Direct Force

• •
  

  Fall or blow to the superior aspect of the shoulder with arm in the adducted position driving the acromion downward and medially (most common mechanism) ( Figure 7-1 ).

  
  

  
  

  
  

  

  
  

  
  

  The most common mechanism of injury is a fall or blow to the superior aspect of the shoulder with arm in the adducted position driving the acromion downward and medially.

  
  
  
  
• •
  

  The magnitude of force determines severity of injury.

Indirect Force

• •
  

  Caused by falling on an adducted outstretched hand or elbow, causing the humerus to translocate superiorly, driving the humeral head into the acromion

Type I Injury

• •
  

  AC ligament sprain

  
  
• •
  

  No displacement on radiographs

Type II Injury

• •
  

  AC ligament tear, CC ligaments intact

  
  
• •
  

  Lateral end of the clavicle superior in relation to acromion but not 100% displaced

Type III Injury

• •
  

  AC and CC ligaments torn

  
  
• •
  

  100% displacement of the clavicle on radiographs ( Figure 7-2A )

  
  

  
  

  
  

  

  
  

  
  

  Bilateral Zanca view for distinguishing between grade III and grade V AC separation. A, Grade III AC separation with 100% displacement of the clavicle. B, Grade V with exaggerated superior dislocation of the AC joint between 100 and 300% on radiographs.

  
  

Type IV Injury

• •
  

  Complete dislocation with posterior displacement of the distal clavicle into or through trapezius muscle

  
  
• •
  

  Posteriorly displaced clavicle on axillary radiographs

Type V Injury

• •
  

  Exaggerated superior dislocation of the AC joint between 100% to 300% on radiographs ( Figure 7-2B )

  
  
  
  
  • •
    

    CC ligament distance increased two to three times

    
    
  • •
    

    Disruption of the delto-trapezial fascia

  
  

Type VI Injury

• •
  

  Complete dislocation with inferior displacement of the distal clavicle into a subacromial or subcoracoid position

Acute Injury

• •
  

  Periods of immobilization and rehabilitation

  
  
  
  
  • •
    

    Sling for 1 to 4 weeks with rehabilitation

  
  

Chronic Injury

• •
  

  Activity modifications of rest

  
  
• •
  

  Antiinflammatories

  
  
• •
  

  Intraarticular corticosteroid injections

  
  
  
  
  • •
    

    Corticosteroid injections are not used by the senior author for acute injuries but are used for treatment of chronic injuries defined as pain at 3 months postinjury

  
  

Guidelines for Choosing Among Nonoperative Treatments

• •
  

  Despite the numerous forms of nonoperative treatment including braces/harnesses, taping, casts, etc., no evidence proves any of these methods to be better than the use of a sling with concurrent rehabilitation

Operative versus Nonoperative Treatment of Type III Injury

• •
  

  Demands on the shoulder need to be taken into account when determining treatment

  
  
  
  
  • •
    

    Hand dominance

    
    
  • •
    

    Occupation

    
    
  • •
    

    Heavy labor

    
    
  • •
    

    Position/sport requirements

    
    
  • •
    

    Scapulothoracic dysfunction

    
    
  • •
    

    Risk of reinjury

  
  
  
  
• •
  

  General consensus for nonoperative treatment

  
  
• •
  

  Phillips et al. conducted a literary review of 1172 type III injuries treated and identified 88% and 87% success rates for operatively and nonoperatively treated patients respectively

Athletes With Type III Injury

• •
  

  General consensus for nonoperative treatment of contact athletes (where risk for reinjury is high) ( Figure 7-6 )

  
  

  
  

  
  

  

  
  

  
  

  Algorithm that can be used when treating an athlete with an acromioclavicular joint injury.

  
  
  
  
• •
  

  Surgical treatment reserved for patients with persistent symptoms after 3 to 6 months

  
  
• •
  

  Time of injury in relation to season

  
  
  
  
  • •
    

    Athletes sustaining a grade III AC injury in early preseason or offseason may lean toward reconstruction, as the window of time for recovery is large, whereas athletes with AC injury mid or late season may opt for nonoperative treatments to allow participation in sport to continue.

  
  
  
  
• •
  

  Position of the athlete

  
  
  
  
  • •
    

    The tasks and demands of the upper extremity vary from position to position, sport to sport and as such may be affected differently by the loss of joint stability occurring with a grade III AC separation.

    
    
  • •
    

    Positions that involve specific positioning of the hand throughout space (baseball pitcher, football quarterback, etc.) may be greatly affected by a loss of stability at the AC joint in comparison to other positions such as those in kicking sports or positions in which the uninjured extremity can assist in overcoming a loss of joint stability (football lineman, etc.).

  
  
  
  
• •
  

  Level of play

  
  
  
  
  • •
    

    In determining an athlete’s appropriateness for sur­gical reconstruction, level of participation (recreational vs. collegiate vs. professional) should be considered.

    
    
  • •
    

    Balancing the risks and time associated with surgical reconstruction with the importance of maximizing stability to allow full sport participation may be different for the recreational athlete who can change sports or positions to accommodate their shoulder versus the professional athlete whose livelihood and career is largely dependent on their ability to use their shoulder.

  
  

Manual Therapy Techniques

• •
  

  Manual therapy techniques such as gentle grade I and II joint mobilization may be helpful modulating pain.

  
  
• •
  

  Given the wide range of manual techniques and modalities, selection of these potential therapeutic interventions are at the discretion of the treating rehab clinician.

Activation of Primary Muscles Involved

• •
  

  Muscle activation of scapular stabilizers with closed chain scapular exercises and kinetic chain activities to allow the patient to focus on scapular control and established movement patterns without creating excessive loads about the shoulder.

Open and Closed Kinetic Chain Exercises

• •
  

  Table slides progressing to graduated wall slides are also utilized to encourage restoration of shoulder elevation initially prescribed at a high frequency, low intensity, and short duration ( Figure 7-7 ).

  
  

  
  

  
  

  

  
  

  
  

  Closed chain progression of active-assistive range of motion.

  
  
  
  
• •
  

  Graduated table slide would be performed 20 to 30 times, three to four times a day (high frequency), within a comfortable or minimal discomfort range of motion (low intensity), repeatedly with no “holding” of end range for stretch (short duration).

  
  
• •
  

  Supine flexion and pulley exercises are added to assist in increasing forward elevation.

  
  
• •
  

  Progress reclined flexion to upright forward elevation ( Figure 7-8 ).

  
  

  
  

  
  

  

  
  

  
  

  Open chain progression of active-assistive range of motion.

  
  
  
  
• •
  

  Scapular clocks for muscle activation ( Figure 7-9 ).

  
  

  
  

  
  

  

  
  

  
  

  Scapular clocks to facilitate muscle activity of the scapular muscles.

  
  

Other Therapeutic Exercises

• •
  

  Conditioning (bike or elliptical)

  
  
• •
  

  Nonweight bearing upper extremity core stability (bridge, crunch, etc.)

Activation of Primary Muscles Involved

• •
  

  Isotonic strengthening exercises directed at restoring and maintaining adequate scapular retraction

Open and Closed Kinetic Chain Exercises

• •
  

  Pushup plus (protraction/retraction against the wall) at shoulder level or below to assist in activating the serratus anterior with less upper trapezius activity when compared to overhead activity

  
  
• •
  

  Multilevel rows (Thera-tubing or cable column)

  
  
• •
  

  External rotation (ER) and internal rotation (IR) for RC musculature (Thera-tubing or cable column)

Neuromuscular Dynamic Stability Exercises

• •
  

  Rhythmic stabilization in supine ( Figure 7-10 )

  
  

  
  

  
  

  

  
  

  
  

  Rhythmic stabilization. The rehab clinician applies manual resistance in alternating directions to challenge the patient’s ability to stabilize the shoulder.

  
  

Functional Exercises

• •
  

  Lower extremity exercise including shoulder dumps ( Figure 7-11 ), single leg trunk flexion bends, single leg balance, hip hike, squats

  
  

  
  

  
  

  

  
  

  
  

  Shoulder dump exercise as described by McMullen J and Uhl TL to facilitate shoulder external rotation and scapular retraction. To perform the exercise for the right shoulder, the athlete stands with the left foot forward and left hip flexed and the trunk flexed and rotated to the left with the right arm positioned at the level of the knee ( A ). The athlete is then instructed to shift weight back to the right foot while extending and rotating the trunk and to move back to an upright position ( B ). As the athlete moves through this movement, the shoulder is externally rotated and the scapula retracts, as if dumping or pouring something out.

  
  

Sport-Specific Exercises

• •
  

  Pain-free nonathletic ADLs

  
  
• •
  

  Full active ROM (equal to the uninjured side with visual estimation) without pain

Manual Therapy Techniques

• •
  

  Continued conditioning described in phase II

  
  
• •
  

  Initiate upper extremity weight-bearing core stability exercise, e.g., plank, side plank (grades I and II may tolerate before or at 6 weeks)

Activation of Primary Muscles Involved

• •
  

  Isotonic exercises are progressed at this phase with continued emphasis on maintaining scapula retraction. Scapular dyskinesis has been shown to be present in among patients with grade III AC separation reinforcing the importance of exercise encouraging scapular retraction. Exercise to address scapular dyskinesis often focus on retraction to encourage normal positioning and movement patterns of the scapula. Conscious correction of scapular position has been shown increase activation levels of the trapezius in overhead athletes. When prescribing exercises for the shoulder, maintenance and correction of scapular position is encouraged to improve muscle activation and function.

  
  
• •
  

  With improved strength, exercise tubing or cable resistance exercises are utilized to progress the strengthening program.

  
  
• •
  

  Strengthening targeted at the rotator cuff muscles (emphasis on ERs), biceps brachii, pectoralis major, and minor and scapular rotators.

  
  
• •
  

  PNF utilizing rubber tubing is introduced at this time.

Techniques to Increase Muscle Strength, Power, and Endurance

• •
  

  Multilevel rows

  
  
• •
  

  Prone scapula exercises—Is, Ts and Ys (start with no weight and high repetitions to fatigue)

  
  
• •
  

  PNF patterns with tubing (D2 pattern—proprioceptive neuromuscular facilitation)

  
  
• •
  

  IR/ER (tubing/cable)

  
  
• •
  

  Scaption

  
  
• •
  

  Upper Extremity PREs (for biceps, triceps, etc.)

Neuromuscular Dynamic Stability Exercises

• •
  

  Rhythmic stabilization in supine

  
  
• •
  

  Manual proprioceptive neuromuscular facilitation (PNF) patterns

  
  
• •
  

  One-hand pushup on wall with light ball ( Figure 7-12 )

  
  

  
  

  
  

  

  
  

  
  

  Pushup on the wall with light ball.

  
  

Plyometrics

• •
  

  90-90 supine ball toss ( Figure 7-13A )

  
  

  
  

  
  

  

  
  

  
  

  A, 90-90 supine ball toss. B, Overhead supine ball toss.

  
  
  
  
• •
  

  Overhead supine ball toss ( Figure 7-13B )

  
  
• •
  

  Medicine ball chest pass

Functional Exercises

• •
  

  Lower extremity exercises including shoulder dumps , trunk bends, single leg balance, hip hike, squats

Sport-Specific Exercises

• •
  

  Sports specific movements with advancement to use of lower limb or trunk from double lower extremity to single lower extremity

Manual Therapy Techniques

• •
  

  Continued conditioning described in phase II

Neuromuscular Dynamic Stability Exercises

• •
  

  Continue one hand ball pushup on wall. As exercise becomes less challenging, the athlete can move away from the wall to increase the amount of load through the arm to increase difficulty.

Plyometrics

• •
  

  Plyometrics should start with two-hand chest pass followed by two-hand overhead pass. When two-handed activities are no longer challenging, progress to single-hand passes.

Functional Exercises

• •
  

  Continue lower extremity exercises.

Sport-Specific Exercises

• •
  

  Initiate throwing program. Our throwing program is adopted and modified from review of previous published programs ( Box 7-1 ).

  
  
  
  

  Box 7-1

  
  

  Interval Throwing Program

  
  

  Adult-Aged Players

  
  

  
  

  
  

  
  
  • •
    

    Each phase should be completed before progressing to the next level.

    
    
  • •
    

    Long throws represent target distance for eventual long throw workouts. We recommend 180 feet as that distance to begin with for adult rehab interval programs. Actual long throw distance is the maximum distance thrown when healthy to a specified 20-feet-wide target area.

  
  

  
  

  Phase I

  
  

  
  

  
  
  • a)
    

    Warm up

    
    
  • b)
    

    15 throws arched—45 feet

    
    
  • c)
    

    15-minute rest

    
    
  • d)
    

    15 throws arched—45 feet

    
    
  • e)
    

    Cool down

  
  

  
  

  Phase II

  
  

  
  

  
  
  • a)
    

    Warm up

    
    
  • b)
    

    20 throws arched—60 feet

    
    
  • c)
    

    15-minute rest

    
    
  • d)
    

    20 throws arched—60 feet

    
    
  • e)
    

    Cool down

  
  

  
  

  Phase III

  
  

  
  

  
  
  • a)
    

    Warm up

    
    
  • b)
    

    20 throws arched—90 feet

    
    
  • c)
    

    15-minute rest

    
    
  • d)
    

    20 throws on a line—45 feet

    
    
  • e)
    

    15-minute rest

    
    
  • f)
    

    20 throws arched—90 feet

    
    
  • g)
    

    Cool down

  
  

  
  

  Phase IV

  
  

  
  

  
  
  • a)
    

    Warm up

    
    
  • b)
    

    20 throws arched—120 feet

    
    
  • c)
    

    15-minute rest

    
    
  • d)
    

    15 throws on a line—60 feet

    
    
  • e)
    

    15-minute rest

    
    
  • f)
    

    20 throws arched—120 feet

    
    
  • g)
    

    Cool down

  
  

  
  

  Phase V Long

  
  

  
  

  
  
  • a)
    

    Warm up

    
    
  • b)
    

    20 throws arched—180 feet

    
    
  • c)
    

    15-minute rest

    
    
  • d)
    

    25 throws arched—180 feet

    
    
  • e)
    

    15-minute rest

    
    
  • f)
    

    20 throws arched—180 feet

    
    
  • g)
    

    Cool down

  
  

  
  

  Phase VI

  
  

  
  

  
  
  • a)
    

    Warm up

    
    
  • b)
    

    15 throws arched—120 feet

    
    
  • c)
    

    15-minute rest

    
    
  • d)
    

    15 throws on a line—90 feet

    
    
  • e)
    

    15-minute rest

    
    
  • f)
    

    15 throws on a line—90 feet

    
    
  • g)
    

    15-minute rest

    
    
  • h)
    

    15 throws arched—120 feet

    
    
  • i)
    

    Cool down

  
  

  
  

  Phase VII

  
  

  
  

  
  
  • 
    

    Return to regular work-out regimen

  
  

  
  

  Courtesy of the New England Musculoskeletal Institute; UConn Health Center. Website http://nemsi.uchc.edu .
  
  
  
  
• •
  

  General strength and conditioning of the UE may begin during this phase if the patient demonstrates full pain-free AROM throughout all planes, full strength throughout the affected UE, and ability to bear weight on the injured side as demonstrated by successive pushups without shifting away from the injured side or complaints of pain. Measurements of strength can be made using a handheld dynamometer, which should reflect a 5% difference or less in strength in comparison to the uninvolved side. If a dynamometer is not available, 5/5 strength with manual muscle testing throughout the UE should be present.

  
  
• •
  

  Exercises that the athlete will return to doing in the gym should be added on at this point at low intensity with close observation by clinician. Gym exercises tend to vary by the sport program in which the athlete is involved. The primary exercises that require vigilance for proper form are the bench press and overhead press. Guidelines listed previously should direct clinician observation. Additional exercises such as biceps curls, triceps pushdowns and dips can be performed according to athlete’s sport-specific gym program. All movements must also remain completely pain free.

  
  
• •
  

  Sport-specific exercises include football lineman-contact drills, light sled push, swimming maneuvers, wrestler-partner drills in quadruped, grappling, basketball-lay up drills with defensive partner to stimulate contact, racket sports-progressive swing /volley drills starting with ground strokes and progressing to overhead service.

Other Therapeutic Exercises

• •
  

  Conditioning (bike or elliptical)

  
  
• •
  

  Nonweight bearing upper extremity core stability (bridge, crunch, etc.)

  
  
• •
  

  Exercises with uninvolved arm (i.e. “cross-talk”/contralateral overflow)

Open and Closed Kinetic Chain Exercises

• •
  

  Closed chain exercises performed on a flat surface can be gradually progressed to inclined surfaces and finally a vertical surface ( Figure 7-7 ).

  
  
• •
  

  Supine flexion and pulley exercises can be added to assist in increasing forward elevation.

  
  
• •
  

  Reclined flexion progressed to upright forward elevation ( Figure 7-8 ).

  
  
• •
  

  Scapular clocks for muscle activation ( Figure 7-9 ).

Neuromuscular Dynamic Stability Exercises

• •
  

  Continued use of side lying manually resisted PNF patterns to the scapula

  
  
• •
  

  Initiate GH rhythmic stabilization in supine ( Figure 7-10 )

Functional Exercises

• •
  

  Lower extremity exercises including shoulder dumps ( Figure 7-11 ) trunk bends, single leg balance, hip hike, squats.

Manual Therapy Techniques

• •
  

  Glenohumeral mobilization as needed

Soft Tissue Techniques

• •
  

  Pectoralis minor stretching as needed

Stretching and Flexibility Techniques for the Musculotendinous Unit

• •
  

  Stretching/flexibility techniques for the musculotendinous unit: Posterior capsule/sleeper stretching as needed.

Other Therapeutic Exercises

• •
  

  Continued conditioning and exercises described in Phase II

  
  
• •
  

  Initiate upper extremity weight-bearing core stability exercises (plank, side plank, etc.)

Sensorimotor Exercises

• •
  

  Continue upper extremity PNF patterns

  
  
• •
  

  Continue rhythmic stabilization exercises

  
  
• •
  

  Initiate mirroring exercise ( Figure 7-16 ) utilizing matched motion in multiple planes of movement in a mirror to improve proprioception and control. The goal of this exercise is the have the athlete match the motion of the involved to the uninvolved side through repetitive synchronous movements

  
  

  
  

  
  

  

  
  

  
  

  Mirror exercise. Patient works on position the postsurgical shoulder in the same position as the nonsurgical shoulder.

  
  

Techniques to Increase Muscle Strength, Power, and Endurance

• •
  

  Multilevel cable column or tubing rows ( Figure 7-17 )

  
  

  
  

  
  

  

  
  

  
  

  Multilevel rows.

  
  
  
  
• •
  

  Advanced strengthening such as Blackburn exercises can be integrated after the patient has demonstrated the ability to complete Phase II exercises without pain or substitution.

  
  
• •
  

  Cable column or tubing external rotation (ER) and internal rotation (IR)

  
  
• •
  

  Scaption with a hand-held weight

Neuromuscular Dynamic Stability Exercises

• •
  

  One-hand push up on wall with light ball ( Figure 7-12 )

Plyometrics

• •
  

  Medicine ball chest pass

  
  
• •
  

  Overhead supine ball toss ( Figure 7-13 A )

  
  
• •
  

  90-90 supine ball toss ( Figure 7-13 B )

  
  
• •
  

  Repeat progression in standing once supine progression completed without pain or loss of control

Functional Exercises

• •
  

  Continued lower extremity described in Phase II

Sport-Specific Exercises

• •
  

  Lower extremity drills (shuttle runs, back pedal, lateral step, etc.)

Other Therapeutic Exercises

• •
  

  Continue conditioning and exercise per Phase II and III.

Techniques to Increase Muscle Strength, Power, and Endurance

• •
  

  Continue strengthening exercise for scapula and rotator cuff musculature

  
  
• •
  

  Return to gym 12 to 14 weeks with focus on regaining appropriate exercise form and early training/hypertrophy phase

  
  
• •
  

  Low-weight bench pressing. In our experience, bench press beginning at 50% or less than presurgical one repetition maximum

  
  
• •
  

  Form changes to include narrower grip, avoid full lock out to minimize stress on healing tissues

  
  
• •
  

  Low weight overhead press, in our experience beginning at 50% or less than presurgical one repetition maximum

  
  
• •
  

  Form changes include avoiding full lock out at top and no behind neck presses

  
  
• •
  

  Gradual return to previous level, progressing as tolerated

Neuromuscular Dynamic Stability Exercises

• •
  

  One hand ball push up on wall progressing toward floor as athlete demonstrates appropriate form and control without pain in earlier phase exercises

Plyometrics

• •
  

  Medicine ball chest pass

  
  
• •
  

  Standing overhead ball toss

  
  
• •
  

  Progress 90/90 ball toss to upright with rebounder

Functional Exercises

• •
  

  Continue lower extremity exercises

Sport-Specific Exercises

• •
  

  Progress lower extremity drills

  
  
• •
  

  Initiate throwing program. Our throwing program is adopted and modified from review of previous published programs. (See Table 7-1 .)

Sport-Specific Exercises

• •
  

  Overhead throwing athletes may begin an interval-throwing program with short distance throws and frequent observation of proper throwing mechanics by the clinician. (Please see interval throwing program guidelines in Table 7-1 .)

  
  
• •
  

  General strength and conditioning of the UE may begin during this phase if the patient demonstrates full pain free AROM throughout all planes, and 5/5 strength throughout the affected UE, and no excessive soreness following rehabilitation exercises. Measurements of strength can be made using a hand-held dynamometer, which should reflect a 5% difference or less in strength in comparison to the uninvolved side. If a dynamometer is not available, 5/5 strength with manual muscle testing throughout the UE should be present.

  
  
• •
  

  Exercises that the athlete will return to doing in the gym should be added on at this point at low intensity with close observation by clinician. All movements must also remain completely pain free.

  
  
• •
  

  LE strength and agility exercises, combined with UE strengthening, may be incorporated at this stage for athletes in which UE function is dependent on LE stability and strength.

  
  
• •
  

  Activities in this category may include box jumping with medicine ball, squat based kettle bell swings, or lateral shuttle run with intermittent medicine ball chest past between therapist and patient. These movements should be performed at low intensity for the purposes of improving endurance and technique rather than strength.

  
  
• •
  

  Sport-specific drills at 24 weeks (football lineman-contact drills, light sled push, swimming maneuvers, wrestler-partner drills in quadruped, etc., basketball-lay up drills with partner to stimulate contact, racket sports-progressive swing/volley drills, etc.)

Sport-Specific

• •
  

  Thrower—successful completion of throwing program

  
  
• •
  

  Contact athlete—contact without symptoms

After Return to Sport

• •
  

  Focus on maintenance of parascapular strength

  
  
• •
  

  Continuation of return to sport phase exercises for total body strength

  
  
• •
  

  Return to team strength and conditioning program

Etiology of Symptoms

Acute sprain:

• •
  

  The minimal and incongruous contact between the articular surfaces of the medial clavicle and sternum would suggest that the SC joint may be easily predisposed to instability. However, it actually is uncommonly injured. In one large series, SC joint trauma represented just 3% of all injuries to the shoulder girdle.

  
  
• •
  

  Ligamentous injury can occur due to a direct force applied to the anteromedial aspect of the clavicle—producing posterior subluxation or dislocation of the joint, or from an indirect force applied to the arm or shoulder—which can result in either anterior or posterior instability.

  
  
• •
  

  In approximately 75% of cases, the instability is anterior, and is produced when an abduction/external rotation force is applied to the ipsilateral shoulder. As with all joints, ligamentous injury can be classified as mild (pain without instability), moderate (sub­luxation), or severe (complete disruption of all SC ligaments).

  
  
• •
  

  Although discomfort generally increases in proportion to the degree of injury, trauma producing anterior instability may be only minimally painful with the arm at rest.

  
  
• •
  

  However, a position of provocation, such as the cocking motion in throwing, which levers the medial clavicle anteriorly, will generally reproduce and exacerbate the symptoms.

  
  
• •
  

  Posterior dislocations typically produce far greater pain than injuries producing anterior instability, and because the displaced medial clavicle can compress the mediastinum, that injury may be associated with venous congestion of neck or upper extremity, cough or hoarseness, shortness of breath, and difficulty swallowing.

  
  
• •
  

  The deformity produced by a posterior dislocation may be obscured by swelling, but the edge of the sternum is palpable, and should provide confirmation during clinical examination. This injury may have life threatening consequences, generally requires prompt reduction in an operating room setting, and so must not be overlooked.

  
  
• •
  

  Many “dislocations” of the SC joint are not ligamentous injuries at all, but represent traumatic separation of the adjacent epiphysis (growth center). The epiphysis of the medial clavicle does not even appear on radiographs until the late teenage years, and is vulnerable into the mid-20s. Most of these injuries readily heal, will remodel with time, and require only initial supportive care.

  
  
• •
  

  Initial treatment for acute ligamentous injuries of the SC joint consists of that typical of all joint sprains: ice and immobilization. The length and degree of pro­tection required are dependent upon the degree of injury.

  
  
• •
  

  Anterior dislocations tend to be unstable after reduction no matter what initial treatment is provided. Posterior dislocations are generally stable after reduction. Although the prominence of the medial clavicle often remains present after an anterior subluxation or dislocation has occurred, scaring about the joint capsule generally prevents symptomatic instability, and the majority of patients with chronic SC joint laxity may be expected to have, at most, minimal functional limitations.

  
  
• •
  

  Although techniques for surgical reconstruction of anterior ligamentous laxity have been described, outcomes are not uniformly successful, and there is significant risk to operating on the SC joint due to its proximity to multiple large vessels.

• •
  

  This condition is most common in the late teen to early adulthood years in those individuals who have significant generalized ligamentous laxity ( Figure 7-18 ). There is a moderate female preponderance.

  
  

  
  

  
  

  

  
  

  
  

  An athlete with spontaneous anterior instability of the right SC joint.

  
  
  
  
• •
  

  The condition is characterized by painful popping localized to the SC joint with elevation of the arm, and (by definition) there is no history of trauma producing ligamentous compromise.

  
  
• •
  

  Participation in overhead sports such as baseball, basketball, and volleyball, and swimming are often associated with this condition. Scapulothoracic dyskinesia and core stability deficits are often present.

  
  
• •
  

  This is a self-limited condition, generally responding successfully to an appropriate rehabilitation algorithm; it should NOT be treated surgically. In fact, operative intervention is associated with an increase in symptoms.

• •
  

  Systemic rheumatoid arthritis may affect the SC joint, and that articulation may upon occasion even represent the initial clinical manifestation.

  
  
• •
  

  Localized osteoarthritis of the SC joint, and avascular necrosis of the medial clavicle may also occur; typical patients are middle aged or elderly, often with an employment history of repetitive overhead work.

  
  
• •
  

  Although localization of arthritic symptoms to the SC joint is generally obvious clinically, confirmation requires appropriate radiographs. SC joint arthritis usually responds to treatment of the systemic condition when secondary to rheumatoid disease and its variants.

  
  
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  Resection of the proximal clavicle for disabling osteoarthritis that is non-responsive to all other treatment has been reported as successful if the CS ligaments and capsule are intact. Otherwise, intervention must also include ligamentous reconstruction. Multiple techniques have been described.

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  In individuals at risk of recurrent bacteremia, such as those with HIV infection; and with drug addiction, alcoholism, and other chronic debilitating diseases, the SC joint may be a site of localized sepsis.

  
  
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  In addition to pain localized to the SC joint area, erythema, warmth, fluctuant exquisite tenderness to palpation, and other signs of joint infection and abscess are evident. Intravenous antibiotics and/or incision and drainage may be necessary.

Stretching and Flexibility Techniques for the Musculotendinous Unit

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  TBS, Core, TLS as tolerated and recommended

Techniques to Increase Muscle Strength, Power, and Endurance

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  Week 2 to 3: Submaximal isometric flexion, abduction, IR, ER in neutral; progress to maximal isometric if pain-free

  
  
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  Week 2 to 3: Active scapular retraction and depression, scapular protraction, biceps curls, triceps extensions

Manual Therapy Techniques

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  For the anteriorly displaced AC joint, posterior SC joint mobilizations prn

  
  
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  Thoracic anterior-posterior glides with overpressure prn to improve lower trapezius activation. Progression of range of motion is based on the absence of SC joint pain and instability

  
  
  
  
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    AAROM 0° to180° (week 3 to 4)

    
    
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    AROM 0° to 90° (week 3 to 4); 0° to 180° (week 4 to 6)

  
  

Stretching and Flexibility Techniques for the Musculotendinous Unit

• •
  

  Address cervicothoracic muscle imbalances through continued stretching of the SCM, upper trapezius and pectoralis muscles prn, and strengthening of middle and lower trapezius, rhomboids and deep cervical flexor muscle groups.

Sensorimotor Exercises

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  Rhythmic stabilization, beginning in neutral with a progression to increasing degrees of arm elevation, decreasing upper extremity support, and greater intensity of perturbation placed distally on the extremity.

  
  
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  PNF patterning in a pain-free ROM

  
  
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  Body blade progression from neutral to 90°

Open and Closed Kinetic Chain Exercises

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  Biodex VSRP for IR/ER from 60° to 180°/sec in neutral.

  
  
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  Week 6 to 8: Initiate closed chain progression based on patient tolerance. A standard progression includes transitioning from a bilateral to unilateral activity with increasing weight bearing on the extremity.

  
  
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  One example may include press-ups, wall pushup with a plus, table pushup, 4-point weight shifts, prone on elbows, prone ball punches ( Figure 7-20 ), standing ball punches with perturbations, modified pushups, partial ball walk-outs, full-walk-outs and full pushups.

  
  

  
  

  
  

  

  
  

  
  

  Prone ball punches.

  
  

Plyometrics

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  Week 6 to 8: Initiate a plyometric progression based on patient tolerance. A typical plyoback progression may begin with a two-handed chest level toss, progress to an overhead throw, and then to a single arm 90/90 step-throw.

  
  
• •
  

  In addition, the base of support may be altered through the utilization of devices such as the BOSU ball or foam to increase the difficulty and engage more of the core muscles.

Stretching and Flexibility Techniques for the Musculotendinous Unit

• •
  

  As needed: Address cervicothoracic muscle imbalances through continued stretching of the SCM, upper trapezius and pectoralis muscles and strengthening of middle and lower trapezius, rhomboids and deep cervical flexor muscle groups.

Sensorimotor Exercises

• •
  

  Incorporate exercises from 90° to the overhead position to improve dynamic control through the full arc of motion.

  
  
• •
  

  Examples include wall dribbles ( Figure 7-21 ), body blade in the overhead position or using PNF patterns, or 90/90 internal and external rotation using resistive tubing.

  
  

  
  

  
  

  

  
  

  
  

  Overhead wall dribbles.

  
  

Open and Closed Kinetic Chain Exercises

• •
  

  Progress to an isokinetic Velocity Spectrum Rehabilitation Protocol 180°/sec to 300°/sec in the 90/90 position.

  
  
• •
  

  Continue to progress the CKC pushup activity by incorporating an unstable surface, an elevated position (box pushups), or unilateral support ( Figures 7-22 and 7-23 ).

  
  

  
  

  
  

  

  
  

  
  

  Pushup with ball rolls.

  
  

  
  

  
  

  

  
  

  
  

  Pushup with unilateral touches.

  
  

Neuromuscular Dynamic Stability Exercises

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  Integrate functional movement patterns, such as multi-directional lunges or squats with overhead press ( Figures 7-27 and 7-28 ) that incorporated the entire upper and lower kinetic chain and require adequate core stability for proper completion.

  
  

  
  

  
  

  

  
  

  
  

  Lunge with overhead press.

  
  

  
  

  
  

  

  
  

  
  

  Squat with overhead press.

  
  

Sport-Specific Exercises

• •
  

  A graduated return to throwing program prn ( Table 7-1 )

  
  
  
  

  Table 7-1

  
  

  High School and College Baseball Pitchers Interval Throwing

  
  

  
  
  
  
  
  
  
  
  
  
  
  

  PHASE I Return to Throwing Throws at 50% effort	PHASE II Return to Pitching Throws at Effort Level Given	PHASE III Intensified Pitching
  Step 1 Warm-up toss to 60 feet 15 throws at 30 feet 15 throws at 30 feet 15 throws at 30 feet 20 long tosses to 60 feet Step 2 Warm-up toss to 75 feet 15 throws at 45 feet 15 throws at 45 feet 15 throws at 45 feet 20 long tosses to 75 feet Step 3 Warm-up toss to 90 feet 15 throws at 75 feet 15 throws at 75 feet 15 throws at 75 feet 20 long tosses to 90 feet Step 4 Warm-up toss to 105 feet 15 throws at 75 feet 15 throws at 75 feet 15 throws at 75 feet 20 long tosses to 105 feet Step 5 Warm-up toss to 120 feet 15 throws at 90 feet 20 throws at 90 feet 15 throws at 90 feet 10 long tosses to 120 feet Step 6 Warm-up toss to 120 feet 20 throws at 105 feet 20 throws at 105 feet 15 throws at 105 feet 20 long tosses at 120 feet Step 7 Warm-up toss to 120 feet 20 throws at 120 feet 20 throws at 120 feet 20 throws at 120 feet 20 long tosses at 120 feet	Step 8 15 throws at 60 feet, 6 in (75%) 20 throws at 60 feet, 6 in (75%) 20 throws at 60 feet, 6 in (75%) 15 throws at 60 feet, 6 in (75%) Step 9 20 throws at 60 feet, 6 in (75%) 20 throws at 60 feet, 6 in (75%) 20 throws at 60 feet, 6 in (75%) 20 throws at 60 feet, 6 in (75%) Step 10 20 fastballs (50%) 20 fastballs (50%) 20 fastballs (50%) 20 fastballs (50%) 25 throws at 60 feet, 6 in (75%) Step 11 20 fastballs (50%) 20 fastballs (75%) 20 fastballs (50%) 15 fastballs (75%) 25 throws at 60 feet, 6 in (75%) Step 12 25 fastballs (50%) 20 fastballs (75%) 20 fastballs (75%) 20 fastballs (75%) 20 fastballs (75%)	Step 13 25 fastballs (75%) 20 fastballs (100%) 10 fastballs (75%) 15 fastballs (100%) 25 fastballs (75%) Step 14 (Active Rest) 20 throws at 80 feet 20 throws at 80 feet 20 throws at 80 feet 20 throws at 80 feet Step 15 20 fastballs (75%) 20 fastballs (100%) 5 off speed pitches 15 fastballs (100%) 5 off speed pitches 20 fastballs (100%) 5 off speed pitches Field bunts and comebacks (Relievers and closing pitchers can go to step 21 on the next throwing day after completing this step) Step 16 20 fastballs (100%) 15 fastballs (100%) 5 off speed pitches 5 pickoff throws to 1 st 20 fastballs (100%) 5 off speed pitches 20 fastballs (100%) 5 off speed pitches Step 17 15 fastballs (100%) 5 off speed pitches 15 fastballs (100%) 3 pickoff throws to 1 st 20 fastballs (100%) 5 off speed pitches 15 fastballs (100%) 3 pickoff throws to 2 nd 15 fastballs (100%) 5 off speed pitches Step 18 (Active rest) Repeat step 14 Step 19 20 fastballs (100%) 5 off speed pitches 20 fastballs (100%) 3 pickoff throws to 1 st 20 fastballs (100%) 3 pickoff throws to 2 nd 15 fastballs (100%) 5 off speed pitches 15 fastballs (100%) 5 off speed pitches Step 20 Batting practice 110 to120 pitches Field bunts and comebacks Step 21 Simulated game

   
  

  (Courtesy of Gunderson Lutheran Sports Medicine.)