Last Updated on Thursday, 21 January 2016 09:46
By Dr. Rob LaPrade
http://drrobertlaprademd.com
Question: After being checked into the boards with my shoulder down, I immediately had pain and a noticeable bump on the top of my shoulder. I was told I have a Grade II shoulder separation. Do I need surgery, and how long will it be until I can get back to playing hockey?
Answer: A shoulder separation, as opposed to a shoulder dislocation, is an injury between the collarbone (clavicle) and the highest point (acromion) of the shoulder blade (scapula). In medical terms, this is a separation of the acromioclavicular joint, or AC joint, which is held together by two ligaments. Shoulder separations are different from shoulder dislocations because dislocations involve the actual shoulder joint, occurring when the ball of the upper end of the arm (humerus) comes out of the socket (glenoid) of the shoulder blade (scapula). Shoulder dislocations tend to be more serious injuries than shoulder separations.
The main types (or grades) of shoulder separations that we see in ice hockey are grades I, II, and III. They are graded according to the amount of tearing of the two ligaments which hold the AC joint together. Type I shoulder separations occur when there is pain at the joint from minor tearing of one of the ligaments, but no visible deformity of the shoulder is present. In type II separations, there is more severe tearing of one ligament and minor tearing of the other ligament, permitting a visible separation between the end of the collarbone and shoulder blade that can be seen as a small bump on the top of the shoulder. For a complete tear of both ligaments (type III), the arm pulls the shoulder blade away from the collarbone, resulting in an even more prominent bump on the top of the shoulder.
The treatment and prognosis for returning back to play after shoulder separations depends upon the grade of the injury. Almost always, you can multiply the grade of the shoulder separation by two to determine the amount of time in weeks that it will take to get back to full competition. Thus, grade I separations usually take up to 2 weeks, grade II separations take 4 weeks, and grade III separations usually take 6 weeks to return back to on-ice competition. However, a noticeable bump will usually remain on the top of the shoulder following grade II and III injury recovery. In rare cases, surgery may be indicated for grade III separations.
The initial treatment of shoulder separations is to place ice on the separation immediately to minimize swelling and bleeding. Icing should then be performed for 20 minutes of every hour for 48 hours. We also use a shoulder sling for comfort to support the arm for the first few days after a separation. Our athletes are encouraged to use the shoulder for motion activities as much as possible to prevent shoulder stiffness from developing. Once they get their full motion back, they work in the training room on rebuilding their muscle strength for their rotator cuff and other shoulder muscles. Athletes are allowed to return back to on-ice activities once they have full motion and full strength of the shoulder. In most instances, we will place a special protective pad over the AC joint under their shoulder pads to minimize pain and the chance of recurrent injury through the end of the season. The pad helps both to provide comfort over the injured joint and also to dissipate the contact force over a wider area of the AC joint to minimize re-injury.
Shoulder separations are the most common shoulder injury in ice hockey players. Proper evaluation and treatment can set the guidelines for an expected return to play and can minimize down time. In general, we recommend that shoulder separations have x-rays to make sure that there is not a fracture of the joint, especially in young athletes who may have a growth plate injury that can look like a shoulder separation. In treating shoulder separations, the most important concept is to ensure that athletes have full strength and full motion before returning to play so that they do not reinjure themselves due to residual shoulder stiffness or weakness.
Robert F. LaPrade, M.D., Ph.D. is a complex knee surgeon at The Steadman Clinic in Vail, Colorado. He is very active in research for the prevention and treatment of ice hockey injuries. Dr. LaPrade is also the Chief Medical Research Officer at the Steadman Philippon Research Institute. Formerly, he was the team physician for the University of Minnesota men’s hockey team and a professor in the Department of Orthopaedic Surgery at the U of M. If you have a question for the Hockey Doc, e-mail it toeditor@letsplayhockey.com.
