Dr. Abene is a board certified Orthopaedic Surgeon. He did his Sports Medicine Fellowship at Stanford where he worked directly with the head team physicians for the San Francisco 49ers and Giants. He is currently the head team physician for the San Jose Sharks AHL affiliate, the San Jose Barracuda. He is also a volunteer team physician for USA Hockey.
What are Shoulder Separations?
Shoulder separations are the most common shoulder injury in ice hockey. The typical mechanism of injury is direct contact with the boards. The medical term for a shoulder separation is an acromioclavicular (AC) joint separation. The “A” stands for Acromion which is part of the shoulder blade and the “C” stands for the Clavicle which is the “collar” bone. Together, they form the AC joint. Normally, these two bones are aligned with each other. A direct blow to the shoulder, whether into the boards, the ice, or another player can cause these two bones to separate.
What exactly happens?
First, it is important to distinguish a separated shoulder from a dislocated shoulder. A dislocated shoulder is when the ball (upper part of humerus/arm bone) comes out of the socket (the glenoid bone). This is typically a more severe injury. In a shoulder separation there is an injury to the joint capsule of the AC joint and at least one of the main two ligaments which basically hold the collar bone to the shoulder blade. These ligaments are the trapezoid and conoid ligaments, otherwise known as the Coracoclavicular (CC) ligaments.
Normal AC joint. Separated AC joint.
How are Shoulder Separations Diagnosed?
A typical story is a player being checked hard into the boards resulting in immediate pain. Often, there will be a noticeable “bump” at the end of the collar bone. There is tenderness directly over the joint. The diagnosis is usually confirmed by a simple x-ray which is “graded” by how separated the bones are. One additional point here is that the growth plate of the collar bone is usually not fused before the age of 18 (earlier in females) which means that an AC separation in someone under the age 18 may actually be a fracture.
What are the “Grades” of Shoulder Separations?
Shoulder separations are “graded” based on the x-ray. The grade typically reflects the severity of the injury.
Grade 1: Tenderness at joint. Mild Sprain. Normal x-ray.
Grade 2: Moderate Spain. Xray can still be normal or slightly separated
Grade 3: Noticeable bump. Complete tear of the Coracoclavicular ligaments. Xray shows complete separation.
Grades 4-6 are rare, but more severe injuries.
How are Shoulder Separations treated?
Most separations are treated non-surgically. The acute injury is treated with ice, anti-inflammatory medications, and a sling for comfort. Normal activity is encouraged to prevent stiffness. It is rare to need surgery for this injury.
What about Return to Play?
Return to play is usually based on the severity of the injury. Grade 1 and 2 injuries typically take about 2 weeks. Grade 3 injuries take 4-6 weeks. Players under the age of 18, who have the equivalent of a fracture, usually take at least four weeks to return. Basically, once the pain has resolved and the player has full range of motion and full strength the player can return. Working with a trainer or therapist can help speed up this process. It also may be beneficial to place extra padding over the injured joint. For professional players there is some evidence that a steroid injection into the joint can expedite return to play. The bump unfortunately is permanent but should not affect the use of the arm once the initial injury has resolved.
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