Acromioclavicular Joint Injuries and Sternoclavicular Joint Injuries









Introduction



John Apostolakos, BS
Mark P. Cote, PT, DPT, MSCTR
Knut Beitzel, MA, MD
Augustus D. Mazzocca, MS, MD

Epidemiology





  • Acromioclavicular (AC) joint injuries are considered among the most common orthopedic injuries to the shoulder in the young athletic population.



  • Incidence often reported to be either 9% or 12% of all injuries to the shoulder; however, review of citations reveals the source of these percentages to be a book published in 1958.



  • In Chapter 17 , Rowe and Marble report on an analysis of 1603 shoulder girdle injuries treated at Massachusetts General Hospital of which 52 (3.2%) were injuries to the AC joint.



  • Type I, II, and III are the most common.



Age





  • Most common among patients in their 20s (43.5%)



  • A majority of injuries affecting this joint occur in the first three decades of life (66%)



Sex





  • AC dislocation has been reported to be more common in males than females (5 : 1 to 10 : 1).



Sport





  • AC dislocation is the most prevalent sports injury to participants in contact sports including hockey, rugby, and American football.



  • AC injury has been reported as 38.5% of shoulder injuries in athletes.



  • The incidence has been reported as 40% and 41% of all shoulder injuries in contact athletes such as National Football League (NFL) quarterbacks and collegiate football players respectively.



Position





  • Kaplan et al. conducted a study of 336 elite collegiate American football players to determine position specific trends in shoulder injuries and reported the following AC joint injuries by position (%=number of AC joint injuries for position/ n × 100; n = total shoulder injuries by position):




    • Running Backs 47% ( n = 19)



    • Quarterbacks 56% ( n = 25)



    • Wide Receivers 70% ( n = 33)



    • Tight Ends 43% ( n = 7)



    • Offensive Lineman 18% ( n = 28)



    • Defensive Lineman 32% ( n = 37)



    • Defensive Backs 36% ( n = 44)



    • Linebackers 38% ( n = 29)



    • Place Kickers 0% ( n = 4)




Pathophysiology


Intrinsic Factors





  • Subcutaneous position of the joint, without a large amount of muscle protection, theoretically increases the incidence of AC joint injury



Extrinsic Factors





  • Trainer et al. report an overall decline in the incidence of AC joint injuries in American football players but a steady rate among ice hockey players.




    • A possible explanation is that protective gear in American football is specifically designed for repeated force to the shoulder.



    • Ice hockey pads have a more loose fit designed for greater mobility.




Traumatic Factors


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 ).




    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



Classification of Injury/Pathological Findings





  • Evaluation based on bilateral Zanca radiograph comparing the injured to uninjured shoulder



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 )




    FIGURE 7-2


    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



Clinical Presentation


History





  • History of direct blow/fall to the AC joint



  • Complaints of pain over the joint



Physical Examination





  • Point tenderness



  • Deformity at the AC joint and is palpable and different from contralateral (uninjured) side



  • Pain at AC joint with forward elevation greater than 140° ( Figure 7-3A )




    FIGURE 7-3


    Physical exam. A, Pain at AC joint with forward elevation greater than 140° is indicative AC joint injury. B, Pain at joint with cross-arm adduction with arm elevated to 90° and then adducted across the chest with the elbow bent at 90° may also be indicative of AC joint arthrosis.



  • Pain at joint with cross-arm adduction




    • May also be indicative of AC joint arthrosis



    • Cross-arm adduction test performed with arm elevated to 90° and then adducted across the chest with the elbow bent at 90° ( Figure 7-3B )



    • Pain will be specifically at the AC joint




  • Relief of symptoms by injection of a local anesthetic agent




    • May also be indicative of AC joint arthrosis



    • Injection with or without corticosteroid can be used both diagnostically and therapeutically




      • Relief of pain implicated AC joint as source of pain



      • Examination should be performed pre- and post- injection to determine change in symptoms





  • Whenever possible, patient should be examined standing or sitting so the weight or the arm pulling downward stresses the AC joint and will make deformity more apparent



Basic Mechanisms, Radiographic Examinations, and Clinical Examinations





  • Type I ( Figure 7-4 )




    • Direct force to the shoulder causing sprain of AC ligaments



    • CC and AC ligaments intact



    • Swelling and joint tenderness



    • Normal radiographic examination




    FIGURE 7-4


    Diagnosis of AC joint injuries includes classification according to extent of ligament damage. Type I sprains involve a partial disruption of the AC ligament and capsule; type II sprains entail a ruptured AC ligament and capsule with incomplete injury to the CC ligament; type III separations exhibit complete tearing of the AC and CC ligaments; type IV injuries involve clavicular displacement posteriorly into or through the trapezius muscles; type V injuries are severe type III injuries with a greater CC interval; and type VI injuries entail displacement of the clavicle inferior to the coracoid process.

    (From Bach BR, Van Fleet TA, Novak PJ: Acromioclavicular injuries: controversies in treatment. Physician Sports Med. 1992;20(12):87–95.)



  • Type II ( Figure 7-4 )




    • Force to shoulder causing rupture of AC ligaments



    • CC ligaments intact



    • Clavicular instability to direct stress examination



    • On radiographic examination the lateral end of the clavicle may be elevated




      • Stress views fail to show 100% separation of clavicle from acromion





  • Type III ( Figure 7-4 )




    • Complete disruption of both AC and CC ligaments



    • No significant disruption of the deltoid and trapezial fascia



    • Upper extremity held in an adducted position




      • Acromion depressed



      • Clavicle appears “high riding”




    • Clavicular instability in both the horizontal and vertical planes



    • Abnormal stress views on radiographic examination




      • Clavicle appears high on the upper extremity however in reality the acromion and remained of upper extremity is displaced inferior to the horizontal plane of the lateral clavicle




    • Severe pain with motions 1 to 3 weeks after injury



    • Negative shrug test




  • Type IV ( Figure 7-4 )




    • Distal clavicle displaced posteriorly into the trapezius muscle




      • Easily seen on an axillary radiograph




    • Important to evaluate the sternoclavicular (SC) joint in this type of injury as there can be anterior dislocation of the SC joint and posterior dislocation of the AC joint




  • Type V ( Figure 7-4 )




    • More severe form of type III injury with trapezial and deltoid fascia stripped off the acromion and clavicle



    • On radiographic examination 100% to 300% increase in clavicle to acromion distance



    • Severe droop secondary to downward displacement of the scapula and humerus



    • Weight of the arm combined with the shape of the chest wall cause an anterior-inferior translation of the scapula around the thorax




      • Referred to as the third translation of the scapula




    • Positive shrug test




  • Type VI ( Figure 7-4 )




    • Inferior dislocation of the distal clavicle under the coracoid process



    • Rare injury caused by severe trauma and is frequently accompanied by other injuries



    • Mechanism of injury is believed to be severe hyperabduction and external rotation of the arm combined with retraction of the scapula



    • Distal clavicle is found in either of two orientations




      • Subacromial



      • Subcoracoid





  • Clavicle becomes lodged behind the intact conjoined tendon



  • The posterior superior AC ligaments which are often attached to the acromion get displaced into the AC interval



Imaging





  • Radiographs of AC joint taken by a routine shoulder exam will be overpenetrated




    • Radiographs of “acromioclavicular joint” must be specifically requested to avoid overlooking subtle lesions




  • Bilateral Zanca view where both AC joints are visualized on a single exposure is helpful in determining asymmetry between injured and contralateral normal AC joints




    • Zanca view is the preferred view of the AC joint



    • View is obtained by tilting the x-ray beam 10° to 15° toward the cephalic direction and using only 50% of the standard shoulder anteroposterior (AP) penetration strength




  • Varying configuration of AC joint on AP radiographs




    • Zanca reported a normal AC joint width of 1–3 mm



    • Petterson reported diminishing joint space with age and considered the normal width of a 60-year-old AC joint to be 0.5 mm




  • Axillary view useful for differentiating type III versus type IV injury




    • Visualization of the scapula anterior to the clavicle indicates a type IV lesion




  • Stryker notch view useful for determining a coracoid fracture in a complete AC dislocation with normal coracoclavicular interspace




    • Coracoid process fracture should be suspected when radiographs reveal AC dislocations with a normal CC distance




  • Stress views can be used to distinguish between type II and III injuries by testing the integrity of the CC ligaments




    • Difference in type II and III injury is rarely significant and stress views typically aren’t necessary for diagnosis




Differential Diagnosis


O’Brien test





  • Useful for differentiating AC joint injury versus intra-articular lesions




    • Especially useful with lesions of the superior glenoid labrum




  • Arm is elevated to 90°, elbow in extension, adduction of 10° to 15°, and maximum pronation of the forearm with obligate internal rotation of the arm, examiner applies downward force resisted by the patient




    • Referred pain directed to the top of the shoulder and confirmed by palpation of the joint indicate AC damage



    • Referred pain to the glenohumeral joint suggest superior labral or long head of the biceps injury




Radiographs for Differential Diagnosis





  • Axillary view useful for differentiating type III versus type IV injury




    • Visualization of the scapula anterior to the clavicle indicates a type IV lesion




  • Stryker notch view useful for determining a coracoid fracture in a complete AC dislocation with normal coracoclavicular interspace




    • Coracoid process fracture should be suspected when radiographs reveal AC dislocations with a normal CC distance




  • Stress views can be used to distinguish between type II and III injuries by testing the integrity of the CC ligaments




    • Difference in type II and III injury is rarely significant and stress views typically aren’t necessary for diagnosis




Shrug Test





  • Used to distinguish type III from type V injuries ( Figure 7-5 )




    • In a type V injury the degree of displacement is exaggerated




    FIGURE 7-5


    The shrug test is performed by having the patient shrug their shoulders and observing for reduction of the clavicle. As a result of the trapezial and deltoid fascia being stripped off the acromion and clavicle, shrugging of the shoulders will not reduce the clavicle indicating a grade V injury.



Manipulation of Joint





  • Helpful in distinguishing type III and V injuries




    • Reduction of deformity suggests an intact deltotrapezial fascia (type III)



    • Failure to reduce indicates violation of fascia with the distal clavicle buttonholed through it (type V)




Treatment





  • Type I and II (incomplete injuries) are typically treated nonoperatively



  • Type IV, V, and VI (complete injuries) are typically treated operatively due to significance of morbidity



  • Type III injuries remain the most controversial




    • Current trends lean more towards initial nonoperative treatment




Nonoperative Management


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



Surgical Indications





  • Over 150 surgical procedures and technique variations have been described on the AC joint that can be broken down into four major categories




    • Primary acromioclavicular joint fixation



    • Primary coracoclavicular ligament fixation



    • Excision of distal end of clavicle



    • Dynamic muscle transfers




  • The senior author prefers an anatomical surgical treatment: Anatomical Coracoclavicular Ligament Reconstruction (ACCR)




    • Tendon graft used placed in an anatomic position to reproduce conoid and trapezoid ligaments



    • Excision of 10 mm of distal clavicle




Controversial Treatments


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 )




    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.




Evidence


  • Kaplan LD, Flanigan DC, Norwig J, et. al.: Prevalence and variance of shoulder injuries in elite collegiate football players. Am J Sports Med 2005; 33: pp. 1142-1146.
  • A study reporting on musculoskeletal injuries in elite American football players evaluated at the National Football League Combine during physical testing. Players were categorized by position to identify correlations between athletic position and occurrence of various shoulder injuries. (Level III evidence)
  • Kelly BT, Barnes RP, Powell JW, et. al.: Shoulder injuries to quarterbacks in the national football league. Am J Sports Med 2004; 32: pp. 328-331.
  • A retrospective review of all injuries to quarterbacks reported to the National Football League (NFL) between 1980 and 2001 utilizing the National Football League Injury Sur­veillance System (NFLISS). This review evaluated injuries based on several factors including playing time lost, injury patterns, and occurrence rates of specific injuries. (Level III evidence)
  • Tamaoki MJ, Belloti JC, Lenza M, et. al.: Surgical versus con­servative interventions for treating acromioclavicular dislocation of the shoulder in adults. Cochrane Database Syst Rev 2010; 4: CD007429
  • A systematic review aimed at assessing the relative effects of operative versus nonoperative treatment of acromioclavicular joint dislocations in adults. Included studies were randomized and quasi-randomized trials obtained in a search of the Cochrane Bone, Joint and Muscle Trauma Group Specialized Register (to February 2009), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2009, Issue 1), MEDLINE (1966 to February 2009), EMBASE (1988 to February 2009), and LILACS (1982 to February 2009), trial registries and reference lists of articles. (Level II evidence)

  • Multiple-Choice Questions




    • QUESTION 1.

      Which of the following patients is most likely to endure an injury to the AC joint?



      • A.

        a 85-year-old inactive male


      • B.

        a 25-year-old active female


      • C.

        a 21-year-old inactive male


      • D.

        a 22-year-old active male



    • QUESTION 2.

      What is the most common mechanism of injury to the AC joint?



      • A.

        Direct force to the superior aspect of shoulder


      • B.

        Indirect force to the superior aspect of shoulder


      • C.

        Direct force caused by falling on an adducted outstretched hand


      • D.

        Indirect force caused falling on an adducted outstretched hand



    • QUESTION 3.

      Which of the following is true regarding treatment of a type III injury?



      • A.

        Surgical intervention is always needed.


      • B.

        Surgical intervention is never needed.


      • C.

        Demands on the affected shoulder should NOT be taken into account when determining treatment.


      • D.

        Treatment of type III should be individualized based on demands of the shoulder.




    Answer Key







    Nonoperative Rehabilitation of Acromioclavicular Joint Sprain/Separation



    Karen E. Wojcik, MSPT, OCS, ATC
    Mark P. Cote, PT, DPT, MSCTR
    Nancy Craven, PT, DPT, OCS
    Gregg Gomlinski, MSPT, OCS, CSCS
    Brian T. Swanson, PT, OCS, FAAOMPT
    Catherine Gauthier Trahiotis, PT
    John Apostolakos, BS
    Augustus D. Mazzocca, MS, MD



    Guiding Principles of Nonoperative Rehabilitation





    • Restoring stability to the AC joint through strength training of the supporting muscles of the shoulder girdle is the primary focus of rehabilitation.



    • Early intervention is directed toward reducing pain and inflammation to allow strength-based exercise to begin as soon as possible.




    Phase I (48 hours to weeks 2)


    Goals





    • Various treatments, both operative and nonoperative, have been described for patients with injury or dysfunction of the AC joint.




      • Grades I and II separations appear to respond favorably to conservative management.



      • Considerable controversy exists over the efficacy of surgical reconstruction versus nonoperative intervention for grade III type injuries.



      • Grades IV, V, and VI often require surgical reconstruction.




    • Rehabilitation both as a part of conservative management as well as the postoperative care plays an important role in the management of each of these injuries.



    • When discussing the approach to rehabilitation, we feel it is best to outline guidelines based on anatomy, pathoanatomy, and biological healing for the progression of activities.




      • These guidelines were designed to allow the rehab clinician to safely and appropriately progress patients through the healing and recovery process.



      • With an understanding and appreciation for the rationale for these guidelines, the rehab clinicians can utilize their entire skillset in a safe and efficient manner, thereby maximizing the quality of care provided to patients.




    Timeline 7-1

    Nonoperative Rehabilitation after AC Joint Separation














    PHASE I (first 48 hours to weeks 2) PHASE II (weeks 2 to 6) PHASE III (weeks 6 to 12) PHASE IV (weeks 12+)



    • Sling




      • Grade I—as needed for pain



      • Grade II—up to 2 weeks



      • Grade III—discontinue sling at 2 weeks (earlier if symptoms allow)



      • D/C sling if the patient is no longer having pain with the UE at the side during ADLs




    • PT Modalities and Manual Techniques




      • As indicated to reduce pain




    • Exercise




      • Closed chain AAROM (table slides, etc.)



      • Supine ER with a cane



      • Isometrics (submaximal, nonpainful)



      • Scapular clocks





    • Exercise




      • AAROM progressing to AROM



      • Progressive forward elevation to the wall



      • Pulleys FE



      • Reclined active flexion progressing to upright



      • Gentle horizontal adduction



      • Gentle shoulder extension



      • Scapula strengthening exercises (emphasizing retraction to stabilize the AC joint)



      • When there is good stability of scapula—strengthening exercises focus on the deltoid, trapezius, and rotator cuff



      • Manual



      • Pushup plus (protraction/retraction against the wall)



      • Continue kinetic chain exercise



      • Restrictions—shoulder press, bench press, pullovers, and pectoralis flys





    • Exercise




      • 3 level rowing with tubing



      • RC muscle strengthening exercise (ER/IR) with tubing



      • Prone scapula exercises—Blackburn exercises or Ts and Ys (start with no weight and high repetitions to fatigue)



      • PNF patters with tubing



      • Pushup on wall progressing towards ground



      • Continued Kinetic chain exercise





    • Exercise




      • Plyometric exercise (chest pass with medicine ball, etc.)



      • Continued Kinetic chain exercise



      • Start chest press



      • Sport-specific training




    Protection





    • Immobilization via a sling is used on as needed basis.



    • The amount of time immobilized will vary depending on the grade of injury.



    • Grade I separations typically require little to no sling use.



    • Grade II separations involve disruption of ligamentous tissue that may result in prolonged periods of pain associated with early phases of tissue healing. During this time, a sling may be required to avoid stress on the AC joint. The sling is discontinued following cessation of pain with the arm at the side and with self-care activities. Generally speaking, this time period does not exceed 1 week.



    • Grades III and V involve complete ligament rupture with little to no potential for healing. While sling use up to 4 weeks for these higher-grade AC separations has been previously reported therefore, we believe patients should be encouraged to cease sling use as soon as their symptoms allow.



    • In all cases, immobilization is discontinued following the cessation of pain at rest with the arm at the side and with self-care activities.



    Management of Pain and Swelling





    • Ice



    • Sling



    Techniques for Progressive Increase in Range of Motion





    • Low load range active-assistive motion exercise is initiated within the first week of injury in an effort to decrease associated morbidity.



    • Avoidance of motions that may increase stress on the AC joint is recommended.



    • Behind the back internal rotation, cross body adduction, and end range forward elevation involve motion at the AC joint and therefore are approached cautiously as they have the potential to provoke pain and slow progression; however, they are not expressly limited as stability is less of a concern than in higher grade separations.



    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 ).




      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 ).




      FIGURE 7-8


      Open chain progression of active-assistive range of motion.



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




      FIGURE 7-9


      Scapular clocks to facilitate muscle activity of the scapular muscles.



    Milestones for Progression to the Next Phase





    • Full passive motion without pain



    • Out of sling



    Phase II (weeks 2 to 6)


    Techniques for Progressive Increase in Range of Motion





    • Active-assistive range of motion is progressed within a comfortable range of motion. In our experience, accelerating care by moving through painful and stressful ranges of motions tends to encourage continued pain and inflammation, making it difficult to progress. By allowing exercises to be progressed within the guidelines of avoiding motions or exercise producing AC joint pain, the patient can maximize their own potential for progress.



    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 )




      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




      FIGURE 7-11


      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



    Phase III (weeks 6 to 12)


    Techniques for Progressive Increase in Range of Motion


    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 )




      FIGURE 7-12


      Pushup on the wall with light ball.



    Plyometrics





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




      FIGURE 7-13


      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



    Milestones for Progression to Advanced Sport-Specific Training and Conditioning





    • Overhead activities including ADLs without pain.



    • Able to bear weight through involved upper extremity without pain. This can be evaluated by asking the athlete to hold the starting position of a pushup. If the athlete can stay in this position for a few seconds without pain or signs of difficulty (e.g., lowering to the floor, or shifting weight away from the injured side), progression to the next stage is warranted.



    Phase IV (weeks 12+)


    Techniques to Increase Muscle Strength, Power, and Endurance





    • Return to gym (grades I and II typically can start gym activity at or before 8 weeks)



    • Bench press at 50% or less than presurgical; one repetition maximum; form changes for bench press include narrower grip; avoid full lock out to minimize stress on healing tissues



    • Overhead press at 50% or less than presurgical; 1 repetition maximum; form changes for bench press include narrower grip; avoid full lock out to minimize stress on healing tissues and behind the neck pressing



    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.

    Progression is as follows: Two-handed medicine ball chest pass, standing two-handed overhead chest pass, single-hand 90/90 ball toss to upright with rebounder.


    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.



    Milestones for Progression to Advanced Sport-Specific Training and Conditioning





    • No pain at the AC joint



    • Forward elevation without scapular dyskinesis as measured by the Scapular Dyskinesis Test. The Scapular Dyskinesis Test, which classifies scapula dyskinesis as either present or absent, is used to determine the presence of dyskinesis. This system involves viewing of the scapula during humeral elevation to observe for “winging” (abnormal prominence of the medial and/or inferior boarder of the scapula) or dysrhythmia with grading of these of findings as normal, subtle (mild, questionable, or inconsistent), and obvious (striking, clear, and consistent)



    • Full shoulder strength in all planes with handheld dynamometer or manual testing of the shoulder



    Criteria for Abandoning Nonoperative Treatment and Proceeding to Surgery or More Intensive Intervention





    • In our experience, patients who have little response after 6 weeks are offered surgical intervention.



    • Patients who benefit and have a significant reduction of symptoms are encouraged to continue with rehabilitation for up to 12 weeks.



    • After 12 weeks the athlete should be pain free with all shoulder motions, able to bear weight per previously listed criteria, and able to demonstrate upper extremity movements related to their sport in a controlled environment, i.e., in the clinic or gym. In our experience, patients who have little response after 6 weeks are offered surgical intervention.



    Specific Criteria for Return to Sports Participation: Tests and Measurements





    • Full active range of motion without scapular dyskinesis as measured by the Scapular Dyskinesis Test



    • Full shoulder with handheld dynamometer or manual testing of the shoulder strength with manual muscle testing



    • Pain-free overhead activities



    • Pain-free sport-specific motions and maneuvers




      • Ability to perform sport-specific activities without pain or difficulty. (This includes successful completion of the throwing program for throwers and contact without symptoms for the collision and contact athlete.)




    Evidence


  • Bannister GC, Wallace WA, Stableforth PG, et. al.: The management of acute acromiclavicular dislocation. J Bone Joint Surg Br 1989; 71-B: pp. 848-850.
  • This prospective randomized control trial compared operative treatment (reduction and fixation with a Kirschner screw) to conservative management consisting of 2 weeks of rest followed by a rehabilitation program. Conservatively treated patients regained motion quicker, returned to work and sport earlier, and had less unsatisfactory results compared to operative treatment. (Level II evidence)
  • Galpin RD, Hawkins RJ, Grainger RW: A comparative analysis of operative versus nonoperative treatment of grade II acromioclavicular separations. Clin Orthop Relat Res 1985; 193: pp. 150-155.
  • Retrospective review of 37 patients who either opted for early motion and rehabilitation or treatment by Bosworth claviculocoracoid screw. Patients in the nonoperative group had equal if not superior results, with an earlier return to activities, sports, and work. (Level IV evidence)
  • Gstettner C, Tauber M, Hitzl W, et. al.: Rockwood type III acromioclavicular dislocation: surgical versus conservative treatment. Clin Orthop Relat Res 2007; 455: pp. 38-44. J Shoulder Elbow Surg. 17:220–225, 2008
  • Retrospective review of 41 of 50 patients treated either operatively with a hook plate to stabilize the AC joint or conservatively consisting of immobilization in a sling followed by a course of rehabilitation. Mean constant score of 80.7 was observed for the conservative group compared to 90.4 in the operative group. (Level IV evidence)
  • Gumina S, Carbone S, Postacchini F: Scapular dyskinesis and SICK scapula syndrome in patients with chronic type III acromioclavicular dislocation. Arthroscopy 2009; 25: pp. 40-45.
  • Scapulothoracic motion and clinical outcome were studied in 34 patients with chronic AC dislocation. Chronic type III AC dislocation was associated with the presence of scapular dyskinesis in 70.6% of patients. The values for the Constant score and SST were lower in patients with dyskinesis. (Level IV evidence)
  • Spencer EE: Treatment of grade III acromioclavicular joint injuries: a systematic review. Clin Orthop Relat Res 2007; 455: pp. 38-44.
  • A systematic review of the literature to determinate efficacy of operative vs. nonoperative care for grade III AC joint separations. Review revealed limited low-evidence literature exists on the treatment of grade III injury. Nonoperative treatment was deemed more appropriate than traditional operative treatments on account of surgical intervention being associated with higher complication rates and time away from work and sport. (Level III evidence)

  • Multiple-Choice Questions




    • QUESTION 1.

      The primary goal of phase I after nonoperative AC joint injury is:



      • A.

        Immobilization


      • B.

        Increase strength


      • C.

        Reduce pain and inflammation


      • D.

        Reduce ROM



    • QUESTION 2.

      When initiating strength exercises in Phase II following nonoperative AC injury, it is best to start with what type of exercise?



      • A.

        Closed kinetic chain


      • B.

        Isokinetic


      • C.

        Isotonic


      • D.

        Open kinetic chain



    • QUESTION 3.

      When the AC ligaments rupture the scapula migrates in which direction?



      • A.

        Upward


      • B.

        Downward


      • C.

        Medial


      • D.

        Lateral



    • QUESTION 4.

      _________________ targets strengthening for serratus anterior.



      • A.

        Horizontal Abduction


      • B.

        Rowing


      • C.

        Wall pushup with plus


      • D.

        Scapular Clock




    Answer Key




    • QUESTION 1.

      Correct answer: C (see Phase I )


    • QUESTION 2.

      Correct answer: A (see Phase II )


    • QUESTION 3.

      Correct answer: B (see Phase II )


    • QUESTION 4.

      Correct answer: C (see Phase II )





    Postoperative Rehabilitation after Distal Clavicular Resection (Mumford)



    Brian T. Swanson, PT, OCS, FAAOMPT
    Karen E. Wojcik, MSPT, OCS, ATC
    Kimberly Cubeta-Gileau, PT, MSAH
    Thomas J.S. Durant, MPT
    John Apostolakos, BS
    Mark P. Cote, PT, DPT, MSCTR
    Augustus D. Mazzocca, MS, MD

    Indications for Surgical Treatment





    • Pain at the acromioclavicular (AC) joint exacerbated with cross body adduction.



    • Failure of conservative management (≥3 months of physical therapy, nonsteroidal antiinflammatory drugs, steroid injection into the AC joint)



    • Radiographic findings consistent with AC joint disease



    Brief Summary of Surgical Treatment


    Major Surgical Steps





    • Open Approach




      • A transverse or “saber” type incision is made over the AC joint with careful dissection of the superior AC ligament, deltoid and trapezial fascia from their flap to expose the distal clavicle.



      • An oscillating saw resects 5 to 10 mm of the distal clavicle from superolateral to inferomedial.



      • The superior joint capsule and deltoid insertion are repaired to preserve clavicular stability and preserve continuity of the deltotrapezial attachment.




    • Arthroscopic Approach—Direct




      • Anterosuperior and posterosuperior portals are created with two small stab incisions in line with the AC joint.



      • A 2.7-mm arthroscope and motorized bur is used to excise 2 to 3 mm off the acromial spur and 5 to 7 mm off the distal clavicle for a total of 8 to 10 mm of excision (confirmed with c-arm and spinal needles).



      • Once the joint is sufficiently widened, a standard 4-mm arthroscope is introduced to complete the resection.




    • Arthroscopic Approach—Indirect




      • Standard arthroscopic anterior, posterior, and lateral portals are created to allow bursectomy and permit visualization of the AC joint.



      • A round or oval bur is used to resect the inferior distal clavicle cortex




    Factors That May Affect Rehabilitation





    • Rarely does the AC pathology that leads to a Mumford procedure occur in isolation, and has been shown to occur as occult pathology in up to 50% of apparent AC joint cases.



    • The concurrent pathology (impingement, labral tear, etc.) will frequently lead to concurrent surgical procedures. This is an important consideration as the nature of concurrent procedures will often dictate the pace of rehabilitation, or will lead to the consideration of other tissues that will need to heal. Recognition of the other involved tissues will allow for a more comprehensive rehabilitation program.



    Before Surgery: Overview of Goals, Milestones, and Guidelines 1



    1 Prehabilitation, if appropriate, is described in the Nonoperative Rehabilitation section of this chapter.



    Guiding Principles of Postoperative Rehabilitation





    • Biologic tissue healing time frames guide progression of rehabilitation.



    • Concomitant operative procedures often involve tissue repair and therefore guide progression of therapeutic activities.



    • Absent of any concomitant procedures, pain is the limiting factor for progression of therapeutic activity. Therapeutic intervention early in the postoperative period should be directed at reducing pain to optimize the potential recovery.



    • Educate patient to the principles guiding to rehabilitation.




    Phase I : Immediate Postoperative Period (days 0 to 14)




    Clinical Pearl





    • Following distal clavicular resection (DCE), immediate motion can be very painful and difficult to perform. Glenohumeral joint mobilization can be useful in this stage for both pain control and ROM.



    • The use of a wedge under the scapula can be useful to isolate motion and avoid stresses through the AC joint soft tissues while inflammation subsides.



    • With the scapula stabilized, restrictions on the glenohumeral joint, should they exist, can be addressed ( Figure 7-14 ).




      FIGURE 7-14


      Positioning for glenohumeral mobilization with wedge to stabilize scapula. In this set up, the rehab clinician would perform general joint mobilizations for pain relief and ROM while avoiding excessive stress to the AC joint and surrounding soft tissue.




    Timeline 7-2

    Postoperative Rehabilitation after Distal Clavicular Resection (DCE) (Mumford)
















    PHASE I (weeks 1 to 2) PHASE II (weeks 3 to 6) PHASE III (weeks 6 to 10) PHASE IV (weeks 10 to 14) PHASE V (weeks 14 to 24)



    • Sling (48 h unless concomitant procedures conflict)



    • Ice



    • ROM-scapular plan elevation, supine cane ER



    • Active-assistive table slides for forward elevation



    • Glenohumeral mobilization with wedge



    • Scapular PNF exercises in side lying




    • ROM—active-assistive ROM in all planes permitted



    • Avoid excessive horizontal adduction



    • Progressive active-assistive motion from closed chain to open chain



    • Closed chain scapular exercises



    • Glenohumeral rhythmic stabilization in supine



    • Lower extremity exercise and conditioning




    • ROM should be full



    • Mobilizations as needed



    • Scapular and rotator cuff musculature PRE



    • PNF exercise



    • Upper extremity plyometrics in supine (90-90 & overhead ball toss) at 10 weeks




    • Scapular and rotator cuff musculature PRE



    • Blackburn exercises (Ts, Ys, and Is)



    • TAS—biceps/triceps PREs



    • Glenohumeral exercises –PREs



    • Rotator cuff exercises –PREs



    • Upper extremity core stability (plank, side plank)



    • PNF exercises



    • Upright 90-90 and overhead ball toss




    • Throwing program



    • Modified bench and overhead press (≤50% of preop reps weight)



    • Glenohumeral exercises—PREs



    • Scapular and rotator cuff musculature PRE



    • PNF exercises



    • Sport-specific training



    Goals





    • D/C sling (if concomitant procedures do not conflict)



    • Reduce pain



    • Ensure adequate patient education to allow patient to progress motion accordingly



    Management of Pain and Swelling





    • Use of sling and ice for the first 24 to 48 hours (additional immobilization to be directed by concomitant procedures)



    Techniques for Progressive Increase in Range of Motion





    • If concomitant procedures do not conflict, range of motion (ROM) can be progressed according to the patient’s pain response.



    • Motion should start with forward elevation in the plane of scapula and external rotation at 30° of abduction with the arm supported.



    • Upper extremity motion of the elbow, forearm, wrist, and hand is also encouraged.



    • Begin passive and active-assisted ROM through formal rehabilitation and home exercise program 2 days postoperatively.



    Open and Closed Kinetic Chain Exercises





    • CKC: ROM exercises with limb-supported activities like the table or wall slide. These closed chain exercises have been shown to elicit low amounts of shoulder muscle activity.



    • OKC: Supine forward elevation and cane ER.



    Neuromuscular Dynamic Stability Exercises





    • The use of side lying manually resisted proprioceptive neuromuscular facilitation (PNF) patterns to the scapula can be useful to initiate strength and control activities without stressing inflamed tissues by allowing for immediate modification of the amount and direction of force applied to the shoulder. This early initiation of resisted exercises may help offset post-operative atrophy and inhibition in the athlete ( Figure 7-15 ).




      FIGURE 7-15


      Positioning for PNF patterns in side lying. The use of manually resisted PNF patterns to the scapula can be useful to initiate strength and control activities without stressing inflamed tissues. This positioning allows for immediate modification of the amount and direction of force applied to the shoulder.



    Phase II (weeks 2 to 6)




    Clinical Pearls





    • In isolated cases of distal clavicle excision (no concomitant procedures), progression of rehabilitative activities is based upon the patient’s tolerance to these activities.



    • If pain is persistent, ROM exercises can be adjusted to focus on high frequency (motion exercises three to four times a day), at low intensity (within a pain-free or to-pain ROM) for short durations (20 to 30 repetitions or 2 to 3 minutes worth). This approach allows existing motion to be maintained and carefully increased while facilitating a reduction in pain and inflammation. It is in these cases that initiating strength training too quickly will lead to continued pain and stiffness.



    • As the patient’s tolerance to rehabilitation (ability to improve mobility without increases in pain) increases, motion exercises can be adjusted to produce more permanent gains, and strengthening can then be initiated.




    Goals





    • Full active range of motion equal to uninvolved shoulder



    • Initiate scapular strengthening



    • Return to non-athletic ADLs



    Protection





    • Continued immobilization via a sling only if indicated by nature of concomitant procedures, e.g., rotator cuff repair, labral repair, etc.



    Management of Pain and Swelling





    • Continued immobilization via a sling only if indicated by nature of concomitant procedures, e.g., rotator cuff repair, labral repair, etc.



    Techniques for Progressive Increase in ROM





    • Progressive ROM exercise emphasizing closed chain (limb supported) and moving to open chain exercises as patient’s tolerance and response to treatment allows.



    • In the absence of concomitant procedures, ROM is progressed at the patient’s tolerance to rehabilitation (ability to improve mobility without increases in pain).



    • Cross-body adduction should be avoided, as it can be provocative at this stage.



    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.



    Milestones for Progression to the Next Phase





    • Absence of pain at rest



    • Full active ROM that is pain free. Residual soreness at the beginning or following activity that subsides on its own is expected and is not considered “pain” in terms of establishing appropriateness to progress to Phase III. It is important to distinguish between lactic acid pain, which resolves following the completion of an exercise or activity, and other sources of pain. Pain that is persistent between therapeutic treatments may be a sign of continued inflammation or delayed onset muscle soreness, which can last for several days. In these cases, progression to the next stage should be delayed until persistent pain is eliminated.



    • Minimal to no scapular substitution with active forward elevation, measured posteriorly, ensuring that the medial border of the scapula is symmetrical and remains protracted to the rib cage during shoulder flexion, and retracts/upwardly rotates appropriately during abduction.



    Phase III (weeks 6 to 10)




    Clinical Pearls





    • As Phase III progresses to the initiation of sport-specific activity, it’s not uncommon to have the athlete experience some pain in the surgical region.



    • Careful monitoring of the intensity and provocative maneuver can lead to a more successful return.



    • This is a good time to reassess scapular mechanics to ensure that scapular dyskinesis is not present. The Scapular Dyskinesis Test, which classifies scapula dyskinesis as either present or absent, is used to determine the presence of dyskinesis. This system involves viewing of the scapula during humeral elevation to observe for “winging” (abnormal prominence of the medial and/or inferior boarder of the scapula) or dysrhythmia with grading of these findings as normal, subtle (mild, questionable, or inconsistent), and obvious (striking, clear, and consistent).




    Goals





    • Restore strength of the shoulder musculature



    • Initiate return to sport training



    • Unrestricted ADLS



    Management of Pain and Swelling





    • Careful monitoring of intensity and provocative movements with rehabilitation activities to allow adjustments to be made



    Techniques for Progressive Increase in ROM


    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




      FIGURE 7-16


      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 )




      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.)



    Milestones for Progression to the Next Phase





    • Pain-free motion



    • Strong and painless rotator cuff strength at 0° ABD



    • No scapular substitution with forward elevation or abduction as discussed earlier



    Phase IV (weeks 10 to 14)




    Clinical Pearls





    • In the late phases of rehabilitation, it is essential that the athlete continue to work to correct any strength or flexibility deficits that have been identified during the rehabilitation process.



    • It is not uncommon for patients to discontinue the exercise regimen prematurely and suffer a return of pain and a functional set back as a result.



    • Frequent communication with the athlete reinforcing the need to continue with the program is critical.




    Goals





    • Full restoration of shoulder strength



    • Appropriate return to sport program



    • Throwing program at 12 weeks



    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 .)



    Phase V (weeks 14 to 24)


    Goals





    • Successful or near completion of throwing program



    • Sport-specific drills without complaints



    • Discharge from formal care in preparation for return to sport



    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.)



    Criteria for Return to Sport


    General





    • Full active ROM without scapular dyskinesis as measured by the Scapular Dyskinesis Test.



    • Full shoulder strength with handheld dynamometer or with manual muscle testing Successful completion of rehabilitation progression without residual soreness/pain



    • Pain-free overhead activities



    • Pain-free sport specific motions and maneuvers



    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



    Evidence


  • Charron KM, Schepsis AA, Voloshin I: Arthroscopic distal clavicle resection in athletes: a prospective comparison of the direct and indirect approach. Am J Sports Med 2007; 35: pp. 53-58.
  • Randomized controlled clinical trial comparing direct and indirect arthroscopic approaches for distal clavicle excision. Outcome scores were comparable at 2-year follow up in both groups, however athletes treated with the direct superior approach improved faster clinically and returned to sports earlier. 18 (Level II evidence)
  • Flatow EL, Duralde XA, Nicholson GP, et. al.: Arthroscopic resection of the distal clavicle with a superior approach. J Shoulder Elbow Surg 1995; 4: pp. 41-50.
  • Forty-one patients who underwent arthroscopic distal clavicle resection were followed for a minimum of 2 years postoperatively. At follow up 18 excellent, 16 good, and 7 poor results were found. High failure rate was associated with previous grade II acromioclavicular separations or acromioclavicular hypermobility. 4 (Level IV evidence)
  • Freedman BA, Javernick MA, O’Brien FP, et. al.: Arthroscopic versus open distal clavicle excision: comparative results at 6 months and 1 year from a randomized, prospective clinical trial. J Shoulder Elbow Surg 2007; 16: pp. 413-418.
  • Randomized, prospective clinical trial comparing the 6-month and 1-year outcomes between patients undergoing arthroscopic DCE to those undergoing open DCE. Both groups had comparable outcomes at 1 year. There was a trend for earlier improvement in the arthroscopic group. 7 (Level II evidence)
  • Kay SP, Dragoo JL, Lee R: Long-term results of arthroscopic resection of the distal clavicle with concomitant subacromial decompression. Arthroscopy 2003; 19: pp. 805-809.
  • Retrospective review of 20 patients followed for a mean of 6 years following combined arthroscopic DCE and subacromial decompression. Good to excellent scores on the Constant score and UCLA were observed in all 20 patients. 20 (Level IV evidence)
  • Robertson WJ, Griffith MH, Carroll K, et. al.: Arthroscopic versus open distal clavicle excision: a comparative assessment at intermediate-term follow-up. Am J Sports Med 2011; 39: pp. 2415-2420.
  • Comparison of 49 shoulders in 48 patients treated either with an open or arthroscopic approach. At 4-to 5-year follow-up, both groups had comparable outcome scores and were satisfied with the result of the procedure. 19 (Level III evidence)

  • Multiple-Choice Questions




    • QUESTION 1.

      Pain is an important component in determining the progression of therapeutic activities. Which of the following is most important when making decisions regarding the pace of rehabilitation?



      • A.

        Sport played


      • B.

        Concomitant procedures


      • C.

        Operative approach


      • D.

        Mechanism of original injury



    • QUESTION 2.

      What is the described progression of ROM exercises in the postsurgical setting?



      • A.

        Start with exercises like the pulleys that elicit moderate amounts of muscle activity. If the patient can’t tolerate this switch to exercises with the limb supported.


      • B.

        Active ROM can be initiated immediately. Only patients reporting high levels of pain need to start with active assistive motion exercises


      • C.

        ROM exercises should start with the limb supported as they produce low levels of muscle activity thereby allowing the patient to move in a tolerable range. As motion improves and pain subsides, active-assistive exercise such as the pulleys and open chain activities like reclined flexion that produce progressive amounts of muscle activity.


      • D.

        All of the above.



    • QUESTION 3.

      Which of the following exercises allow the patient to focus on scapular control and established movement patterns without creating excessive loads about the shoulder?



      • A.

        Scaption with a hand-held weight


      • B.

        Scapular clock


      • C.

        Active forward elevation


      • D.

        Cable column external rotation




    Answer Key







    Nonoperative Rehabilitation of Sternoclavicular Joint Sprains



    Richard L. Romeyn, MD
    Becky Heinert, MS, PT, SCS

    Introduction


    Anatomy





    • The structure of the sternoclavicular (SC) joint is unique. It is a saddle-type articulation of partially incongruent surfaces, but it essentially functions as a ball-and-socket joint. Virtually any motion of the upper extremity produces some degree of stress upon the SC joint. Because the medial clavicle’s articular surface is much larger than that on the sternum (less than half of the medial clavicle actually articulates with it), a lack of bony stability means that SC joint stability is largely dependent upon the integrity of its investing soft tissue constraints to control rotation and resist displacement.



    • The posterior capsule (posterior sternoclavicular ligament) and the costoclavicular ligaments are the strongest and most important. Typically, 30° to 35° of upward elevation, 35° of combined anterior/posterior displacement, and 45° to 50° of rotation about the long axis of the clavicle are allowed.



    • The muscles that act upon the SC joint do so indirectly, and as with the AC joint, stresses upon it are significantly influenced by scapulothoracic (kinematics).



    • Adjacent to the SC joint is the epiphysis (growth center) of the medial clavicle. That epiphysis is the last one to close as skeletal maturity is reached, and it generally remains patent until midway through the third decade of life.



    Symptoms





    • SC joint pathology produces localized pain over the joint surfaces and adjacent capsule. Distant pathologies do not generally refer pain to the area of the SC joint, and SC joint pathologies generally do not produce pain referred to other locations.



    • Because the SC joint is superficial, even in muscular or obese patients, swelling is usually visually evident, and discomfort and instability can be readily palpated.



    • The SC joint can be difficult to assess with standard radiographic views. Cephalic tilt views may allow more sensitive images to be obtained, but the current standard of care, if significant pathology or injury is suspected, is an advanced imaging study such as a CT or MRI scan.



    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.

    Spontaneous instability:


    • 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.




      FIGURE 7-18


      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.

    Arthritis:


    • 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.



    • 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.

    Infection:


    • 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.



    • 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.



    Guiding Principles of Rehabilitation





    • Protect the SC joint to help minimize the likelihood of chronic subluxation.



    • Correct any underlying scapulothoracic dyskinesia to allow normalized shoulder girdle biomechanics during arm elevation.



    • Prevent chronic SC joint subluxation through strengthening of the shoulder and scapular stabilizers and improved flexibility of the sternocleidomastoid, upper trapezius, pectoralis major, and pectoralis minor muscles.




    Phase I (weeks 0 to 4)


    Goals





    • The SC joint pathology can be divided into those caused by trauma and those of insidious onset.



    • The acute sprain can be classified into grade I (mild), grade II (moderate) and grade III (severe). The duration of immobilization and progression through the rehabilitation program will be dependent on the degree of instability in the SC joint.



    • A grade I SC joint sprain is symptom-limited with a fairly rapid return to activity based on resolution of symptoms within 7 to 10 days.



    • The treatment of grade II and III SC joint sprain is identical except the period of immobilization. For grade III SC joint sprains, the timeline for the rehabilitation protocol provided will be delayed by approximately 2 weeks to help minimize the likelihood of chronic SC joint subluxation.



    • For the rehabilitation of a non-traumatic SC joint injury it is recommended that provocative activities be avoided for 2 to 3 weeks and that local modalities such as ultrasound, interferential current and ion­tophoresis be utilized for inflammatory and pain control. Upon resolution of acute symptoms, the athlete can begin the rehabilitation protocol beginning with Phase II.



    Timeline 7-3

    Nonoperative Rehabilitation of the Sternoclavicular Joint Sprain














    PHASE I (week 0 to 1) PHASE II (weeks 2 to 4) PHASE III (weeks 4 to 8) PHASE IV (weeks 8 to 12)



    • Sling or “figure of 8” brace



    • PT modalities



    • PROM–flexion and scaption 0°–90°



    • Active ROM-elbow, wrist



    • Codman’s exercises



    • TBS/TAS/TLS activities as recommended and tolerated




    • D/C sling or “figure of 8” brace



    • PT modalities as needed



    • PROM–flexion and scaption 0°–180°



    • AAROM flexion and scaption 0°–90° (week 2–3)



    • AAROM flexion and scaption 0°–180° (week 3–4)



    • Submaximal to maximal isometrics for GH joint muscles



    • Biceps, triceps, and scapular exercises



    • SCM, UT, Pectoralis stretches



    • TBS/TAS/TLS activities as recommended and tolerated




    • Brace/taping prn



    • PT modalities as needed



    • AROM–full



    • Mobilizations (SC join, GH, thoracic spine) as needed



    • SCM, UT, pectoralis stretches prn



    • TBS/TAS/TLS activities as recommended and tolerated



    • Scapular exercises—PREs



    • TAS–biceps/triceps PREs



    • Glenohumeral exercises—PREs



    • Rotator cuff exercises–PREs



    • PNF exercises



    • Week 6–Plyometric progression (two-hand chest pass progressing to one-arm 90/90 step-throw)



    • Week 6–CKC progression (supported weight shift progressing to full pushup; bilateral progressing to unilateral)




    • Brace/taping prn



    • PT modalities as needed



    • PROM–full



    • Mobilizations as needed



    • SCM, UT, Pectoralis stretching prn



    • TBS/TAS/TLS activities as recommended and tolerated



    • Scapular exercises–PREs



    • TAS–Biceps/Triceps PREs



    • Glenohumeral exercises–PREs



    • Rotator cuff exercises–PREs



    • Overhead strengthening exercises



    • PNF exercises



    • OKC rhythmic stabilization exercises



    • CKC exercises



    • Initiate sport-specific exercises



    • Return to sport program



    Protection





    • Grade I: 5 to 10 days in a sling



    • Grade II: 2 to 3 weeks using a sling for anterior in­stability and “figure of 8” brace for posterior instability



    • Grade III: 3 to 4 weeks using a sling for anterior instability and “figure of 8” brace for posterior instability



    Management of Pain and Swelling





    • Ice, Ultrasound, Interferential Current Electrical Stimulation



    Techniques for Progressive Increase in Range of Motion





    • PROM flexion and scaption:




      • 0° to 90° (week 1 to 2) to avoid excessive clavicular retraction, elevation, and posterior rotation on the thorax



      • 0° to 180° (week 2 to 3)




    • AAROM 0° to 90° flexion and scaption (week 2 to 3)



    • Pendulum exercises



    • Active elbow and wrist ROM



    Stretching and Flexibility Techniques for the Musculotendinous Unit





    • TBS, Core, TLS as tolerated and recommended



    Techniques to Increase Muscle Strength, Power, and Endurance





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



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



    Milestones for Progression to the Next Phase





    • D/C sling or brace



    • Visual analog scale (VAS) 0/10 at rest



    • PROM 0° to 180° for flexion/scaption



    • Pain-free maximal isometrics for shoulder flexion, abduction, IR, ER in neutral



    • Correct sitting posture demonstrated



    Phase II (weeks 4 to 8)


    Protection





    • Taping prn for anterior instability ( Figure 7-19 )




      FIGURE 7-19


      Utilization of kinesiotape for chronic anterior SC joint instability.



    Techniques for Progressive Increase in Range of Motion


    Manual Therapy Techniques





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



    • 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




      • AAROM 0° to180° (week 3 to 4)



      • 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.



    Other Therapeutic Exercises





    • TBS, Core, TLS as tolerated and recommended



    Sensorimotor Exercises





    • 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.



    • PNF patterning in a pain-free ROM



    • Body blade progression from neutral to 90°



    Open and Closed Kinetic Chain Exercises





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



    • 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.



    • 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.




      FIGURE 7-20


      Prone ball punches.



    Techniques to Increase Muscle Strength, Power, and Endurance





    • Continue total arm strengthening, including bicep curls, triceps extensions



    • Progress strengthening of scapular stabilizers, posterior cuff, and glenohumeral muscles




      • Standing flexion, scaption 0° to 90°; increase ROM as strength and dynamic control improve



      • Prone rows



      • Prone GH extension



      • Supine protraction



      • Horizontal abduction with external rotation



      • Sidelying ER



      • TheraBand IR/ER




    Plyometrics





    • 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.



    Milestones for Progression to the Next Phase





    • VAS 0/10 with activities of daily living.



    • Full AROM



    • Manual muscle test 5/5 glenohumeral, scapular, and rotator cuff strength



    • Isokinetic strength testing within 10% of the uninvolved shoulder for IR/ER in neutral at 60°/second, 180°/second and 300°/second



    • Normal scapular assessment and/or normal scapular dyskinesis test



    Phase III (weeks 8 to 12)


    Protection





    • Taping prn for anterior instability



    Management of Pain and Swelling





    • Ice, Ultrasound, Interferential Current Electrical Stimulation prn



    Techniques for Progressive Increase in Range of Motion


    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.



    Other Therapeutic Exercises





    • TBS, Core, TLS as tolerated and recommended



    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.




      FIGURE 7-21


      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 ).




      FIGURE 7-22


      Pushup with ball rolls.



      FIGURE 7-23


      Pushup with unilateral touches.



    Techniques to Increase Muscle Strength, Power, and Endurance





    • Continue to increase resistance to the rotator cuff, scapular stabilizers and glenohumeral muscles. Utilize high repetition, low resistance for endurance training for the postural muscles such as the lower and middle trapezius muscle groups. Consider using a stability to engage more of the core muscles including:




      • Prone “Y”s ( Figure 7-24 )




        FIGURE 7-24


        Prone Y exercise.



      • Prone “T”s ( Figure 7-25 )




        FIGURE 7-25


        Prone T exercise.



      • Prone goalpost ( Figure 7-26 )




        FIGURE 7-26


        Prone goalpost exercise.




    Neuromuscular Dynamic Stability Exercises





    • 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.




      FIGURE 7-27


      Lunge with overhead press.



      FIGURE 7-28


      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.)



    Milestones for Progression to Advanced Sport-Specific Training and Conditioning





    • Successful completion of Phase III exercises, including closed kinetic chain, plyometric, functional movement pattern progressions, and return to throwing program with VAS 0-1/10 pain reported.



    Criteria for Abandoning Nonoperative Treatment and Proceeding to Surgery or More Intensive Intervention





    • Continued pain or instability interfering with upper extremity function



    Performance Enhancement and Beyond Rehabilitation: Training/Trainer and Optimization of Athletic Performance





    • For an athlete returning to sport, a gradual transition is necessary to avoid excessive stress across the SC joint.



    • The athlete with the goal of returning to a contact sport or one that requires overhead power may benefit from a biomechanical assessment by a physical therapist or athletic trainer, with the assistance of their positional coach to provide recommendations for technique modifications.



    Specific Criteria for Return to Sports Participation: Tests and Measurements





    • VAS 0-1/10 during sport-specific exercises



    • Closed Kinetic Chain Upper Extremity Test scores within 10% of the uninvolved shoulder



    • Isokinetic strength testing within 10% of the uninvolved shoulder for desired motions. IR/ER in 90/90 position at 60°/sec, 180°/sec, and 300°/ pain-free completion of a return to throwing program prn.



    Evidence


  • Bontempo NA, Mazzocca AD: Biomechanics and treatment of acromioclavicular and sternoclavicular joint injuries. Br J Sports Med 2010; 44: pp. 361-369.
  • This descriptive article reviews the etiology, examination, and management of SC joint pathologies. (Level V evidence)
  • Cleland J, Selleck B, Stowell T, et. al.: Short term effects of thoracic manipulation on lower trapezius muscle strength. J Manual Manipulative Ther 2004; 12: pp. 82-90.
  • This randomized, controlled study evaluated the short-term effects of thoracic manipulation on lower trapezius muscle activation using a hand-held dynamometer. The subjects that received the thoracic manipulation demonstrated an increase of lower trapezius strength of 14% as compared with the control group which improved 3%. (Level I evidence)
  • Cools AM, Dewitte V, Lanszweert F, et. al.: Rehabilitation of scapular muscle balance; Which exercises to prescribe?. Am J Sports Med 2007; 35: pp. 1744-1751.
  • This controlled laboratory study of 45 healthy subjects evaluated the electromyographic activity of the three trapezius parts during commonly used scapular stabilization exercises. The exercises of sidelying external rotation, sidelying forward flexion, prone horizontal abduction with external rotation and prone extension were found to be the most effective in promoting lower and middle trapezius muscle activity with minimal activation of the upper trapezius. (Level II evidence)
  • Jaggard MK, Gupte CM, Gulati V, et. al.: A comprehensive review of trauma and disruption to the sternoclavicular joint with the proposal of a new classification system. J Trauma 2009; 66: pp. 576-584.
  • This review article discusses the anatomy of the SC joint, classification of injuries, and the management of these injuries using primarily immobilization and physical therapy. (Level V evidence)
  • MacDonald PB, Lapointe P: Acromioclavicular and sternoclavicular joint injuries. Orthop Clin North Am 2008; 39: pp. 535-545.
  • This descriptive article briefly outlines the anatomy of the SC joint and the management of traumatic anterior and posterior dislocations. Recommendations regarding prolonged immobilization and a return to full activities within 12 to 16 weeks were included. (Level V evidence)
  • Neviaser JS: Injuries of the clavicle and its articulations. Orthop Clin North Am 1980; 11: pp. 233-237.
  • This brief commentary discusses the etiology and symptoms of SC joint injuries along with the conservative management of sprains using immobilization. (Level V evidence)
  • Robinson CM, Jenkins PJ, Markham PE, et. al.: Disorders of the sternoclavicular joint. J Bone Joint Surg Br 2008; 90: pp. 685-696.
  • This review article discusses the anatomy and pathophysiology of the SC joint, clinical presentation, and the conservative management of disorders involving the SC joint. (Level V evidence)
  • Rockwood CA, Odor JM: Spontaneous atraumatic anterior subluxation of the sternoclavicular joint. J Bone Joint Surg Am 1989; 71A: pp. 1280-1288.
  • This retrospective comparative study evaluates the outcomes of 37 patients treated for spontaneous atraumatic anterior subluxation of the SC joint with either conservative or surgical intervention. The authors recommend that this disorder be treated with a conservative approach that includes immobilization and reassurance of a full recovery. (Level IV evidence)
  • Tate AR, McClure P, Kareha S, et. al.: A clinical method for identifying scapular dyskinesis. Part 2: Validity. J Athl Train 2009; 44: pp. 165-173.
  • This validation study rated the scapular dyskinesia in 142 collegiate athletes performing weighted shoulder flexion and abduction. Athletes judged as having either normal motion or obvious dyskinesia underwent three-dimensional electromagnetic kinematic testing while performing the same movements. Shoulders visually judged as having dyskinesia showed significant differences in kinematic motion. (Level II evidence)

  • Multiple-Choice Questions




    • QUESTION 1.

      The etiology of symptoms involving the sternoclavicular joint includes all of the following except:



      • A.

        Recurrent bacteremia (HIV infection, drug addiction, alcoholism)


      • B.

        Trauma to the anterior lateral clavicle


      • C.

        Referral pain from the cervical spine


      • D.

        Systemic rheumatoid arthritis



    • QUESTION 2.

      Which of the following is NOT a typical finding of a potential sternoclavicular joint pathology:



      • A.

        Painful popping in the SC joint region with arm elevation


      • B.

        Generalized multi-joint laxity


      • C.

        Shortness of breath


      • D.

        Abnormality obvious on standard plain x-ray views



    • QUESTION 3.

      A key component of Phase II of rehabilitation includes:



      • A.

        Immobilization of the joint to maximize healing and prevent chronic shoulder subluxation


      • B.

        Overhead strengthening


      • C.

        Return to sport program


      • D.

        Closed chain exercise progression



    • QUESTION 4.

      The timeline for return to sports is most closely related to:



      • A.

        Severity of the sprain


      • B.

        Location of pain


      • C.

        Direction of the sprain (anterior versus posterior)


      • D.

        Age of the athlete




    Answer Key




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    Apr 5, 2019 | Posted by in PHYSICAL MEDICINE & REHABILITATION | Comments Off on Acromioclavicular Joint Injuries and Sternoclavicular Joint Injuries

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