice gains in your endurance and levels of balance. In fact, increased bending and flexibility also play a pivotal role in bettering overall posture, which over time, will strengthen your core and keep your performance at a maximum. Pre-game stretches and warm ups are also crucial for increasing the heart rate so oxygen can be transported to those muscles where major nutrients are consumed.

Considerable research has proven that increased stretching harvests a powerful impact on performance outcomes during a physically-demanding activity. When deciding to focus on specific dynamic or static stretches before hitting the field – the experts at ATI Physical Therapy recommend (after loosening up) incorporating these varying levels of stretching techniques to help support your pre-game regimen.

Skipping with High Knees

Standing in an upright position, begin skipping forward, driving your knee up each time you jump as you swing your opposite arm up overhead. Be sure to keep your movements controlled and maintain your balance.

Single Leg Cross Jumps

Begin in a standing upright position, balancing on one foot, with a crossed line on the ground beside you. Jump into each section on the same foot in a crisscross pattern. While doing the exercise, do not let your knee collapse inward as you land from each jump, and keep your foot facing forward.


Standing in an upright position with your hands on your hips and feet positioned shoulder width apart, step forward and lower your body towards the ground, then in a controlled motion, carefully return to the starting position. While doing the exercise, do not let your knee collapse inward and keep your trunk steady.

Standing Quad Stretch

Standing in an upright position on one leg, reach back and pull the opposite foot up toward your body and push your hips forward until you feel a stretch in front of your thigh (to maintain balance, you may hold the wall or a chair). Be sure to keep your thighs aligned with each other and the bent leg in line with the hip. Repeat on the opposite side. To increase the stretch, keep your knees together and push your hips forward. This stretch should be held between 10 and 30 seconds.

Standing Calf Stretch

Face a wall and keep approximately a foot’s distance from it. Extend one leg straight behind you, keeping your heels flat on the ground and your rear knee straight. Begin to lean toward the wall until you feel tension in the calf muscle of the extended leg. Hold this stretch between 10 and 30 seconds. Repeat on the opposite leg.

Kneeling Hip Flexor Stretch

Kneel on the ground with one knee bent in front of your body and make sure the bottom of your foot is flat on the ground. Tighten your abdominals, tilt your pelvis backward and gently shift your weight forward until you feel a stretch in the front of your hip. Hold this stretch between 10 and 30 seconds. Repeat on the opposite side.

Butterfly Stretch

While in an upright seated position on the ground, bring the soles of your feet together to form a diamond shape and gently pull your heels towards you while also easing your knees to the ground. Be sure to sit upright and place your hands on the top of your feet. Hold this stretch between 10 and 30 seconds.

Lower Back Twist Stretch

Lay flat on the ground with your knees bent and feet resting on the ground. Extend both arms out to form a ‘T’ position. Keeping your back flat and shoulders on the ground, gently rotate your knees down towards the ground until you feel a stretch in your trunk. Hold this position for 10-30 seconds then return to the starting position. Repeat on the other side. When performing this stretch, be sure not to lift your shoulders off the ground when rotating your knees.

IT Band Stretch

Begin sitting on the ground with your legs bent to one side. Take your top leg and cross it over your opposite knee. Using your hands, hug your knee to your chest and hold this position. Hold this stretch between 10 and 30 seconds. Repeat on the opposite leg.

Seated Hamstring Stretch

While in a seated position, fully extend your legs keeping your feet together and bend forward at your hips until you feel a stretch in the back of your thighs and hold. Be sure to tuck your chin towards your chest and hold this stretch between 10 and 30 seconds.

These stretches should take no longer than 20 minutes, conditional to age and fitness levels. Remember, stretching is your last opportunity to prep your body before taking to the field, so incorporating these techniques into your pre-game warm up will get your body to the levels required to meet the demands of the sport and deliver that bomb between the sticks.

Considerations for Returning to Soccer after ACL Surgery

By Dan Czajkowski, PT, DPT, ATC, CSCS for Athletico Physical TherapyConsiderations for returning to soccer after ACL surgery

You’re almost there. The initial ACL injury you sustained months ago seems so distant. You’ve endured all the time healing from the surgery, the rehab, and now you are pushing ahead to get better, stronger and faster. You can almost taste the grass, outperforming your opponents, and scoring a goal in the final minutes of the game.

But wait. Despite finishing rehab and being cleared to progress to sports specific activities, you haven’t even run on grass yet. You haven’t tried cutting at full speed. You haven’t practiced your best moves or even shot at a goal, let alone scored against anyone. You can see the finish line of your recovery, but you don’t really know exactly what you need to do in order to get there.

Many soccer players coming back from an ACL surgery don’t always know the best way to get themselves back on the field safely. However, the secret is simple – start small, stay consistent and progress slowly. Here are a few things to take into consideration as you work toward getting back onto the field:

1. Start by getting fit.

Soccer is a unique game that includes sprinting, changing direction and endurance. You need to train all these factors to be successful, especially when coming back from an injury where you haven’t trained in months. You will need to train yourself in a variety of ways. A few examples are listed below:

  • Interval sprinting and jogging progressions (i.e. jogging for three minutes, sprinting for two minute and repeating for 30 minutes total)
  • Deceleration and Acceleration (i.e. sprint 5 yards and back to endline, sprint 10 yards and back to endline, etc)
  • Endurance running (i.e. 2-4 miles long run)
  • Agility (i.e. sprinting in Box Shape, agility ladder, 5 or 10 yard zig-zag sprints with cones)

2. Start small with your ball skills and progress very slowly

Even though this is usually the most fun aspect of training for soccer, your knee will need time and practice to get used to manipulating the ball. Start by doing simple moves (i.e. turning, using in/out of foot, tic tocs, roll-overs, etc). Gradually increase your speed of the movement as well as sprinting a few steps after finishing your move.

The same progression goes with passing, crossing and shooting. Start out with kicking the ball in place or using a wall to perform short one and two touch passing. Gradually increase your distance as you get more comfortable, and then start passing while you jog, followed by passing while you sprint.

3. Always work on and perfect your cutting/jumping mechanics.

Just because you are training on your own does not mean that you neglect your responsibility to progress, which can help to prevent future injury. As you get stronger, you will need to learn to control your body and keep your knee stable. ACL Injury prevention programs that focus on improving landing and cutting strategies as well as neuromuscular control have been shown to reduce the risk of injury. The trick with these drills is to land with a soft-landing and maintain a half squat position (i.e. slight forward lean, knee bent and knee aligned over ankles). Practice performing two-leg and one-leg jumping in a variety of directions, including forward, sideways, diagonally and over hurdles. Doing 5-10 reps in each direction can help improve your performance and decrease the risk of injury.

4. Perform SAFE strength training under fatigue.

Soccer is a demanding sport. You will be in situations when your body is tired and fatigued, but you don’t want to let your knee become unstable due to this. Performing strength training after you run or perform a workout that fatigues your body can help improve your knee stability. You can perform a 5-10 minute high intensity sprinting workout and then perform body weight or light weight exercises. Some useful exercises include single leg squat, Bulgarian split squats, side walking with a theraband, or single leg balance on an unstable surface. It is import to make sure you have excellent form (keeping trunk stable, knee aligned forward and behind your toes, etc) when performing these exercises. Keep in mind that strengthening routines can also be performed prior to fatigue and have still been shown to reduce re-injuries as well.

Getting Back on the Field

The journey to returning to sport is long, tiring mentally and physically, and takes a lot of hard work. However, many athletes are successful in this journey and you can be too!

Make sure to consult your physical therapist if you have any questions about your recovery process or how to effectively return to sport during your journey. For information about Athletico’s ACL 3P  Program, which can help athletes minimize the risk of ACL injury as well as help those who have experienced an ACL injury progress after surgery, please email