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Athletic Training Services Team
Texas Medical Center/San Jacinto
Bene Barrera ATC, LAT
Jeff Collins, LAT
Jace Duke, ATC, LAT
Emery Hill, ATC, LAT
Terry King, LAT
Michelle Leget, ATC, LAT
Ha Nguyen ATC, LAT
Caitlyn Prescott ATC, LAT
Scott Tidwell, LAT
Jerry Meins, ATC, LAT
Stephen Melancon, ATC, LAT
Brandon Roberts, ATC, LAT
Bill Wissen, ATC, LAT
Richard Gregoire, ATC, LAT
Layne Schramm, ATC, LAT
Dwight Adsit, ATC, LAT
Paula Douglas, ATC, LAT
Keith Jahn, ATC, LAT
Mike Pace, ATC, LAT
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Acromioclavicular Joint Injuries
Acromioclavicular (AC) injuries are generally a result of a fall on the acromion process, or lateral “tip” of the shoulder. This injury often occurs in football when an athlete is tackled and falls to the ground on the lateral shoulder, transmitting force through the acromion to the AC joint. The force is often more than the AC ligament can endure, resulting in a tear and loss of its supportive ability. With great enough force, secondary structures, such as the coracoclavicular (CC) ligaments, tear causing the distal tip of the clavicle to displace upward, or in another direction.
Classification of AC Injuries
An AC dislocation classification was described in a 1998 publication authored by Charles Rockwood, M.D.
- Type I, or partial AC ligament tear, often heals to a normal state and causes nothing more than a little pain in the AC joint without a deformity.
- Type II involves a complete tear of the AC ligament, but not the CC ligament and the clavicle is partially displaced. With this injury, there is a risk for late arthritis development.
- Type III is a tear of both the AC ligament and the CC ligament and treatment remains controversial. Types I, II, and III however are almost always treated conservatively initially. Type IV and VI are rare and beyond the scope of this discussion. Type V is a severe type III, with the skin showing signs of blanching and severe displacement and generally requires surgery. Emergency treatment on the field for any of these injuries is evaluation and ice. Same day return to play is not recommended for any acromioclavicular separation except for type I.
|Structure||Type I||Type II||Type III||Type IV||Type V||Type VI|
|AC ligament||mild sprain||ruptured||ruptured||ruptured||ruptured||ruptured|
|trapezius muscle||intact||minimally detached||detached||detached||detached||detached|
|clavicle||not elevated||elevated||above acromion||posteriorly displaced||extremely elevated||under bicep tendon|
Treatment of AC Injuries
Treatment of AC separations is dependent on two or three factors, including pain and loss of function of shoulder motion. Generally, type I and II are treated non-operatively, while type III is most often, but not always, surgically repaired. Type III injuries are often repaired even if non-symptomatic due to the risk of early onset arthritis. Types IV-VI are very rare and require surgical repair.
Orthopedic surgeons at Houston Methodist commonly use an allograft modified Weaver-Dunn procedure to reconstruct the AC joint. Tissue bank grafts are used to accurately reconstruct the torn ligaments. Post-surgical care starts with controlling pain and swelling and at approximately four to six weeks, gradual range of motion exercises begin. Strength and proprioception activities lead to return to sport activities prior to returning to full activity.
Post Concussion Return to Play
Concussion, a form of mild traumatic brain injury (TBI), is recognized as a leading public health problem. Each year, an estimated 1.6 – 3.8 million sport-related concussions occur in the United States. The majority of athletes with sport-related concussion recover within a seven to 10 day period; however, children and adolescents require more time to recover than do collegiate or professional athletes. The post-concussion recovery time frame is not scientifically established and is influenced by factors such as age, sex, and history of prior concussions.
Laboratory induced brain injury in rats creates a cascade of neurochemical, ionic, and metabolic changes that alter cerebral glucose metabolism, blood flow, and mitochondrial function. Following a TBI, an initial phase of hyper glycolysis is followed by a prolonged phase of metabolic depression that can last seven to 10 days in adult laboratory rats. This basic pathologic response has been reported after human brain injury in positron emission tomography studies showing a similar pattern of early hyper glycolysis, followed by metabolic depression. In studies of human concussion, athletes who were symptom free at three to 15 days post injury, on average, may not demonstrate complete metabolic recovery until 30 days post-injury.
Most physicians treating concussion recommend a period of cognitive and physical rest in the early post-injury period. Symptoms can increase with cognitive activities (reading, texting, video games) and physical exertion (aerobic and anaerobic exercise). Once the symptoms have resolved, a progressive return to physical activity may be instituted. If prolonged rest is required, especially in athletes, deconditioning of the cardiorespiratory and muscular systems, metabolic disturbances, and secondary symptoms like fatigue and reactive depression may occur. Cognizance of these issues is important, so that the activity restriction phase is not overly long enough to induce unnecessary problems.
In children, most post-concussion symptoms resolve within a month, if not within seven to 10 days. The exceptions are children who have a history of previous head injury, learning difficulties or family stressors. Information on strategies for dealing with posttraumatic symptoms (including the school district’s return to play protocol) have resulted in fewer symptoms and less behavioral changes in children three months after injury. Neurocognitive rehabilitation employs cognitive tasks to improve cognition, or may help in developing compensatory strategies to address difficulties with aspects of cognition, such as attention, memory, and executive functioning.
The key to safe return to contact sport is complete recovery of symptoms. Judicious neurocognitive testing, sign/symptom analysis, rest and resolution of symptoms can lead to a step-wise progression from light aerobic activity, such as walking or stationary cycling, up to sport- or work-specific activities. A key benchmark during recovery is the cessation of symptoms during the step-wise progression toward resumption of full activity.