Rehabilitation after Conservative and Operative Treatment of Acromioclavicular Joint Injuries

SHOULDER ACROMIOCLAVICULAR JOINT INJURIES

CHAP T ER 26

Rehabilitation after Conservative and Operative Treatment of Acromioclavicular Joint Injuries James W. Matheson, PT, DPT, MS, SCS, CSCS Christopher R. Price, MD

CHAPTER OUTLINE Nonoperative Management of Acromioclavicular Joint Injury Davies Resistive Exercise Continuum Precautions during Rehabilitation of the Patient with Acromioclavicular Injury Return to Activity or Sport Operative Management of Acromioclavicular Joint Injury Primary Fixation across the Acromioclavicular Joint Dynamic Stabilization Secondary Stabilization The Future of Acromioclavicular Surgery Rehabilitation following Acromioclavicular Surgery Summary

Anatomy and Biomechanics of the Acromioclavicular Joint Osseous Anatomy Stabilizing Structures of the Acromioclavicular Joint Motion at the Acromioclavicular Joint Mechanism of Acromioclavicular Joint Injury Classification of Acromioclavicular Joint Injuries Evaluation of the Patient with Acromioclavicular Joint Injury History and Examination Radiographic Evaluation of the Acromioclavicular Joint Treatment of Acromioclavicular Joint Injuries Type I Type II Immobilization, Strapping, and Bracing after Acromioclavicular Injury Type III Types IV, V, and VI

491

492

SEC TION III: SHOULDER ACROMIOCL AVICUL AR JOINT INJURIES

ACROMIOCLAVICULAR JOINT INJURIES are common in today’s athletic population. Young athletes who participate in such contact team sports as football, hockey, rugby, and soccer are at high risk for acromioclavicular joint injury. Furthermore, increased participation in noncontact recreational activities such as cycling, skiing, snowboarding, and skateboarding by “weekend warriors” has resulted in more individuals being susceptible to acromioclavicular joint injury.1-8 Acromioclavicular joint injuries are five times more likely to occur in males than females and usually occur during the third decade of life.9,10 The majority (2 : 1) of acromioclavicular injuries are incomplete rather than complete and, depending on the severity of the pathology, may be associated with significant pain, muscle weakness, and fatigue.9,11 These are critical issues for sports medicine clinicians to consider when managing acromioclavicular joint injuries in all individuals, particularly those who participate in strenuous overhead athletic or work activities. Therefore physicians and rehabilitation professionals require a good understanding of the current operative techniques and rehabilitation concepts related to acromioclavicular joint pathology.

ANATOMY AND BIOMECHANICS OF THE ACROMIOCLAVICULAR JOINT Osseous Anatomy The acromioclavicular joint (Figure 26-1) is a diarthrodial synovial joint formed by the distal clavicle and the medial facet of the acromion. Together with the sternoclavicular joint, the acromioclavicular joint helps serve as the only true

joint linkage between the upper extremity and the axial skeleton. The acromioclavicular joint articulation consists of the medial facet of the acromion and the distal end of the clavicle. The average articular surface has been described as being 9 by 19 mm in size 12 This is a relatively small area of contact when one considers the high forces placed on the joint during athletic activities such as throwing. The articular surfaces of the distal clavicle and the clavicular end of the acromion each undergo a change from hyaline cartilage to fibrocartilage around 17 and 23 years of age, respectively.13 The joint congruency of the articular surfaces of the acromioclavicular joint varies significantly in the general population. Several different angles of joint inclination have been found in both the frontal and sagittal planes.14 On examination of 100 random radiographs, Urist15 found the clavicle to be in an overriding (49%), underriding (3%), vertical (27%), or incongruent (21%) orientation to the acromion. At present the research is limited on whether there is a relationship between joint inclination and disease.16,17 Interposed inside the acromioclavicular joint is a fibrocartilaginous disk of variable size, shape, and completeness.18-21 To observe the variation in disk morphology, Salter and colleagues21 examined 53 acromioclavicular joints from 13 male and 14 female cadavers of individuals who died in their sixth or seventh decade of life. Their findings revealed 1 joint with a complete disk, 11 joints without disks, 16 joints with disk remnants, and 25 joints with meniscoid disks. 21 In general, it appears that the disk’s function in the acromioclavicular joint is limited and that it undergoes rapid degeneration with aging.18-21 This may be related to the fact that the acromioclavicular joint space itself is on average 1 to 3 mm in width and also decreases with age. 22

Clavicle Superior acromioclavicular ligament Coracoclavicular Conoid ligament: Trapezoid

Acromion Coracoacromial ligament Coracohumeral ligament

Coracoid process Greater tubercle Capsular ligament Lesser tubercle Scapula

Tendon of biceps Humerus

Figure 26-1: Anatomy of the acromioclavicular joint. (From Gray H: Anatomy of the human body, Philadelphia, 1918, Lea & Febiger. Internet document available at www.bartleby.com [accessed 2000].)

Chapter 26: Rehabilitation after Conservative and Operative Treatment of Acromioclavicular Joint Injuries

Stabilizing Structures of the Acromioclavicular Joint The acromioclavicular joint is stabilized by both static and dynamic stabilizers. The static stabilizers consist of the acromioclavicular joint capsule, the acromioclavicular ligaments (superior, inferior, anterior, and posterior), the coracoclavicular ligaments (trapezoid and conoid), and the coracoacromial ligament. The middle deltoid and upper trapezius muscles provide dynamic stabilization of the acromioclavicular joint. The joint capsule of the acromioclavicular joint is thin and is supported on all sides by the four acromioclavicular ligaments. This capsule-ligamentous complex is the primary restraint to posterior displacement and posterior axial rotation of the distal clavicle.23 The inferior ligament is difficult to identify on cadaveric dissection and the superior ligament appears more pronounced and thicker. 21,24 Fibers from the superior ligament also tie directly into the fascia of the deltoid and trapezius muscles, adding to the stability of the acromioclavicular joint.21 Klimkiewicz and colleagues25 determined that the superior ligament contributes more than twice the resistance to posterior displacement of the distal clavicle as compared with the posterior ligament. When the integrity of the superior and posterior ligaments is disrupted, such as following injury or surgical resection, posterior restraint is lost and the posterolateral distal clavicle may abut against the anterior surface of the spine of the scapula. The coracoclavicular ligament complex consists of the posteromedial conoid ligament and the anterolateral trapezoid ligament. These two ligaments provide vertical stability to the clavicle. Several studies have examined the insertion locations of these two ligaments on the distal clavicle. 24,26,27 Based on their results, it appears that the insertion of the trapezoid is variable and on average 9 to 16 mm from the articular surface of the distal clavicle. 24,26 This is important to consider when performing a lateral clavicle resection in the patient with acromioclavicular joint pathology. Excessive resection greater than 10 to 15 mm may violate the trapezoid ligament and lead to acromioclavicular instability. The trapezoid ligament prevents axial compression of the clavicle against the acromion with either high or low displacements of the distal clavicle. In contrast, the degree of anterior or superior clavicular restraint provided by the conoid ligament is displacement dependent. Fukuda and colleagues23 have shown that with small displacements the conoid ligament acts as a secondary restraint to the acromioclavicular ligaments in resisting superior translation. However, with greater displacement of the clavicle, the conoid ligament becomes the primary restraint to superior and anterior displacement.23 Recently, other researchers have demonstrated that one cannot consider the actions of the acromioclavicular and coracoclavicular ligaments in isolation. 23,28,29 It appears that the noncontractile stabilizers of the acromioclavicular joint act in a synergistic manner. Injury to one stabilizing structure will shift load onto another structure, which may or may not

493

be able to compensate. This concept is important to consider when determining surgical reconstruction and stabilization of the acromioclavicular joint. Compared with the acromioclavicular joint capsule and the acromioclavicular and coracoclavicular ligaments, the coracoacromial ligament contributes little directly to the stability of the acromioclavicular joint. Salter and colleagues21 demonstrated that the coracoacromial ligament was directly confluent with fibers of the inferior capsule of the acromioclavicular joint and therefore contributes indirectly to joint stability. 30 The coracoacromial ligament also serves as a secondary static glenohumeral joint stabilizer, limiting anterior and inferior motion of the humeral head in individuals with a history of chronic rotator cuff arthropathy.21,30,31 As will be discussed later, the greatest contribution of the coracoacromial ligament to acromioclavicular joint instability has been the role it has played in surgical reconstructions of the acromioclavicular joint.32 Besides static ligamentous stabilization, the acromioclavicular joint receives dynamic stability from the middle deltoid and upper trapezius muscles. They contribute significantly to acromioclavicular joint stability via their attachments to the distal clavicle and superior capsuloligamentous complex. This is apparent in overhead activities, such as pitching, in which these muscles are active during the cocking phase.33,34

Motion at the Acromioclavicular Joint In Inman and co-workers’ classic article35 on the biomechanics of the shoulder joint, it was determined that 40 to 50 degrees of upward rotation occurred at the clavicle during complete elevation of the shoulder. This was determined by the use of a percutaneous pin drilled into the clavicle of a volunteer. They also observed that when the pin was held manually, shoulder elevation was limited to 110 degrees. Inman and co-workers35 concluded that rigid fi xation of the acromioclavicular joint after dislocation would limit postoperative axial rotation. However, surgeons using rigid fi xation methods to stabilize the acromioclavicular joint have reported greater than 165 degrees of elevation postoperatively.9,36,37 To answer this question, Rockwood and colleagues9,37 placed Kirschner wires into both the clavicle and acromion and repeated the original work of Inman and co-workers.35 It was determined that the clavicular pin did indeed rotate 40 to 50 degrees; however, when observing the pins placed in the scapula, a relative difference of only 5 to 8 degrees of rotation occurred.9,37 Clinically this implies that rigid fi xation of the acromioclavicular joint may not cause a loss of shoulder range of motion (ROM). However, the 5 to 8 degrees of motion that remains may explain why, in some cases of rigid fi xation, hardware migration or failure has occurred.31,38,39 In addition one must consider that these in vivo studies were single-subject designs using two-dimensional radiographs for correlation. Recently, new technology allowing three-dimensional analysis of clavicular motion has

494

SEC TION III: SHOULDER ACROMIOCL AVICUL AR JOINT INJURIES

demonstrated that a better understanding of clavicular kinematics is needed.40

MECHANISM OF ACROMIOCLAVICULAR JOINT INJURY Acromioclavicular joint injury can be secondary to either direct or indirect trauma. The most common mechanism of injury is one of direct force (Figure 26-2, A). It is a result of the patient falling on the point of the shoulder onto the ground or a firm object with the arm in an adducted position. This is consistent with the typical mechanism of injury observed in hockey, football, and rugby players.3 The directcontact force drives the acromion medially and inferiorly in relation to the clavicle. If no fracture occurs, the clavicle remains in its normal anatomic position because of an interlocking of the sternoclavicular ligaments as described by Bearn.41 As the scapula is driven further medially and inferiorly, an injury of propagation occurs. First the acromioclavicular ligaments and joint capsule are stretched and torn. If the downward force is large enough, the coracoclavicular ligaments stretch and tear, followed by damage to the deltoid and trapezius muscles, fascia, and overlying skin. Once the acromioclavicular and coracoclavicular ligaments are torn, the integrity of the structural suspension system of the upper extremity on the trunk is lost. The weight of the upper extremity pulls the shoulder downward and away from the distal end of the clavicle. This results in the visible step-off deformity observed during examination of the patient.

A

Indirect trauma, such as a fall on an outstretched arm or elbow, may also result in acromioclavicular injury (Figure 26-2, B). In this case an upward force is transmitted through the humeral head into the acromion process. This disrupts the acromioclavicular ligaments in isolation because the coracoclavicular ligaments are not under tension. With this mechanism of injury, fractures of the acromion and glenohumeral joint and rotator cuff pathology should be ruled out.9

CLASSIFICATION OF ACROMIOCLAVICULAR JOINT INJURIES The pathoanatomy of acromioclavicular dislocation was first classified by Cadenat in 1917.42 This system recognized two types of injuries, complete or incomplete, based on the integrity of the acromioclavicular and coracoclavicular ligaments. In the 1960s, Tossy and co-workers43 and Allman44 expanded this original system to include three categories of injury. This classification scheme divided Cadenat’s incomplete classification into a type I and type II level of injury. In 1984, Rockwood and colleagues37 expanded the Tossy and Allman type III classification into types III through VI based on the direction and amount of clavicular displacement (Figure 263). At present, this is the most accepted classification system in the literature. Table 26-1 describes each of the six types of injury in detail based on ligamentous and radiographic findings.9,11,37,45,46

B

Figure 26-2: Mechanisms of injury to the acromioclavicular joint. A, Classic mechanism of direct downward force onto the point of the shoulder. B, An indirect force through an outstretched hand or elbow may also cause acromioclavicular joint injury. (From Beim GM: Acromioclavicular joint injuries, J Athl Train 35[3]:261-267, 2000.)

Chapter 26: Rehabilitation after Conservative and Operative Treatment of Acromioclavicular Joint Injuries

Type I

495

Type II

A

B Type III

Type III

C

D

Type V

Type IV

F E

Type VI

G Figure 26-3: Classification of acromioclavicular joint dislocations. A, Type I: acromioclavicular ligament sprain. B, Type II: disruption of acromioclavicular joint capsule. C, Type III: disruption of both the acromioclavicular and coracoclavicular ligaments. D, Type III: displacement of the distal clavicle through a tear in the periosteal tube of the clavicle. This may occur in children. Note that the acromioclavicular and coracoclavicular ligaments are still attached to the periosteum. E, Type IV: disruption of the acromioclavicular and coracoclavicular ligaments with posterior displacement of the distal clavicle into the trapezius muscle fibers. F, Type V: disruption of the acromioclavicular and coracoclavicular ligaments with superior displacement of the distal clavicle. G, Type VI: disruption of the acromioclavicular and coracoclavicular ligaments with inferior displacement of the distal clavicle to the coracoid process. (From Beim GM: Acromioclavicular joint injuries, J Athl Train 35[3]:261-267, 2000.)

Intact (sprain)

Torn

Torn

Torn

Torn

Torn

Type I

Type II

Type III*

Type IV

Type V

Type VI†

Torn in subcoracoid type and intact in subacromial type

Torn

Torn

Torn

Intact (sprain)

Intact

CC LIGAMENTS

Detached from distal clavicle

Detached from distal half of clavicle

Detached from distal end of clavicle

Detached from distal end of clavicle

Intact

Intact

Dislocated completely

Dislocated completely

Dislocated completely

Dislocated completely

Less than 4 mm or 40% difference

Some widening

Normal

Clavicle displaced inferior to either acromion or coracoid process; CC interspace is reversed with subcoracoid type or decreased if subacromial type

CC space increases 100% -300%; clavicle may tent the skin

Clavicle is displaced posterior into or through trapezius muscle belly; therefore may appear equal to uninvolved shoulder

CC space increases 25% -100%; clavicle may tent the skin

A downward displacement of scapula may be evident

None

R ADIOGR APHIC FINDINGS WIDTH OF WIDTH OF CC AC JOINT INTERSPACE

*Variants of type III may exist, including pseudodislocation through an intact periosteal tube of the clavicle, physeal injury, or fracture of the coracoid process. †Extremely rare injury requiring severe trauma. Type VI dislocations are often associated with multiple fractures and brachial plexus injury. AC, Acromioclavicular; CC, coracoclavicular.

AC LIGAMENTS

T YPE

DELTOID AND TR APEZIUS AT TACHMENTS

Descriptions of Acromioclavicular Joint Injury by Rockwood Classifications I through VI

TA B L E 26 -1

May be lodged under coracoid

Horizontal and vertical

Horizontal and vertical

Horizontal and vertical

Horizontal

None

CL AVICUL AR INSTABILIT Y

496 SEC TION III: SHOULDER ACROMIOCL AVICUL AR JOINT INJURIES

Chapter 26: Rehabilitation after Conservative and Operative Treatment of Acromioclavicular Joint Injuries

EVALUATION OF THE PATIENT WITH ACROMIOCLAVICULAR JOINT INJURY To be able to correctly classify the type of acromioclavicular injury, determine the appropriate course of nonoperative or operative management, and provide the patient with a prognosis, a thorough initial examination should be performed.

History and Examination The initial interview with the patient should focus on the mechanism of injury. Was it a direct or an indirect force? Did the patient feel structures tear? Was there an audible pop? Does or could the patient have open growth plates? Has the patient injured this shoulder before? Is there a possibility of an associated head or cervical spine injury? Where is the pain located? Gerber and colleagues47 mapped the pain referral pattern of the acromioclavicular joint by injecting subjects’ acromioclavicular joints with a hypertonic saline solution. Subjects reported pain in the area directly over the acromioclavicular joint and also in the anterolateral neck, upper trapezius, and anterolateral deltoid.47 Any reports of paresthesias or other neurologic symptoms should be addressed immediately. Neurovascular status may be compromised in type V and VI injuries. The patient’s age, occupation, level of sports participation, and recreational activities are important aspects to consider when determining the appropriate interventions. To best examine the patient, he or she should be placed in a seated position with clothing removed to completely expose both shoulders. The physical examination should begin with a visual inspection of both shoulders. Observations of the patient from superior, anterior, and lateral views are necessary to determine if a step-off deformity or posterior clavicular displacement is present. A neurovascular evaluation of the patient, including checking distal pulses at the wrist, capillary refi ll in the digits, and gross sensation testing, is performed. If neurovascular status is compromised, it represents a medical emergency and the patient should be transported to a medical facility immediately. Palpation of the bony structures, including the acromion, acromioclavicular joint, clavicle, sternoclavicular joint, and coracoid process, is necessary to test for fractures. Following bony palpation, palpation of both the contractile and noncontractile tissues near the acromioclavicular joint and coracoclavicular interspace should be carried out in order to inspect for swelling, tenderness, and tissue defects. If a dislocation of the acromioclavicular joint is apparent, gentle manual distal clavicular mobilization may be attempted in an effort to assess end feel and determine the degree of instability. This is performed by supporting the ipsilateral arm and manually depressing the distal clavicle.11 In a type IV dislocation, the clavicle has perforated the deltotrapezial fascia and may be hooked or caught in the muscle fibers of the trapezius. In this case, manual reduction of the clavicle will not be possible. In addition, palpation, ROM assessment, and manual muscle

497

testing of the cervical spine and distal upper extremity should be performed to rule out and clear these areas of involvement. Finally, depending on the acuteness and severity of the injury, ROM measurements and specific orthopedic special tests should be carried out. Acromioclavicular joint special tests that have been described in the literature include the crossarm adduction stress test, O’Brien’s active compression test, the Paxinos test, the acromioclavicular anterior-posterior shear test, and the acromioclavicular resisted extension test.48-52 Recent research has examined the usefulness of these tests in assessing acromioclavicular joint pathology and has determined that a combination of several tests is more diagnostic than one special test used in isolation.53

Radiographic Evaluation of the Acromioclavicular Joint Radiographs for evaluation of the injured acromioclavicular joint include anteroposterior, scapular Y, and lateral axillary views.46,54 For anteroposterior views the subject should be standing with the injured arm resting at the side without support. If there are any doubts on the degree of injury, views of the uninjured shoulder could be easily obtained for normative comparison. If the acromioclavicular joint is superimposed on the spine of the scapula or the acromioclavicular radiograph is too dark, a Zanca view with reduced exposure (kilovoltage) is recommended.9,11,31,46,55,56 The Zanca view involves taking a standing anteroposterior view with a 10- to 15-degree cephalic tilt of the radiograph beam.56 Axillary lateral views are required to examine any posterior displacement of the clavicle. This view is taken with the arm abducted 70 to 90 degrees and the radiographic beam directed cranially. In the past, stress radiographs of the acromioclavicular joint have been described. However, investigators have determined that they are largely unnecessary and do not correlate with the surgeon’s decision to perform a surgical reconstruction.57-59 Therefore they are not routinely used in current practice. Other radiographic views may be necessary to adequately examine the patient with suspected acromioclavicular pathology. If the patient has a normal coracoclavicular interspace but a complete acromioclavicular dislocation, a fracture of the coracoid should be suspected. A Stryker notch view is recommended in this situation. 31,60 In addition, patients with open growth plates or individuals who have suffered severe or multiple trauma may require further imaging studies. In these cases and others, additional radiographic views, computed tomography, or magnetic resonance imaging may be necessary to rule out physeal injuries, occult fractures, and other soft tissue and bony lesions.60,61 Normal radiographic values vary significantly for the acromioclavicular joint. In his review of 1000 cases, Zanca 56 reported a variable acromioclavicular joint width of between 1 and 3 mm. However, because the joint width diminishes with age, a width of 0.5 mm in an individual greater than 60 years of age should be considered normal.19 The coracoclavicular interspace also exhibits variability in the general

498

SEC TION III: SHOULDER ACROMIOCL AVICUL AR JOINT INJURIES

population. The original work of Bosworth,62 reporting a distance of 11 and 13 mm, is commonly cited in the literature. The variability in these joint and interspace numbers illustrates the importance of comparison with the contralateral acromioclavicular joint whenever possible.

TREATMENT OF ACROMIOCLAVICULAR JOINT INJURIES Review of the current literature reveals that in most cases, type I and II injuries are treated conservatively and type IV, V, and VI injuries are treated operatively. Treatment of type III injuries remains controversial, and several opinions exist on whether immediate surgery, delayed surgery, or conservative treatment in type III injuries is appropriate. Detailed treatment interventions for each classification of acromioclavicular joint injury are described here. It is important to recognize that acromioclavicular injuries occur on a continuum and the severity of injury will vary within the six different Rockwood classifications.

Type I Type I injuries involve minimal damage to the acromioclavicular joint and surrounding structures. They can be treated conservatively with a sling, cryotherapy, relative rest, and nonsteroidal antiinflammatory drugs (NSAIDs). The sling is used to reduce stress to the joint for several days; length of use is dictated by the patient’s symptoms. Most athletes with type I acromioclavicular injuries return to full activities 2 weeks from the date of injury.9,11,31 An over-the-counter orthosis (Figure 26-4) or a soft felt or gel doughnut pad may be used under shoulder pads in football or hockey players to

reduce the risk of reinjury from a second impact to the acromion.54,63 Full pain-free active ROM, no joint tenderness with palpation, and strength within 10% of the uninvolved shoulder are criteria that may be used in the decision to return to sport activities. It is suspected that many athletes with type I injuries never seek medical attention.64 Refractory pain following type I acromioclavicular injuries is usually a result of degenerative changes within the joint. This may be a result of the most recent injury or a culmination of a history of minor injuries, physical labor, or sports participation. In any case, if pain remains after several weeks of analgesics and rest, a steroid injection into the acromioclavicular joint may reduce discomfort.65 If physical therapy, steroid injections, and active rest fail to resolve the patient’s pain and loss of function, a distal clavicle excision may be performed. The open distal clavicle resection originally described by both Mumford and Gurd over six decades ago has been the “gold standard” for surgical treatment of acromioclavicular joint pathology.66-68 In the past two decades arthroscopic resection of the distal clavicle has also become popular and has been shown to have comparable outcomes.69-74 Both open and closed procedures require adequate clavicle excision to decompress the acromioclavicular joint (4 to 10 mm) in order to avoid leaving bone to impact the joint or removing too much bone and risking joint instability.68 The choice of an open or closed distal clavicle excision depends on the experience and training of the surgeon, as well as individual patient characteristics. Both arthroscopic resection and open resection of the distal clavicle have allowed patients to return to physically demanding occupations or sports with minimal loss of strength or upper extremity ROM.63,75

Type II

Figure 26-4: An example of pad used by athletic trainers to protect the acromioclavicular joint in contact sports. (Photo of the IMPACT AC Pad was provided courtesy of Arthron, Inc., at www.sportsinjuries.com.)

Type II injuries involve disruption of the acromioclavicular joint capsule and ligaments resulting in widening of the joint space and a downward displacement of the scapula (see Figure 26-3 and Table 26-2). The soft tissue trauma sustained in type II injuries is more extensive than in type I injuries. Therefore the initial time frame of immobilization and rest of the involved extremity is longer. As with a type I injury, initial treatment involves protection with a sling, relative rest, and analgesics.9,32,37,44,64,76 Unlike type I injuries, type II injuries may demonstrate a visible step-off deformity and more degenerative changes because of the increased sagittal plane instability caused by disruption of the acromioclavicular capsuloligamentous complex.76,77 A supervised rehabilitation program is necessary to ensure that goals of return to preinjury levels of strength and function are accomplished. Walsh and colleagues78 noted that deficits in horizontal adduction strength may persist as late as 3 years following a type II injury. A supervised rehabilitation program with objective strength testing throughout the patient’s rehabilitation may help prevent and measure objectively these types of chronic strength deficits.

Chapter 26: Rehabilitation after Conservative and Operative Treatment of Acromioclavicular Joint Injuries

499

TA B L E 26 -2

Nonoperative Rehabilitation Protocol for Type II and Type III Acromioclavicular Joint Injuries (Phases I and II)

Goals (May not progress to next phase until goals are met)

PHASE I: PROTEC TION AND MOTION PHASE

PHASE II: INTERMEDIATE PHASE (INITIAL STRENGTHENING)

WEEK S 1 TO 2 FOR T YPE II OR WEEK S 1 TO 3 FOR T YPE III*

WEEK S 3 TO 4 FOR T YPE II OR WEEK S 4 TO 6 FOR T YPE III

Full pain-free scaption† AROM to approximately 140 degrees

Full pain-free AROM equal to the contralateral side

Equal lateral rotation ROM to contralateral side Measured in a seated position with arm in 30 degrees of abduction Minimal pain and tenderness with palpation of the AC joint

No pain or tenderness with palpation Less than 25% deficit with handheld dynamometer testing of middle deltoid and upper trapezius

Able to perform pain-free maximal multiangle (less than 90 degrees) isometric contractions in glenohumeral flexion, extension, abduction, adduction, medial rotation, and lateral rotation

Less than 10% deficit to contralateral shoulder with testing of medial and lateral rotators

Avoid supine ROM (see text),

Avoid supine exercises (see text)

No heavy lifting, pushing/pulling

No heavy lifting, pushing/pulling

No contact sports

No contact sports

No resisted overhead motion greater than 90 degrees

No resisted overhead motion greater than 90 degrees

Restrict horizontal extension and flexion ROM

No resisted horizontal extension and flexion

No PROM/AAROM/AROM into pain

Avoid military or bench press

Avoid traction through upper extremity

Avoid traction through upper extremity

Fit with AC (Kenny-Howard) sling for comfort and to prevent downward displacement of scapula

Wean from splint as tolerated

Precautions

Interventions Protection

Taping for pain relief and protection

Taping for pain relief and protection (not done for anatomic reduction) Modalities

Cryotherapy Electrical stimulation modalities for pain control and neuromuscular reeducation

Cryotherapy following exercise Electrical stimulation modalities for pain control and neuromuscular reeducation May use heat for warm-up, stretching, and pain relief

ROM

Elbow and wrist AROM PROM in seated or side-lying position Begin AAROM exercises with wand or T-bar Begin gentle AROM exercises in pain-free ROM

Full AROM, all planes

500

SEC TION III: SHOULDER ACROMIOCL AVICUL AR JOINT INJURIES

TA B L E 26 -2

Nonoperative Rehabilitation Protocol for Type II and Type III Acromioclavicular Joint Injuries (Phases I and II)—cont’d

Strengthening

PHASE I: PROTEC TION AND MOTION PHASE

PHASE II: INTERMEDIATE PHASE (INITIAL STRENGTHENING)

WEEK S 1 TO 2 FOR T YPE II OR WEEK S 1 TO 3 FOR T YPE III*

WEEK S 3 TO 4 FOR T YPE II OR WEEK S 4 TO 6 FOR T YPE III

Initiate trial of submaximal shoulder isometrics in all planes and at multiple angles at the beginning of week 2

Initiate trial of short-arc isotonic strengthening exercises

Progress intensity of isometrics as tolerated by symptoms and visual analog scale pain rating less than 2/10 or 3/10

Progress resistance as defined by symptoms, scapular control, and quality of motion

Forearm and hand intrinsic strengthening with putty or squeeze ball Begin pain-free AAROM and AROM scapular retraction and protraction May continue lower extremity and uninvolved upper extremity exercises Initiate core trunk stability exercises

Progress ROM as tolerated by symptoms

Strengthening exercises should include the following exercises with individualized ROM modifications based on severity and irritability of patient’s injury: Seated chest press with plus (limit ROM) Seated row (limit ROM) Scaption limited to 90 degrees elevation Bent-over horizontal abduction (no resistance, AROM only) Shoulder flexion limited to 90 degrees elevation Shoulder shrugs (avoid traction force) Lateral and medial rotation strengthening Biceps and triceps strengthening (avoid traction force) Core trunk stability exercises With all dumbbell exercises, care should be taken to avoid traction force through upper extremity

Neuromuscular reeducation exercises

Submaximal rhythmic stabilizations Slow speed Known pattern Submaximal resistance Perform in side-lying position

Assessment Clinical testing

Progress side-lying rhythmic stabilizations in all planes of the scapula and up to 90 degrees scaption of the glenohumeral joint Moderate speed More random pattern Moderate resistance

Weekly AROM measurements

Weekly AROM measurements

Seated isometric strength tests end of week 2 (type II) and end of week 3 (type III)

Strength testing at end of phase Isokinetic testing Handheld dynamometer testing

*The number of weeks suggested in this table is only a guideline. Determination of when to advance the patient to the next phase of the protocol is based on objective measurements and reported symptoms. Some patients may advance faster or slower than others. Quality of injured tissue, patient characteristics, and clinical testing and measurements should determine protocol advancement. †Elevation in the plane of the scapula. AAROM, Active-assistive range of motion; AC, acromioclavicular; AROM, active range of motion; PROM, passive range of motion; ROM, range of motion.

Chapter 26: Rehabilitation after Conservative and Operative Treatment of Acromioclavicular Joint Injuries

Immobilization, Strapping, and Bracing after Acromioclavicular Injury A review of the literature reveals that nonoperative treatment of type II and III acromioclavicular joint injuries has involved two distinct treatment protocols.9 The first protocol involves an attempted closed reduction of the distal clavicle using a sling and harness, adhesive strapping, crotch loops or casts, or plaster casts for a prolonged period of time. The purpose of these acromioclavicular braces is to maintain continuous pressure under the elbow and on the top of the distal clavicle for approximately 6 weeks to accomplish a closed reduction of the clavicular deformity. A current acromioclavicular sling, or Kenny-Howard sling, is shown in Figure 26-5. The difficulty with this type of prolonged bracing is twofold. First, compliance in wearing the orthosis is usually a problem. Second, authors have reported episodes of skin breakdown and nerve compression injuries from prolonged brace use.79 In the second protocol, considered the standard of care today, closed anatomic reduction is not attempted. Instead, the residual deformity is ignored and short-term sling use and early ROM are recommended. This method has been referred to in the literature as one of “skillful neglect.” 9,80,81 Acromioclavicular slings and taping may still be used in type II and III injuries following a “skillful neglect” protocol. Here the purpose of the acromioclavicular sling and taping becomes one of pain relief versus anatomic reduction. In addition to

Figure 26-5: Acromioclavicular (Kenny-Howard) sling. (Courtesy of dj Orthopedics, Inc., www.djortho.com/products/ProCare/details. asp?id=268.)

501

bracing, taping may also help reduce the patient’s symptoms. Shamus and Shamus82 have described a taping technique that significantly reduced pain and improved function in two patients following acromioclavicular injury.

Type III The management of type III acromioclavicular joints remains controversial. Type III injuries involve complete disruption of the acromioclavicular joint capsule and coracoclavicular ligaments. Instability is present in both the horizontal and vertical planes. It is also important to recognize that a type III classification is also the classification that represents a transition from conservative to surgical care. One hypothesis as to why the controversy exists is related to the sensitivity of the classification system. Perhaps subcategories of type III injuries need to be developed. In 1974, Powers and Bach83 documented surgical intervention in 92% of 116 Tossy type III injuries. The surgical procedure of choice was pin fi xation of the acromioclavicular joint. In contrast, in 1992, a survey study by Cox84 reported that 72% of residency chairpersons and 86% of professional team physicians were recommending nonoperative treatment in Rockwood type III injuries. Cox’s survey also demonstrated that surgical fi xation had also changed, with the majority of surgeons using fi xation between the clavicle and coracoid. In 1998, Phillips and colleagues85 performed a meta-analysis review of the literature. They found a total of 24 research studies that met their inclusion criteria. Only five of these studies involved a direct comparison of nonsurgical and surgical treatment. However, these studies are difficult to interpret because of the large number of different surgical interventions described and the differences in each study’s postoperative protocol and long-term follow-up. Regardless, Phillips and colleagues85 were able to review 1171 patients, 833 of whom underwent acromioclavicular surgery. They determined that in terms of overall satisfaction, ROM, and strength, conservative treatment is recommended over surgical management of type III injuries. The only advantage of surgery according to their report was the potential reduction of the clavicular step-off deformity.85 Recently, Bradley and Elkousy86 have written a concise review of the current literature surrounding this controversy. They reiterate that no perfect prospective randomized study currently exists that demonstrates the superiority of surgical or nonsurgical treatment. They, like Phillips and co-workers,85 state the need for a large multicenter trial that has enough statistical power to resolve this continuing controversy.85,86 Other issues surrounding the decision for operative management include timing of the surgery and the patient’s occupation or sport. Larsen and colleagues87 found operative treatment to be best for patients who perform heavy physical work. Several authors have suggested that acute surgical treatment is warranted in cases where the injury involves the dominant arm of a professional pitcher.9,37,63 On the other

502

SEC TION III: SHOULDER ACROMIOCL AVICUL AR JOINT INJURIES

hand, studies demonstrate that full return to sport in this elite population is possible following conservative treatment.88,89 Timing of acromioclavicular surgery in type III injuries is also an important consideration.90,91 Weinstein and colleagues92 published a retrospective paper comparing early (less than 3 weeks) and late (greater than 3 weeks) surgical intervention in type III injuries. A modified Weaver-Dunn procedure using suture augmentation of the coracoclavicular interspace was the most common procedure used. Their results demonstrated a trend toward improved results in the early intervention group and a significant improvement in satisfaction when the early group was compared with patients who underwent surgery greater than 3 months after injury.92 In summary, the research literature has yet to provide sufficient evidence supporting the benefit of operative treatment over conservative treatment. However, general consensus appears to be that regardless of occupation or sport, conservative treatment is suggested for the fi rst 12 weeks. If substantial disability, deformity, or loss of function is present at this time, surgical intervention is warranted.86 Unlike a type II injury, in which distal clavicle excision is the standard of care, type III injuries also require stabilization of the distal clavicle. Occupation, sport, and surgical timing are other important variables to consider when making the decision to aggressively or conservatively manage these injuries.

Types IV, V, and VI Because of the marked persistent displacement of the distal clavicle and clavicular stripping of the deltotrapezial fascia, operative intervention is generally recommended to a patient with a type IV, V, or VI injury.9,31,37,64,92

NONOPERATIVE MANAGEMENT OF ACROMIOCLAVICULAR JOINT INJURY Conservative treatment of type II and III acromioclavicular injuries requires the patient’s participation in a supervised rehabilitation program. The number of rehabilitation visits depends on the severity of the initial injury and the patient’s ability to meet the rehabilitation goals. A four-phase rehabilitation program for the nonoperative treatment of acromioclavicular joint injuries has been described by Gladstone and colleagues.91 Phase I consists of pain control and immediate protected ROM. Isometrics are also initiated in this phase. During phase II, exercises are advanced with the addition of isotonic strengthening exercises. Phase III of the protocol initiates dynamic strengthening exercises to ensure the patient reaches goals of returning strength, power, endurance, and neuromuscular control to a preinjury level. Finally, phase IV returns the athlete or laborer to his or her prior sport or occupation with sport-specific drills.91 The goals of any acromioclavicular rehabilitation

program are to achieve a pain-free shoulder with full ROM, full strength, and no functional limitations. However, one should realize that the demands placed on the rehabilitated shoulder after discharge from therapy will vary significantly from patient to patient. What is satisfactory for the sedentary 30-year-old computer programmer may not be a good outcome for the 60-year-old carpenter or the 22-year-old collegiate pitcher. Therefore rehabilitation protocols will have to be modified on an individual basis to best meet the needs of each patient. This illustrates the importance of determining and discussing the rehabilitation goals with the patient during his or her initial evaluation. A sample rehabilitation protocol for the nonoperative treatment of type II and III acromioclavicular joint injuries is shown in Tables 26-2 and 26-3.

Davies Resistive Exercise Continuum The issue of determining when to progress the patient’s ROM and strength training exercises is both an art and a challenge. All too often, clinicians rely solely on past experience and “cookbook”-type protocols when working with a patient. This type of method lacks significant evidence and objective measurement. To reduce the guesswork involved in progressing a patient through a resistive exercise program, Davies93 has developed a resistive exercise continuum. This continuum can assist the rehabilitation professional in advancing the patient’s exercise load and intensity in a logical, systematic manner (Figure 26-6).93 The patient’s progression through the resistive exercise continuum is dictated by continual reassessment of the patient’s subjective symptoms and objective measurements of ROM and strength.93 Davies recommends continually monitoring these symptoms and measurements during the rehabilitation program. To advance a patient’s program, a trial treatment of the desired exercise is administered. The following is an example of how the continuum might be used for a patient with an acromioclavicular injury. If the patient is able to complete 100% of his or her maximal external rotation isometrics on Monday without difficulty, on Wednesday a trial of 50% maximal isometrics and 50% short-arc isokinetics is performed. If isokinetic equipment is not available, a trial of short-arc isotonic exercise is performed instead. After this trial treatment the patient is reassessed using a subjective, objective, assessment, and plan (SOAP) format. If there is no increase in symptoms with the trial of short-arc isotonic external rotation, on Friday, during the patient’s next visit, he or she will complete 100% of the external rotation exercise using the trial resistance and ROM from Wednesday’s treatment. However, if the patient has any adverse effects during or after the new exercise, the patient continues his or her current exercise program at the prior level of intensity and load. The new exercise is withheld and not added until after the next successful trial.93

Chapter 26: Rehabilitation after Conservative and Operative Treatment of Acromioclavicular Joint Injuries

503

TA B L E 26 -3

Nonoperative Rehabilitation Protocol for Type II and III Acromioclavicular Joint Injuries (Phases III and IV)

Goals (May not progress to next phase until goals are met)

PHASE III: DYNAMIC STRENGTHENING PHASE

PHASE IV: RE TURN TO AC TIVIT Y PHASE

WEEK S 5 TO 6 FOR T YPE II OR WEEK S 6 TO 8 FOR T YPE III*

WEEK S 7 TO 8 FOR T YPE II OR WEEK S 8 TO 10 FOR T YPE III

No pain or tenderness with palpation

No functional deficits when compared with uninvolved extremity

Less than 10% deficit with handheld dynamometer testing of deltoid and upper trapezius Ability to perform several repetitions of specific sport task without pain or instability

Isokinetic testing of medial and lateral rotation and horizontal flexion and extension within 10% of normative data and contralateral extremity

No observed scapular dyskinesias

Independent in home strengthening program Discharge from rehabilitation

Precautions Avoid supine ROM (see text) Caution when performing military or bench press

Avoid excessive traction through upper extremity with repetitive work or sport activity

Suggest modifying ROM and arc of motion to limit AC joint stress Suggest alternative exercises No heavy lifting, pushing/pulling No contact sports Avoid traction through upper extremity Interventions Protection Modalities

ROM

Padding and protection for work or sport if necessary

Padding and protection for work or sport if necessary

Cryotherapy as needed following exercise

Cryotherapy as needed following exercise

May use heat for warm-up, stretching, and pain relief

May use heat for warm-up, stretching, and pain relief

Begin some repetitive overhead motion without resistance (only if necessary for work tasks or sport)

No changes

Establish home program of stretching if necessary to maintain ROM Strengthening

Progress resistance and increase ROM of all exercises from phase II

Continue with a core program based on specific demands of vocation or sport

Progress to strengthening in all planes of motion based on symptoms

Use periodization principles

Begin supervised horizontal extension and flexion resistance exercises Progress resistance based on trial treatments with short-arc isotonics Progress to overhead strengthening (90/90 position) based on trial treatments with short-arc isotonics

504

SEC TION III: SHOULDER ACROMIOCL AVICUL AR JOINT INJURIES

TA B L E 26 -3

Nonoperative Rehabilitation Protocol for Type II and III Acromioclavicular Joint Injuries (Phases III and IV)—cont’d

Neuromuscular reeducation exercises

PHASE III: DYNAMIC STRENGTHENING PHASE

PHASE IV: RE TURN TO AC TIVIT Y PHASE

WEEK S 5 TO 6 FOR T YPE II OR WEEK S 6 TO 8 FOR T YPE III*

WEEK S 7 TO 8 FOR T YPE II OR WEEK S 8 TO 10 FOR T YPE III

Advance to diagonal (PNF) patterns of motion

Advance exercises from phase III by decreasing clinician control and increasing exercise intensity

Increase speed and intensity of exercises Initiate submaximal upper extremity plyometrics using minimal resistance and control parameters of bilateral to unilateral, partial to full ROM, low to high speed, and low to high repetitions and resistance

Activity specific

Advance plyometrics drills to incorporate demands of sport or work activity

Initiate work conditioning and simulated work tasks

Sport-specific testing

Perform work-site evaluation

Continue return to throwing program

Trial return to sport or activity

Initiate return to throwing program Initiate sport-specific drills Initiate preparation for closed kinetic chain upper extremity functional test Assessment Clinical testing

Strength testing at end of phase Assessment of abilities or deficits with work or sport activities (these deficits will be focus of phase IV)

Closed kinetic chain upper extremity test (see text)

*The number of weeks suggested in this table is only a guideline. Determination of when to advance the patient to the next phase of the protocol is based on objective measurements and reported symptoms. Some patients may advance faster or slower than others. Quality of injured tissue, patient characteristics, and clinical testing and measurements should determine protocol advancement. AC, Acromioclavicular; PNF, proprioceptive neuromuscular facilitation; ROM, range of motion.

Precautions during Rehabilitation of the Patient with Acromioclavicular Injury Several precautions should be followed during the rehabilitation of a patient with an acute acromioclavicular injury or a patient following surgical reconstruction. The majority of these precautions are straightforward and are listed in Tables 26-2 through 26-5. However, two recommendations or clinical pearls specific to the patient with an acromioclavicular injury need to be explained in more detail. Because of the “scapuloclavicular” coupled motion described earlier, active or passive ROM exercises with the patient in a supine position should be avoided. In supine, the patient’s body weight prevents scapular motion. This results in greater clavicular rotation occurring at the acromioclavicular joint. Therefore it is suggested that all ROM activities

initially be performed in a side-lying, seated, or standing position. The second recommendation involves the avoidance of allowing traction forces through the upper extremity. For example, during dumbbell shoulder shrugs to isolate the upper trapezius muscle, the patient will often let the dumbbell apply a distraction force through the upper extremity. Patients require verbal cues to isometrically set the muscles to support the weight before lifting it off the table or weight rack (Figure 26-7). Resting the weight on an adjustable highlow treatment table can also help the patient begin and end each repetition with the weight on the table to avoid the inferior traction force. The patient should also be discouraged from carrying the weight around between sets and allowing distraction forces on weight machines such as the lat pulldown or seated row machines.

Chapter 26: Rehabilitation after Conservative and Operative Treatment of Acromioclavicular Joint Injuries

STAGES: I Multiple angle isometrics sub-maximal

IV Short arc isotonics

VII Full ROM isotonics (if not contraindicated)

II Multiple angle isometrics maximal

V Short arc isokinetics maximal

III Short arc isokinetics sub-maximal

% of Exercise Effort

VI Full ROM isokinetics sub-maximal

VIII Full ROM isokinetics maximal

505

Exercise Program

100%

Submaximal multiple angle isometrics (SMAI) subjective, objective, assessment plan (SOAP) trial treatment (TT) of maximal multiple angle isometrics (MMAI).

50/50

SMAI + MMAI SOAP

100%

MMAI SOAP TT-Submaximal short arc isokinetics (SSAI)

50/50

MMAI + SSAI SOAP

100%

SSAI SOAP TT-Maximal Short Arc Isokinetics (MSAI) and/or Short Arc Isotonics (SAIsot) SOAP

50/50

SSAI + MSAI SOAP

100%

MSAI SOAP TT-Submaximal Full ROM Isokinetics (SFROMI) SOAP

50/50

MSAI + SFROMI SOAP

100%

SFROMI SOAP TT-Maximal Full ROM Isokinetics (MFROMI) SOAP (Full ROM Isotonics here, if not contraindicated)

50/50

100%

SFROMI + MFROMI SOAP MFROMI SOAP

Figure 26-6: The Davies resistive exercise progression continuum. (From Davies GJ: A compendium of isokinetic exercise, ed 4, Onalaska, WI, 1994, S & S Publishing.)

Return to Activity or Sport When is the patient ready for the heavy demands of physical labor or sport? The requirements of the patient’s occupation or sport should be considered early in the rehabilitation process. Knowing the repetitive physical demands that will be placed on the patient helps the physician and therapist determine when partial or full return to activity may occur. To decrease the risk of reinjury, a qualitative assessment of strength and function is required. Evaluation of strength and power may be completed using a handheld dynamometer or a computerized isokinetic dynamometer if available. With this instrumentation, measurements of isometric strength, peak torque, agonist/antagonist muscle ratios, and other strength-related criteria may be carried out. Comparison

with the contralateral upper extremity and with normative data from the current literature is used to interpret the results.93-95 If the patient demonstrates minimal or no deficits with strength testing, he or she may advance to sport-specific testing. Sport- or occupation-specific testing of the patient should include tests that simulate actual tasks that place the rehabilitated extremity in positions of stress. It is up to the clinician and physician to determine what sport-specific tests are appropriate, reliable, and valid for each individual patient. The closed kinetic chain upper extremity stability test originally described by Goldbeck and Davies96 is an excellent example of a reliable clinical test that is appropriate for evaluation of patients following acromioclavicular joint injury and rehabilitation. The test involves placing two pieces of athletic

506

SEC TION III: SHOULDER ACROMIOCL AVICUL AR JOINT INJURIES

A

B

C

Figure 26-7: Example of upper trapezius exercise (shoulder shrug) performed with care being taken to avoid traction through upper extremity. A, Isometric contraction before lifting dumbbell off table. B, Maintaining isometric contraction during exercise. C, Picture showing improper form of allowing traction through upper extremity when weight is at side.

tape 3 feet apart on the floor. The subject assumes a push-up position with each hand placed on each piece of tape. Verbal cues are used to remind the subject to keep the legs and trunk as parallel to the floor as possible. The examiner shouts “Go!” and the subject, maintaining good posture, must remove one hand from the floor, cross midline to touch the opposite piece of tape, and then return the hand back to the original tape line (Figure 26-8). The other hand is then removed and the process is repeated. This alternate sequencing of horizontal extension and flexion is repeated for 15 seconds and the number of touches is recorded on a data sheet. Three trials with rest intervals of 45 seconds are performed. Goldbeck and Davies96 retested the subjects a week apart and found a reliability interclass coefficient of 0.92. The subjects in this reliability study were 20-year-old collegiate football players who scored mean values of 27.8 and 27.9 touches on the test and retest, respectively. In contrast, Davies97 has performed retrospective analyses of clinical data and found averages closer to 21 touches in males and 23 touches in females in the high school–age and college-age athletic populations following upper extremity rehabilitation (Figure 26-9). Females have higher scores because they were tested in a modified push-up position. Further studies are needed to establish normative data for different gender, age, occupational, and sport-specific groups. Because of the specific stresses this test applies to the acromioclavicular joint, qualitative assessment of the patient’s confidence or apprehension during the test is as important to assess during testing as the patient’s quantitative test score.

Serial strength and functional testing of the patient during the rehabilitation protocol is an important tool to determine when return to activity is safe and appropriate. This format also allows the patient to be part of the rehabilitation team because he or she knows from day 1 what must be accomplished in order for discharge from rehabilitation to occur.

OPERATIVE MANAGEMENT OF ACROMIOCLAVICULAR JOINT INJURY The decision to proceed surgically must be carefully discussed with the patient. Surgical intervention is used when it demonstrates a superior clinical outcome to conservative treatment or when nonoperative treatment has been attempted and failed. Furthermore, once the decision to operate has been made, a specific procedure has to be chosen. Like the previous decision, this decision is based on many factors: the surgeon’s expertise and preferences, the quality of the injured tissues, the patient’s health status, the patient’s ability to adhere to a supervised postoperative rehabilitation program, and the patient’s anticipated activity level following surgery. This being said, one realizes that no single procedure is adaptable to fit all patients. Rather, the choice to pursue surgery and what procedure to perform is individualized. Over 60 different surgical procedures have been described to correct acromioclavicular joint instability.98 The goal of all these procedures has been to statically or dynamically reproduce or reconstruct the anatomic restraints of the acromioclavicular joint. To logically discuss the history, surgical

Chapter 26: Rehabilitation after Conservative and Operative Treatment of Acromioclavicular Joint Injuries

A

B

C

D

507

Figure 26-8: Illustration of closed kinetic chain upper extremity functional test. A, Start position with subject in push-up position. B, Subject crosses one arm over to touch opposite piece of tape. C, Return to start position. D, Subject crosses opposite arm over.

technique, and reported outcomes of these different procedures, they may be broadly categorized into three different types as described by Kwon and Lannotti.99 These types are as follows: primary fi xation across the acromioclavicular joint, dynamic stabilization of the joint via muscle transfer, and secondary stabilization of the acromioclavicular joint by re-creating the link between the distal clavicle and coracoid with autograft or synthetic materials. One should understand that these categories are not mutually exclusive. It is common to see procedures from one category combined with another in order to best reproduce the mechanical stability of the original structures.

Primary Fixation across the Acromioclavicular Joint Historically, surgical fi xation of the acromioclavicular joint has been performed with the use of Kirschner wires, Steinman pins, hook plates, screws, and other hardware.100-107 Often this use of hardware to transfi x the acromioclavicular joint was done in conjunction with repair of the superior acromioclavicular ligament.108 Neviaser107 stabilized the

acromioclavicular joint with a pin and then detached the coracoacromial ligament from the coracoid and swung it up over the distal clavicle. A careful review of these studies reveals that no single fi xation device has demonstrated superiority over another. Furthermore, all of the aforementioned papers report on relatively small numbers of subjects, and follow-up differs greatly between reports.99 These fi xation devices were placed either percutaneously or during an open procedure. The thin shape of the acromion and the curved clavicle also make this type of procedure technically demanding. In addition, migration of the pins or wires following surgical fi xation may have disastrous and possibly fatal consequences.38,39,55,109-111 Therefore in most cases the hardware is removed after 6 to 8 weeks of healing. Unfortunately, this means a second invasive procedure that can be extensive. Because of the potential risks of infection, hardware migration, and often the requirement of a second surgery, primary fi xation of the acromioclavicular joint with pins or wires has fallen by the wayside with the development of other techniques, biodegradable fi xation devices, and a greater emphasis on coracoclavicular ligament repair or reconstruction.

508

SEC TION III: SHOULDER ACROMIOCL AVICUL AR JOINT INJURIES

Closed Kinetic Chain Upper Extremity Stability Test Patient Name: Clinician: Diagnosis:

DOB: Date of Injury / Surgery: Ht:

in

Wt:

lbs

Procedure: 1. Subject assumes push-up (male) or modified push-up (female) position. 2. Subject has to move both hands back and forth from each line as many times as possible in 15 sec. Lines are three feet apart. 3. Count the number of lines touched by both hands. 4. Begin with one submaximal warm-up. Repeat 3 times and average. 5. Normalize score by following formula: Score = Avg. # of lines touched Height (in) Determine power by using following formula: (68% body weight = trunk, head and arms) Power = 68% weight x avg. # of lines touched 15 sec Data Collection Area Date of Test: Trial 1

2

3

Mean

Date of Test: Trial 1

Touches:

Touches:

Score:

Score:

Power:

Power:

Date of Test: Trial 1

2

3

Mean

Date of Test: Trial 1

Touches:

Touches:

Score:

Score:

Power:

Power:

Date of Test: Trial 1

2

3

Mean

2

3

Mean

Normative Data 2

3

Mean

Touches: Score: Power:

Average # of Touches

Males

Females

21.0 touches

23.0 touches

Figure 26-9: Data sheet for closed kinetic chain upper extremity stability test.

Dynamic Stabilization Dynamic stabilization involves transferring a musculotendinous unit to the inferior surface of the distal clavicle. This results in the creation of force that dynamically depresses the clavicle.112-116 This transfer is accomplished by removing the tip of the coracoid process with its attachments to the short head of the biceps tendon and coracobrachialis intact and fi xing it to the bottom of the distal clavicle. Berson and col-

leagues114 reported satisfactory results in 29 patients with both acute and chronic dislocations. Brunelli and Brunelli116 have also reported good functional results in 51 patients following a dynamic transfer procedure in which the short head of the biceps tendon is transferred to the clavicle surface directly above the coracoid. Dynamic stabilization of the acromioclavicular joint remains an unpopular procedure. This is due to the concerns of whether the transferred musculotendinous unit can maintain the desired anatomic stabil-

Chapter 26: Rehabilitation after Conservative and Operative Treatment of Acromioclavicular Joint Injuries

ity during rehabilitation and return to activity.99 In addition, several incidents of transient injury to the musculocutaneous nerve have been documented.117

Secondary Stabilization Secondary stabilization of the acromioclavicular joint is carried out by surgically reconstructing or re-creating the vertical restraint of the coracoclavicular ligaments. The incision required for surgical exposure during open coracoclavicular reconstruction is very similar to the incisions used for primary fi xation of the acromioclavicular joint. The opening incision is made along Langer’s line, but in the case of secondary stabilization, the incision is longer, extending from the posterior aspect of the distal clavicle down to the coracoid process (see Figure 26-10). The deltoid muscle is then released along its bony attachments as much as necessary to provide adequate visualization. Once this is completed, the anterior deltoid can be split parallel to the muscle fibers and the underlying bursal tissue removed. This results in exposure of the distal clavicle, coracoacromial ligament, and coracoid process. Clinicians involved in the patient’s rehabilitation should be aware of how much the deltoid was taken down and the quality of the reattachment during closure. This is one of the most important factors in determining the initial intensity of the rehabilitation program and cannot be overemphasized. Fixation of the clavicle to the coracoid process using a lag screw was originally described by Bosworth in 1941.62 It is generally accepted that screw fi xation be completed with surgical exposure. In 1989, Tsou118 reported a 32% failure rate with percutaneous cannulated screw coracoclavicular fi xation. Subsequent modifications have combined the screw fi xation with open exploration and primary repair of the acromioclavicular and coracoclavicular ligaments.9 Biomechanical studies have revealed that it is important that the lag screw purchase on the coracoid is bicortical. If the lag screw penetrates only the superior surface of the coracoid, the strength of this fi xation method is significantly inferior to other forms of coracoclavicular fi xation. However, if the lag screw is placed in a bicortical manner, the resultant fi xation strength is significantly greater than that of the uninjured coracoclavicular ligaments.119,120 The drawback of using a lag screw for fi xation is that a secondary surgery for hardware removal is generally required after healing has occurred. Also, a recent study has shown that the fi xation provided by the screw increases contact forces in the acromioclavicular joint by 200%.121 Therefore use of a lag screw without distal clavicle excision is not recommended. Coracoclavicular loops or slings also have been used to provide secondary stabilization of the acromioclavicular joint. Under tension the material is either looped or anchored between the coracoid and clavicle. These coracoclavicular cerclage or loop fi xation techniques were used in isolation in the past.101,122 However, today they are commonly used in combination with the modified Weaver-Dunn procedure

509

described later. Materials such as wire,101 Dacron,101,122,123 Merselene tape,124,125 resorbable braided polydioxanonsulphate (PDS) bands,124-127 Gore-Tex,128,129 and tendon autografts31,130-132 all have been used with success. Wire loops are no longer used in order to avoid the secondary surgery for hardware removal and limit the consequences of hardware migration. Some care needs to be taken when placing the suture or tendon loops around the coracoid process and the distal clavicle to achieve adequate reduction of the acromioclavicular joint. It is recommended that the inferior loop is placed around the absolute base of the coracoid process whereas the superior loop is passed through drill holes in the anterior one third of the distal clavicle.99 There are some concerns about the technical difficulty and risk of neurovascular injury when passing the loop material around the base of the coracoid. To avoid this issue, some surgeons have reported success with the use of suture anchors instead of suture loops.133,134 In all these coracoclavicular cerclage procedures there is a tendency for the clavicle to be displaced anteriorly relative to the acromion. This is because anatomically the clavicle does not set directly above the coracoid process. Baker and co-workers135 examined three variations of clavicular drill hole placement and determined that joint congruity improved as the drill hole moved anteriorly on the clavicle. However, none of the three methods of coracoclavicular loop fi xation restored full alignment. Another method of obtaining fi xation between the distal clavicle and the coracoid process is through transfer of the coracoacromial ligament.32 In their widely cited article from 1972, Weaver and Dunn32 describe a procedure in which the acromial end of the coracoacromial ligament is detached and the ligament is dissected free of the coracoid process. After excision of 2 cm of its lateral end, the clavicle is held in its anatomic position with traction applied to the coracoacromial ligament. The ligament is then cut for size and, with heavy nonabsorbable sutures, is secured through previously placed drill holes to the medullary canal of the clavicle. The deltoid and trapezius insertions are then restored. 32 Since its initial publication, the use of the Weaver-Dunn procedure has gained widespread use and popularity. Multiple modifications of the original procedure have been developed with reported clinical success.90,92,128,136,137 The procedure has been performed with or without distal clavicle excision, and the coracoacromial ligament may be transferred with or without a sliver of bone from the acromion. Theoretically, the concept of using a bone sliver attached to the ligament and a distal clavicle excision is ideal because it allows for bone-to-bone contact, which may accelerate healing and remodeling.99 Recently, Jari and co-workers121 have examined the biomechanical function of the intact coracoclavicular ligaments in comparison with reconstruction methods using the Weaver-Dunn or coracoacromial ligament transfer, Rockwood lag screw, or coracoclavicular fi xation with a suture or autograft tendon cerclage technique. They found that both primary translation and coupled translation in the anterior,

510

SEC TION III: SHOULDER ACROMIOCL AVICUL AR JOINT INJURIES

A

B

D

E

F

G

C

Figure 26-10: Pictorial and text description of a modified Weaver-Dunn surgical technique using tendon graft as material to reconstruct coracoclavicular ligaments. A, Saber-type incision (dashed line) starts slightly medially and posterior to the acromioclavicular joint and extended to just above the coracoid. This is accomplished after diagnostic glenohumeral arthroscopy and an arthroscopic distal clavicle excision have been performed. B, A horizontal incision is made in the deltoid trapezial fascia across the acromioclavicular joint. The joint is completely exposed with careful anterior and posterior subperiosteal dissection to assure full thickness of the flaps. C, The coracoacromial ligament is dissected off the acromion and a No. 2 permanent Ethibond suture is placed in a Krakow-type manner. The clavicle is secured. D, A curet is used to hollow out a trough for the coracoacromial ligament in the distal clavicle, and a large hole is made in the clavicle approximately 1 cm from the edge using a 4.5-mm drill. It is then made larger either with a curet or using the drill as a reamer. Two smaller holes are made on either side of this with a 3.2-mm drill. E, The two limbs of the Ethibond suture tied around the coracoacromial ligament are then placed through the small holes, and the ligament is placed into the bone tunnel. (Inset shows this with magnification.) Upward pressure is placed on the scapulohumeral complex to reduce the coracoclavicular distance. A suture can be placed around the coracoclavicular ligaments if possible. F, A tinaculum clamp is used to hold the reduction that has been accomplished with upper traction on the scapulohumeral complex. This facilitates easy and tight fitting of the coracoacromial ligament into its bone tunnel and passage of the semitendinosus graft. G, Shown is the placement of the semitendinous graft and the braided Ethibond suture in a figure-eight pattern around the base of the coracoid and through the large hole in the distal clavicle, with concomitant fi xation of the coracoacromial ligament in the bone tunnel. Of note and not shown in these illustrations is repair of the deltotrapezial fascia with nonabsorbable sutures, which is extremely important. (From Mazzocca AD, Sellards R, Garretson R, et al: Injuries to the acromioclavicular joint in adults and children. In DeLee J, Drez D, Miller MD, editors: DeLee and Drez’s orthopaedic sports medicine: principles and practice, ed 2, Philadelphia, 2003, Saunders.)

Chapter 26: Rehabilitation after Conservative and Operative Treatment of Acromioclavicular Joint Injuries

posterior, and superior planes were significantly higher in the Weaver-Dunn and coracoclavicular cerclage constructs compared with the native ligaments.121 This study, along with others, has shown that although clinically good results are obtained, the anatomic reduction achieved during surgery is difficult to maintain once the patient returns to activity.92 Therefore it has become popular to combine the aforementioned procedures into one that involves distal clavicular excision, transfer of the coracoclavicular ligament and fi xation of the clavicle to the coracoid,86,128,137-139 and repair of the deltotrapezial fascia. All of these procedures have been loosely referred to by some as “modified Weaver-Dunn” techniques. A detailed example of a modified Weaver-Dunn procedure is illustrated and described in Figure 26-10. 31

The Future of Acromioclavicular Surgery The future of acromioclavicular joint surgery is exciting. Although the conventional techniques available involve open surgeries, recent documentation of arthroscopic techniques has appeared in the literature.140-143 Arthroscopic reconstruction of the acromioclavicular joint has the potential to be a less invasive method while simultaneously achieving cosmetic and clinical results of the open procedures. Further biomechanical studies and long-term clinical follow-up are necessary to determine whether arthroscopic reconstruction will be a viable alternative to the open procedures. A new and novel technique that attempts to anatomically reconstruct both the acromioclavicular and the coracoclavicular ligaments has been suggested.144 This technique is unique in that it attempts to place autogenous semitendinosus graft material into the exact anatomic footprint of the native coracoclavicular ligaments. Autograft tendon fi xation is achieved with interference screw fi xation to bone.144 Longterm follow-up will determine if this new procedure will be more successful than the modified Weaver-Dunn. Nevertheless, it is hoped that this new procedure, as well as the recent modifications to the Weaver-Dunn procedure, will result in the number of surgical options available for acromioclavicular reconstruction being limited to several options. This will, it is hoped, allow for a greater number of prospective outcome studies and trials.

REHABILITATION FOLLOWING ACROMIOCLAVICULAR SURGERY Following a modified Weaver-Dunn or similar surgical reconstruction technique, the patient, therapist, and physician need to follow a criterion-based rehabilitation protocol. This protocol must also incorporate the principles of exercise progression and serial testing that were described for nonoperative rehabilitation. However, because of the importance of protecting the fragile coracoacromial ligament transfer and clavicular reduction, a 4- to 6-week protective postoperative phase is required. During this phase, an acromioclavicular sling is used for support and to protect the surgical reconstruction. It is hoped that significant healing occurs during

511

this protective time period. Once this protective phase is completed, the patient may be progressed according to the principles and exercises described for rehabilitation following nonoperative treatment as described previously. Tables 26-4 and 26-5 (pp. 512-515) illustrate a sample 24-week protocol for patients following modified Weaver-Dunn acromioclavicular reconstruction.

SUMMARY Rehabilitation following conservative or operative acromioclavicular joint injury requires a team approach from the surgeon, physical therapist, and athletic trainer. All members of the rehabilitation team should have a thorough understanding of the anatomy and biomechanics of the acromioclavicular joint, the mechanisms of injury and initial examination and evaluation techniques, and the appropriate conservative and operative interventions for acromioclavicular joint injury. Successful outcomes for the patient depend on close communication among team members and objective documentation of patient progress.

References 1. Stuart MJ, Morrey MA, Smith AM, et al: Injuries in youth football: a prospective observational cohort analysis among players aged 9 to 13 years, Mayo Clin Proc 77(4):317-322, 2002. 2. Stuart MJ, Smith A: Injuries in junior A ice hockey. A three-year prospective study, Am J Sports Med 23(4):458-461, 1995. 3. Webb J, Bannister G: Acromioclavicular disruption in fi rst class rugby players, Br J Sports Med 26(4):247-248, 1992. 4. Kocher MS, Dupre MM, Feagin JA Jr: Shoulder injuries from alpine skiing and snowboarding. Aetiology, treatment and prevention, Sports Med 25(3):201-211, 1998. 5. Kocher MS, Feagin JA Jr: Shoulder injuries during alpine skiing, Am J Sports Med 24(5):665-669, 1996. 6. Jeys LM, Cribb G, Toms AD, et al: Mountain biking injuries in rural England, Br J Sports Med 35(3):197-199, 2001. 7. Molsa J, Kujala U, Myllynen P, et al: Injuries to the upper extremity in ice hockey: analysis of a series of 760 injuries, Am J Sports Med 31(5):751-757, 2003. 8. Kelly BT, Barnes RP, Powell JW, et al: Shoulder injuries to quarterbacks in the national football league, Am J Sports Med 32(2):328-331, 2004. 9. Rockwood CA Jr, Williams GR, Young DC: Disorders of the acromioclavicular joint. In Rockwood CA Jr, Matsen FA III, editors: The shoulder, ed 2, Philadelphia, 1998, Saunders. 10. Williams GR, Rockwood CA Jr: Injuries to the acromioclavicular joint, sternoclavicular joint, clavicle, scapula, coracoid, sternum and ribs. In DeLee JC, Drez D, editors: Orthopaedic sports medicine: principles and practice, Philadelphia, 1994, Saunders. 11. Beim GM: Acromioclavicular joint injuries, J Athl Train 35(3):261-267, 2000. 12. Bosworth BM: Complete acromioclavicular dislocations, N Engl J Med 241:221-225, 1949. 13. Tyurina TV: Age-related changes characteristics of the human acromioclavicular joint, Arkh Anat Gistol Embriol 89:75-81, 1985. 14. DePalma AF: Degenerative changes in the sternoclavicular and acromioclavicular joints in various decades, Springfield, IL, 1957, Charles C Thomas.

512

SEC TION III: SHOULDER ACROMIOCL AVICUL AR JOINT INJURIES

TA B L E 26 - 4

Postoperative Rehabilitation Protocol following Acromioclavicular Joint Reconstruction (Phases I and II)

Goals (May not progress to next phase until goals are met)

PHASE I: IMMEDIATE POSTOPER ATIVE PHASE

PHASE II: INTERMEDIATE PHASE (INITIAL STRENGTHENING)

WEEK S 1 TO 4*

WEEK S 5 TO 8

Minimal pain and tenderness with palpation of AC joint

Full pain-free AROM

Stable AC joint on clinical examination

Measured in a seated position with arm in 30 degrees of abduction

Able to perform submaximal lateral and medial isometric contractions in standing (30 degrees of abduction/scaption†) without pain

Equal lateral rotation to contralateral side

Minimal pain and tenderness with palpation of the AC joint Able to perform maximal isometric contractions pain free in all planes No observed scapular dyskinesias

Precautions Avoid supine PROM (see text)

Avoid supine exercises (see text)

No heavy lifting, pushing/pulling

No heavy lifting, pushing/pulling

No contact sports

No contact sports

No overhead motion greater than 90 degrees Restrict horizontal extension and flexion ROM

No resisted overhead motion greater than 90 degrees

No PROM/AAROM/AROM into pain

No resisted horizontal extension and flexion

Avoid traction through upper extremity

Avoid military or bench press motions Avoid traction through upper extremity

Interventions Protection

Fit with AC (Kenny-Howard) sling for comfort and to prevent downward displacement of scapula

Slowly wean from splint as tolerated weeks 5-6

Taping for pain relief and protection Modalities

Cryotherapy

Cryotherapy following exercise

Electrical stimulation modalities for pain control and neuromuscular reeducation

Electrical stimulation modalities for pain control and neuromuscular reeducation May use heat for warm-up, stretching, and pain relief

ROM

Elbow and wrist AROM PROM in seated or side-lying position Begin AAROM exercises with wand or T-bar week 2 Begin gentle AROM exercises in pain-free ROM week 4

Full AROM all planes

Chapter 26: Rehabilitation after Conservative and Operative Treatment of Acromioclavicular Joint Injuries

513

TA B L E 26 - 4

Postoperative Rehabilitation Protocol following Acromioclavicular Joint Reconstruction (Phases I and II)—cont’d

Strengthening

PHASE I: IMMEDIATE POSTOPER ATIVE PHASE

PHASE II: INTERMEDIATE PHASE (INITIAL STRENGTHENING)

WEEK S 1 TO 4*

WEEK S 5 TO 8

Initiate trial of submaximal shoulder isometrics week 3

Initiate trial of short-arc isotonic strengthening exercises

Isometrics in 30 degrees of abduction and scaption for shoulder flexion, medial rotation, and lateral rotation

Progress ROM as tolerated by symptoms

Progress intensity of isometrics as tolerated by symptoms and visual analog scale pain rating less than 2/10 or 3/10

Strengthening exercises should include the following exercises with ROM modifications:

Isometrics should all be performed below chest level

Seated row

Forearm and hand intrinsic strengthening with putty or squeeze ball Begin pain-free AROM scapular retraction and protraction week 2 in sling May continue lower extremity and uninvolved upper extremity exercises Initiate core trunk stability exercises

Progress resistance as defined by symptoms, scapular control, and quality of motion

Seated chest press with plus Scaption limited to 90 degrees of elevation Bent-over horizontal abduction (no resistance, AROM only) Shoulder flexion limited to 90 degrees of elevation Shoulder shrugs (avoid traction force) Lateral and medial rotation strengthening Biceps and triceps strengthening Core trunk stability exercises

Neuromuscular reeducation exercises

Assessment Clinical testing

Biofeedback to encourage correct arthrokinematics with standing or seated

Submaximal rhythmic stabilizations

AAROM (goal to facilitate inhibition of upper trapezius activity during activity)

Known pattern

PROM measurements week 2

Perform in side-lying position

AROM measurements week 4

Weekly AROM measurements

Slow speed Submaximal resistance

*The number of weeks suggested in this table is only a guideline. Determination of when to advance the patient to the next phase of the protocol is based on objective measurements and reported symptoms. Some patients may advance faster or slower than others. Quality of injured tissue, patient characteristics, and clinical testing and measurements should determine protocol advancement. †Elevation in the plane of the scapula. AAROM, Active-assistive range of motion; AC, acromioclavicular; AROM, active range of motion; PROM, passive range of motion; ROM, range of motion.

514

SEC TION III: SHOULDER ACROMIOCL AVICUL AR JOINT INJURIES

TA B L E 26 -5

Postoperative Rehabilitation Protocol following Acromioclavicular Joint Reconstruction (Phases III and IV)

Goals (May not progress to next phase until goals are met)

PHASE III: DYNAMIC STRENGTHENING PHASE

PHASE IV: RE TURN TO AC TIVIT Y PHASE

WEEK S 9 TO 15*

WEEK S 16 TO 24

Full pain-free AROM equal to the contralateral side

No functional deficits when compared with uninvolved extremity

No pain or tenderness with palpation

Isokinetic testing of medial and lateral rotation and horizontal flexion and extension within 10% of normative data and contralateral extremity

Less than 25% deficit with handheld dynamometer testing of middle deltoid and upper trapezius Less than 10% deficit to contralateral shoulder with testing of internal and external rotators

Independent in home strengthening program

Avoid supine ROM (see text)

Caution when performing military or bench press

Discharge from rehabilitation

Precautions No heavy lifting, pushing/pulling No contact sports No resisted overhead motion greater than 90 degrees Restrict horizontal extension and flexion ROM No PROM/AAROM/AROM into pain

Suggest modifying ROM and arc of motion to limit AC joint stress Suggest alternative exercises Avoid excessive traction through upper extremity with repetitive activity

Avoid traction through upper extremity Interventions Protection Modalities

Padding and protection for work or sport if necessary

Padding and protection for work or sport if necessary

Cryotherapy following exercise

Cryotherapy as needed following exercise

Electrical stimulation modalities for pain control and neuromuscular reeducation

May use heat for warm-up, stretching, and pain relief

May use heat for warm-up, stretching, and pain relief ROM

Begin some repetitive overhead motion without resistance For endurance training Avoid loss of scapular control or pain Begin supervised horizontal extension and flexion resistance exercises Progress resistance based on trial treatments with short-arc isotonics Establish home program of stretching if necessary to maintain ROM

No changes

Chapter 26: Rehabilitation after Conservative and Operative Treatment of Acromioclavicular Joint Injuries

515

TA B L E 26 -5

Postoperative Rehabilitation Protocol following Acromioclavicular Joint Reconstruction (Phases III and IV)—cont’d

Strengthening

PHASE III: DYNAMIC STRENGTHENING PHASE

PHASE IV: RE TURN TO AC TIVIT Y PHASE

WEEK S 9 TO 15*

WEEK S 16 TO 24

Progress resistance and increase ROM of all exercises from phase II

Continue with a core program based on specific demands of vocation or sport

Progress to strengthening in all planes of motion based on symptoms

Use periodization principles Initiate return to throwing program

Week 12: carefully progress to overhead strengthening (90/90 position) based on trial treatments with short-arc isotonics Neuromuscular reeducation exercises

Advance to diagonal (PNF) patterns of motion Increase speed and intensity of exercises Initiate submaximal upper extremity plyometrics using minimal resistance and control parameters of bilateral to unilateral, partial to full ROM, low to high speed, and low to high repetitions and resistance

Activity specific

Initiate work conditioning and simulated work tasks Perform work-site evaluation Initiate sport-specific drills

Advance exercises from phase III by decreasing clinician control and increasing exercise intensity Advance plyometrics drills to incorporate demands of sport or work activity

Sport-specific testing Trial return to sport or activity Continue return to throwing program

Initiate preparation for closed kinetic chain upper extremity functional test Assessment Clinical testing

Strength testing at end of phase Assessment of abilities or deficits with work or sport activities (these deficits will be focus of phase IV)

Closed kinetic chain upper extremity test (see text)

*The number of weeks suggested in this table is only a guideline. Determination of when to advance the patient to the next phase of the protocol is based on objective measurements and reported symptoms. Some patients may advance faster or slower than others. Quality of injured tissue, patient characteristics, and clinical testing and measurements should determine protocol advancement. AAROM, Active-assistive range of motion; AC, acromioclavicular; AROM, active range of motion; PNF, proprioceptive neuromuscular facilitation; PROM, passive range of motion; ROM, range of motion.

516

SEC TION III: SHOULDER ACROMIOCL AVICUL AR JOINT INJURIES

15. Urist MR: Complete dislocations of the acromioclavicular joint: the nature of the traumatic lesion and effective methods of treatments with an analysis of forty-one cases, J Bone Joint Surg Am 28:813-837, 1946. 16. Pettrone FA, Nirschl RP: Acromioclavicular dislocation, Am J Sports Med 6(4):160-164, 1978. 17. Pitchford KR, Cahill BR: Osteolysis of the distal clavicle in the overhead athlete, Oper Tech Sports Med 5(2):72-77, 1997. 18. Tillmann B, Peterson W: Clinical anatomy. In Fu FH, Ticker JB, Imhoff AB, editors: Analysis of shoulder surgery, Stamford, CT, 1998, Appleton & Lange. 19. Petersson C: Degeneration of the AC joint: a morphological study, Acta Orthop Scand 54:434-438, 1983. 20. DePalma AF, Callery G, Bennett G: Variational anatomy and degenerative lesions of the shoulder joint, Instr Course Lect 6:255281, 1949. 21. Salter EJ, Nasca R, Shelley B: Anatomical observations on the AC joint and supporting ligaments, Am J Sports Med 15:199-206, 1987. 22. Bonsell S, Pearsall AW, Heitman RJ, et al: The relationship of age, gender, and degenerative changes observed on radiographs of the shoulder in asymptomatic individuals, J Bone Joint Surg Br 82(8):1135-1139, 2000. 23. Fukuda K, Craig EV, An KN, et al: Biomechanical study of the ligamentous system of the acromioclavicular joint, J Bone Joint Surg Am 68(3):434-440, 1986. 24. Renfree KJ, Wright TW: Anatomy and biomechanics of the acromioclavicular and sternoclavicular joints, Clin Sports Med 22(2):219-237, 2003. 25. Klimkiewicz JJ, Williams GR, Sher JS, et al: The acromioclavicular capsule as a restraint to posterior translation of the clavicle: a biomechanical analysis, J Shoulder Elbow Surg 8(2):119-124, 1999. 26. Boehm TD, Kirschner S, Fischer A, et al: The relation of the coracoclavicular ligament insertion to the acromioclavicular joint: a cadaver study of relevance to lateral clavicle resection, Acta Orthop Scand 74(6):718-721, 2003. 27. Harris RI, Vu DH, Sonnabend DH, et al: Anatomic variance of the coracoclavicular ligaments, J Shoulder Elbow Surg 10(6):585588, 2001. 28. Debski RE, Parsons IM, Woo SL, et al: Effect of capsular injury on acromioclavicular joint mechanics, J Bone Joint Surg Am 83A(9):1344-1351, 2001. 29. Debski RE, Parsons IM, Fenwick J, et al: Ligament mechanics during three degree-of-freedom motion at the acromioclavicular joint, Ann Biomed Eng 28(6):612-618, 2000. 30. Lee TQ , Black AD, Tibone JE, et al: Release of the coracoacromial ligament can lead to glenohumeral laxity: a biomechanical study, J Shoulder Elbow Surg 10(1):68-72, 2001. 31. Mazzocca AD, Sellards R, Garretson R, et al: Injuries to the acromioclavicular joint in adults and children. In DeLee J, Drez D, Miller MD, editors: DeLee and Drez’s orthopaedic sports medicine: principles and practice, ed 2, Philadelphia, 2003, Saunders. 32. Weaver JK, Dunn HK: Treatment of acromioclavicular injuries, especially complete acromioclavicular separation, J Bone Joint Surg Am 54(6):1187-1194, 1972. 33. Gowan ID, Jobe FW, Tibone JE, et al: A comparative electromyographic analysis of the shoulder during pitching. Professional versus amateur pitchers, Am J Sports Med 15(6):586-590, 1987. 34. Jobe FW, Moynes DR, Tibone JE, et al: An EMG analysis of the shoulder in pitching. A second report, Am J Sports Med 12(3):218-220, 1984. 35. Inman VT, Saunders JB, Abbott LC: Observations on the function of the shoulder joint, J Bone Joint Surg Am 26:1-30, 1944.

36. Kennedy JC, Cameron H: Complete dislocation of the acromioclavicular joint, J Bone Joint Surg Br 36:202-208, 1954. 37. Rockwood CA Jr, Williams GR, Young DC: Injuries to the acromioclavicular joint. In Rockwood CA Jr, Green D, editors: Fractures in adults, vol 1, ed 2, Philadelphia, 1984, JB Lippincott. 38. Falappa PG, Danza FM, Cotroneo AR, et al: Percutaneous removal of a Kirschner wire from the thoracic aorta, Rays 14(1):65-68, 1989. 39. Foster GT, Chetty KG, Mahutte K, et al: Hemoptysis due to migration of a fractured Kirschner wire, Chest 119(4):1285-1286, 2001. 40. Ludewig PM, Behrens SA, Meyer SM, et al: Three-dimensional clavicular motion during arm elevation: reliability and descriptive data, J Orthop Sports Phys Ther 34(3):140-149, 2004. 41. Bearn JG: Direct observations on the function of the capsule of the sternoclavicular joint in clavicle support, J Anat 101:159-170, 1967. 42. Cadenat FM: The treatment of dislocations and fractures of the outer end of the clavicle, Int Clin 1:145-169, 1917. 43. Tossy JD, Mead NC, Sigmond HM: Acromioclavicular separations: useful and practical classification for treatment, Clin Orthop 28:111-119, 1963. 44. Allman FL: Fractures and ligamentous injuries of the clavicle and its articulation, J Bone Joint Surg Am 49:774-784, 1967. 45. Turnbull JR: Acromioclavicular joint disorders, Med Sci Sports Exerc 30(4 suppl):S26-32, 1998. 46. Garretson RB, Williams GR Jr: Clinical evaluation of injuries to the acromioclavicular and sternoclavicular joints, Clin Sports Med 22(2):239-254, 2003. 47. Gerber C, Galantay RV, Hersche O: The pattern of pain produced by irritation of the acromioclavicular joint and the subacromial space, J Shoulder Elbow Surg 7(4):352-355, 1998. 48. McLaughlin HL: On the frozen shoulder, Bull Hosp Jt Dis 12:383-390, 1951. 49. O’Brien SJ, Pagnani MJ, Fealy S, et al: The active compression test: a new and effective test for diagnosing labral tears and acromioclavicular joint abnormality, Am J Sports Med 26(5):610613, 1998. 50. Walton J, Mahajan S, Paxinos A, et al: Diagnostic values of tests for acromioclavicular joint pain, J Bone Joint Surg Am 86A(4):807812, 2004. 51. Magee DJ: Orthopedic physical assessment (chap 5), ed 4, Philadelphia, 2002, Saunders. 52. Jacob AK, Sallay PI: Therapeutic efficacy of corticosteroid injections in the acromioclavicular joint, Biomed Sci Instrum 34:380385, 1997. 53. Chronopoulos E, Kim TK, Park HB, et al: Diagnostic value of physical tests for isolated chronic acromioclavicular lesions, Am J Sports Med 32(3):655-661, 2004. 54. Johnson RJ: Acromioclavicular joint injuries, Phys Sports Med 29(11):31-35, 2001. 55. Aalders GJ, van Vroonhoven TJ, van der Werken C, et al: An exceptional case of pneumothorax—“a new adventure of the K wire,” Injury 16(8):564-565, 1985. 56. Zanca P: Shoulder pain: involvement of the acromioclavicular joint (analysis of 1,000 cases), Am J Roentgenol Radium Ther Nucl Med 112(3):493-506, 1971. 57. Bannister GC, Wallace WA, Stableforth PG, et al: The management of acute acromioclavicular dislocation. A randomised prospective controlled trial, J Bone Joint Surg Br 71(5):848-850, 1989. 58. Bossart PJ, Joyce SM, Manaster BJ, et al: Lack of efficacy of “weighted” radiographs in diagnosing acute acromioclavicular separation, Ann Emerg Med 17(1):20-24, 1988.

Chapter 26: Rehabilitation after Conservative and Operative Treatment of Acromioclavicular Joint Injuries

59. Yap JJ, Curl LA, Kvitne RS, et al: The value of weighted views of the acromioclavicular joint. Results of a survey, Am J Sports Med 27(6):806-809, 1999. 60. Ernberg LA, Potter HG: Radiographic evaluation of the acromioclavicular and sternoclavicular joints, Clin Sports Med 22(2):255-275, 2003. 61. Schimpf M, Carlos N, McFarland EG: The deceptive nature of clavicle fractures in young patients, Phys Sports Med 27(3):119128, 1999. 62. Bosworth BM: Acromioclavicular separation: new method of repair, Surg Gynecol Obstet 73:866-871, 1941. 63. Nuber GW, Bowen BK: Acromioclavicular joint injuries and distal clavicle fractures, J Am Acad Orthop Surg 5(1):11-18, 1997. 64. Lemos MJ: The evaluation and treatment of the injured acromioclavicular joint in athletes, Am J Sports Med 26(1):137-144, 1998. 65. Bergfeld JA, Andrish JT, Clancy WG: Evaluation of the acromioclavicular joint following fi rst- and second-degree sprains, Am J Sports Med 6(4):153-159, 1978. 66. Mumford EB: Acromioclavicular dislocation: a new operative treatment, J Bone Joint Surg Am 23:799-802, 1941. 67. Gurd FB: The treatment of complete dislocation of the outer end of the clavicle: an hitherto undescribed operation, Ann Surg 113:1094-1098, 1941. 68. Alford W, Bach BR Jr: Open distal clavicle resection, Oper Tech Sports Med 12(1):9-17, 2004. 69. Kay SP, Dragoo JL, Lee R: Long-term results of arthroscopic resection of the distal clavicle with concomitant subacromial decompression, Arthroscopy 19(8):805-809, 2003. 70. Kay SP, Ellman H, Harris E: Arthroscopic distal clavicle excision. Technique and early results, Clin Orthop 301:181-184, 1994. 71. Bigliani LU, Nicholson GP, Flatow EL: Arthroscopic resection of the distal clavicle, Orthop Clin North Am 24(1):133-141, 1993. 72. Flatow EL, Cordasco FA, Bigliani LU: Arthroscopic resection of the outer end of the clavicle from a superior approach: a critical, quantitative, radiographic assessment of bone removal, Arthroscopy 8(1):55-64, 1992. 73. Flatow EL, Duralde XA, Nicholson GP, et al: Arthroscopic resection of the distal clavicle with a superior approach, J Shoulder Elbow Surg 4(1 pt 1):41-50, 1995. 74. Sellards R, Nicholson GP: Arthroscopic distal clavicle resection, Oper Tech Sports Med 12(1):18-26, 2004. 75. Nuber GW, Bowen MK: Arthroscopic treatment of acromioclavicular joint injuries and results, Clin Sports Med 22(2):301-317, 2003. 76. Clarke HD, McCann PD: Acromioclavicular joint injuries, Orthop Clin North Am 31(2):177-187, 2000. 77. Mouhsine E, Garofalo R, Crevoisier X, et al: Grade I and II acromioclavicular dislocations: results of conservative treatment, J Shoulder Elbow Surg 12(6):599-602, 2003. 78. Walsh WM, Peterson DA, Shelton G, et al: Shoulder strength following acromioclavicular injury, Am J Sports Med 13(3):153158, 1985. 79. O’Neill DB, Zarins B, Gelberman RH, et al: Compression of the anterior interosseous nerve after use of a sling for dislocation of the acromioclavicular joint. A report of two cases, J Bone Joint Surg Am 72(7):1100-1102, 1990. 80. MacDonald PB, Alexander MJ, Frejuk J, et al: Comprehensive functional analysis of shoulders following complete acromioclavicular separation, Am J Sports Med 16(5):475-480, 1988. 81. Imatani RJ, Hanlon JJ, Cady GW: Acute, complete acromioclavicular separation, J Bone Joint Surg Am 57(3):328-332, 1975.

517

82. Shamus JL, Shamus EC: A taping technique for the treatment of acromioclavicular joint sprains: a case study, J Orthop Sports Phys Ther 25(6):390-394, 1997. 83. Powers JA, Bach PJ: Acromioclavicular separations. Closed or open treatment? Clin Orthop 104:213-223, 1974. 84. Cox JS: Current method of treatment of acromioclavicular joint dislocations, Orthopedics 15(9):1041-1044, 1992. 85. Phillips AM, Smart C, Groom AF: Acromioclavicular dislocation. Conservative or surgical therapy, Clin Orthop 353:10-17, 1998. 86. Bradley JP, Elkousy H: Decision making: operative versus nonoperative treatment of acromioclavicular joint injuries, Clin Sports Med 22(2):277-290, 2003. 87. Larsen E, Bjerg-Nielsen A, Christensen P: Conservative or surgical treatment of acromioclavicular dislocation. A prospective, controlled, randomized study, J Bone Joint Surg Am 68(4):552555, 1986. 88. Glick JM, Milburn LJ, Haggerty JF, et al: Dislocated acromioclavicular joint: follow-up study of 35 unreduced acromioclavicular dislocations, Am J Sports Med 5(6):264-270, 1977. 89. McFarland EG, Blivin SJ, Doehring CB, et al: Treatment of grade III acromioclavicular separations in professional throwing athletes: results of a survey, Am J Orthop 26(11):771-774, 1997. 90. Dumontier C, Sautet A, Man M, et al: Acromioclavicular dislocations: treatment by coracoacromial ligamentoplasty, J Shoulder Elbow Surg 4(2):130-134, 1995. 91. Gladstone J, Wilk K, Andrews JR: Nonoperative treatment of AC joint injuries, Oper Tech Sports Med 5:78-87, 1997. 92. Weinstein DM, McCann PD, McIlveen SJ, et al: Surgical treatment of complete acromioclavicular dislocations, Am J Sports Med 23(3):324-331, 1995. 93. Davies GJ: A compendium of isokinetic exercise, ed 4, Onalaska, WI, 1994, S & S Publishing. 94. Dvir Z: Isokinetics: muscle testing, interpretation and clinical applications, ed 2, Philadelphia, 2003, Elsevier Science. 95. Tibone J, Sellers R, Tonino P: Strength testing after third-degree acromioclavicular dislocations, Am J Sports Med 20(3):328-331, 1992. 96. Goldbeck TG, Davies GJ: Test-retest reliability of the closed kinetic chain upper extremity stability test: a clinical field test, J Sports Rehabil 9:35-45, 2000. 97. Davies GJ: Normative data for the closed kinetic chain upper extremity stability test. Personal communication, 2001. 98. Ponce BA, Millett PJ, Warner JP: Acromioclavicular joint instability—reconstruction indications and techniques, Oper Tech Sports Med 12(1):35-42, 2004. 99. Kwon YW, Lannotti JP: Operative treatment of acromioclavicular joint injuries and results, Clin Sports Med 22(2):291-300, 2003. 100. O’Carroll PF, Sheehan JM: Open reduction and percutaneous Kirschner wire fi xation in complete disruption of the acromioclavicular joint, Injury 13(4):299-301, 1982. 101. Bargren JH, Erlanger S, Dick HM: Biomechanics and comparison of two operative methods of treatment of complete acromioclavicular separation, Clin Orthop 130:267-272, 1978. 102. Sim E, Schwarz N, Hocker K, et al: Repair of complete acromioclavicular separations using the acromioclavicular-hook plate, Clin Orthop 314:134-142, 1995. 103. Smith MJ, Stewart MJ: Acute acromioclavicular separations. A 20-year study, Am J Sports Med 7(1):62-71, 1979. 104. Habernek H, Weinstabl R, Schmid L, et al: A crook plate for treatment of acromioclavicular joint separation: indication, technique, and results after one year, J Trauma 35(6):893-901, 1993.

518

SEC TION III: SHOULDER ACROMIOCL AVICUL AR JOINT INJURIES

105. Lizaur A, Marco L, Cebrian R: Acute dislocation of the acromioclavicular joint. Traumatic anatomy and the importance of deltoid and trapezius, J Bone Joint Surg Br 76(4):602-606, 1994. 106. Paavolainen P, Bjorkenheim JM, Paukku P, et al: Surgical treatment of acromioclavicular dislocation: a review of 39 patients, Injury 14(5):415-420, 1983. 107. Neviaser JS: Acromioclavicular dislocation treated by transference of the coraco-acromial ligament. A long-term follow-up in a series of 112 cases, Clin Orthop 58:57-68, 1968. 108. Roper BA, Levack B: The surgical treatment of acromioclavicular dislocations, J Bone Joint Surg Br 64(5):597-599, 1982. 109. Lindsey RW, Gutowski WT: The migration of a broken pin following fi xation of the acromioclavicular joint. A case report and review of the literature, Orthopedics 9(3):413-416, 1986. 110. Sethi GK, Scott SM: Subclavian artery laceration due to migration of a Hagie pin, Surgery 80(5):644-646, 1976. 111. Yadav V, Marya KM: Unusual migration of a wire from shoulder to neck, Indian J Med Sci 57(3):111-112, 2003. 112. Bailey RW: A dynamic repair for complete acromioclavicular joint dislocation, J Bone Joint Surg Am 47:858, 1965 (abstract). 113. Bailey RW, Metten CF, O’Connor GA, et al: A dynamic method of repair for acute and chronic acromioclavicular disruption, Am J Sports Med 4(2):58-71, 1976. 114. Berson BL, Gilbert MS, Green S: Acromioclavicular dislocations: treatment by transfer of the conjoined tendon and distal end of the coracoid process to the clavicle, Clin Orthop 135:157164, 1978. 115. Dewar FP, Barrington TW: The treatment of chronic acromioclavicular dislocation, J Bone Joint Surg Br 47:32-35, 1965. 116. Brunelli G, Brunelli F: The treatment of acromio-clavicular dislocation by transfer of the short head of biceps, Int Orthop 12(2):105-108, 1988. 117. Caspi I, Ezra E, Nerubay J, et al: Musculocutaneous nerve injury after coracoid process transfer for clavicle instability. Report of three cases, Acta Orthop Scand 58(3):294-295, 1987. 118. Tsou PM: Percutaneous cannulated screw coracoclavicular fi xation for acute acromioclavicular dislocations, Clin Orthop 243:112121, 1989. 119. Harris RI, Wallace AL, Harper GD, et al: Structural properties of the intact and the reconstructed coracoclavicular ligament complex, Am J Sports Med 28(1):103-108, 2000. 120. Motamedi AR, Blevins FT, Willis MC, et al: Biomechanics of the coracoclavicular ligament complex and augmentations used in its repair and reconstruction, Am J Sports Med 28(3):380-384, 2000. 121. Jari R, Costic RS, Rodosky MW, et al: Biomechanical function of surgical procedures for acromioclavicular joint dislocations, Arthroscopy 20(3):237-245, 2004. 122. Fleming RE, Tornberg DN, Kiernan H: An operative repair of acromioclavicular separation, J Trauma 18(10):709-712, 1978. 123. Stam L, Dawson I: Complete acromioclavicular dislocations: treatment with a Dacron ligament, Injury 22(3):173-176, 1991. 124. Pearsall AW, Hollis JM, Russell GV Jr, et al: Biomechanical comparison of reconstruction techniques for disruption of the acromioclavicular and coracoclavicular ligaments, J South Orthop Assoc 11(1):11-17, 2002. 125. Wickham MQ , Wyland DJ, Glisson RR, et al: A biomechanical comparison of suture constructs used for coracoclavicular fi xation, J South Orthop Assoc 12(3):143-148, 2003. 126. Clayer M, Slavotinek J, Krishnan J: The results of coracoclavicular slings for acromio-clavicular dislocation, Aust N Z J Surg 67(6):343-346, 1997.

127. Pfahler M, Krodel A, Refior HJ: Surgical treatment of acromioclavicular dislocation, Arch Orthop Trauma Surg 113(6):308-311, 1994. 128. Morrison DS, Lemos MJ: Acromioclavicular separation. Reconstruction using synthetic loop augmentation, Am J Sports Med 23(1):105-110, 1995. 129. Stone KR, Carli AD, Day R, et al: Acromioclavicular joint reconstruction using Gore-Tex tape: evaluation of a new surgical technique and rehabilitation protocol. Internet document available at www.stoneclinic.com/acjoint2 (accessed May 5, 2004). 130. Sloan SM, Budoff JE, Hipp JA, et al: Coracoclavicular ligament reconstruction using the lateral half of the conjoined tendon, J Shoulder Elbow Surg 13(2):186-190, 2004. 131. Lee SJ, Nicholas SJ, Akizuki KH, et al: Reconstruction of the coracoclavicular ligaments with tendon grafts: a comparative biomechanical study, Am J Sports Med 31(5):648-655, 2003. 132. Jones HP, Lemos MJ, Schepsis AA: Salvage of failed acromioclavicular joint reconstruction using autogenous semitendinosus tendon from the knee. Surgical technique and case report, Am J Sports Med 29(2):234-237, 2001. 133. Breslow MJ, Jazrawi LM, Bernstein AD, et al: Treatment of acromioclavicular joint separation: suture or suture anchors? J Shoulder Elbow Surg 11(3):225-229, 2002. 134. Su EP, Vargas JH, Boynton MD: Using suture anchors for coracoclavicular fi xation in treatment of complete acromioclavicular separation, Am J Orthop 33(5):256-257, 2004. 135. Baker JE, Nicandri GT, Young DC, et al: A cadaveric study examining acromioclavicular joint congruity after different methods of coracoclavicular loop repair, J Shoulder Elbow Surg 12(6):595-598, 2003. 136. Kumar S, Sethi A, Jain AK: Surgical treatment of complete acromioclavicular dislocation using the coracoacromial ligament and coracoclavicular fi xation: report of a technique in 14 patients, J Orthop Trauma 9(6):507-510, 1995. 137. Pavlik A, Csepai D, Hidas P: Surgical treatment of chronic acromioclavicular joint dislocation by modified Weaver-Dunn procedure, Knee Surg Sports Traumatol Arthrosc 9(5):307-312, 2001. 138. Rokito AS, Oh YH, Zuckerman JD: Modified Weaver-Dunn procedure for acromioclavicular joint dislocations, Orthopedics 27(1):21-28, 2004. 139. Guy DK, Wirth MA, Griffin JL, et al: Reconstruction of chronic and complete dislocations of the acromioclavicular joint, Clin Orthop 347:138-149, 1998. 140. Rolla PR, Surace MF, Murena L: Arthroscopic treatment of acute acromioclavicular joint dislocation, Arthroscopy 20(6):662668, 2004. 141. Wolf EM, Pennington WT: Arthroscopic reconstruction for acromioclavicular joint dislocation, Arthroscopy 17(5):558-563, 2001. 142. Wolf EM, Fragomen AT: Arthroscopic reconstruction of the coracoclavicular ligaments for acromioclavicular joint separations, Oper Tech Sports Med 12(1):49-55, 2004. 143. Imhoff AB, Chernchujit B: Arthroscopic anatomic stabilization of acromioclavicular joint dislocation, Oper Tech Sports Med 12(1):43-48, 2004. 144. Mazzocca AD, Conway JE, Johnson S, et al: The anatomic coraclavicular ligament reconstruction, Oper Tech Sports Med 12(1):56-61, 2004.