Alright! As said last night, I am presenting one of the common acute shoulder injuries which is an Acromioclavicular (ACJ) joint injury.
Why is this so common?
The common population with the ACJ injury is mostly contact sport athletes in terms of rugby players. Why is that?
Rugby involves a lot of tackling that exposes a shoulder joint to heavy trauma. Yes! The ACJ injury is mostly direct traumatic.
Not to mention, it is also present in non sporty people who fall over the tip of their shoulder. On top of that, putting overload over the ACJ can be a contributing factor such as benching a heavy weight, overhead activity, carrying a heavy bag, etc.
its common symptoms is pain located in the ACJ. If worse, it can result in referred pain through the lateral side of the neck. It is very rare to have referred pain below the affected shoulder. This is a key difference to cervical radiculopathy.
What is cervical radiculopathy?
Yes! It is the result of nerve root compression in the cervical region. The common affected levels in the Cx are C5, 6 and 7. Just letting you know that cervical area has 7 vertebrates but 8 cervical nerves from C1 to C8. Just came across someone who got confused with this today. Just letting you know:)
Anyways, once the nerve roots are compressed, you should expect neurological symptoms in terms of altered strength, sensation or/and relfex. Why is that? Yes! A nerve contains sensory and motor axons. Imagine! If one of them or both of them are impinged, their axons’ nerve conduction is blocked. Get me?
if this is not the case then, don't worry about the cervical radiculopathy. However, do not underestimate peripheral nerve entrapment. Again, if the cervical region is not involved, that does not mean that it is more likely a shoulder injury. Why is that?
Yes! Thoracic outlet syndrome (TOS) is one of the reasons that you can have shoulder pain, especially, the lower brachial plexus that passes in between the clavicle and 1st rib after running through the inter-scalene triangle. If somewhere in those spots are entrapping the brachial plexus, you are more likey to have neurological symptoms. Why is that? Yes! The brachial plexus is compressed.
However, how do you differentiate between cervical radiculopathy and TOS?
Yes! Think of where the origin of the problem. Ipsilateral rotation and a combination of cervical extension and ipsilatera rotation will surely narrow the affected cervical foramen, impinging Cx nerve root.
What about tests for the Cx radiculopathy apart from Cx rotation and Cx compression test?
Yes! Cx distraction test to take pressure off the nerve roots can decrease the affected arm symptoms. However, in TOS, this test can irritate the brachial plexus. Why is that? Yes! You are overstretching it. This can be a good test. What else? Yes! Hyper shoulder abduction test is my favourite one? Again. 1 test can not give you 100% accurate diagnosis but a combination of relavent tests all together with a good history taking. Right? Anyways, why do I use this test much?
Think of where the nerve root impingement is.
Cervical nerve root impingement occurs in the cervical area. What does it mean to you during hyper-shoulder abduction test?
Yes! This shoulder abduction will shorten the nerve root rather than lengthening it, being able to reduce the neural tension. If dropping your affected shoulder and arm, this position will overstretch the affected nerves. Right?
BUT this same test can aggravate TOS symptoms. Why is that? Yes! Think of where the brachial plexus perpetrate?
Where about?
Yes! In between the clavicle and 1st rib. Right? So hyper-abduction of the shoulder joint can over-lengthen it even more, impinged in that small space. The worse scenario is the depressed 1st rib which will eventually impinge it. Get me?
What other tests? There is a lot. But the importance of differentiate diagnosis is based on how you interpret your assessment findings.
It is not about using the “best” diagnostic test.
Back to ACJ injury.
How severe is the ACJ injury?
There are 6 grades! Thats a lot right?
Grade 1: sprain of the AC ligament.
Grade 2: disruption of the AC ligament
Grade 3: disruption of the CC ligament.
Hang on! What is the CC ligament? Yes! It is costoclavicular ligament that is made of trapezoid and conoid ligament.
Grade 4: posterior dislocation of the clavicle
Grade 5: superior dislocation of the clavicle
Grade 6: inferior dislocation of the clavicle (this is very rare!) this means surgery required if present.
Anyways, why do we have to know its grades?
According to research, its grade 1 and 2 recover well by a conservative physio rehab.
What about grade 3? as said earlier, CC and AC ligaments have been all ruptured. Does it need operation?
I recommend a second opinion from a shoulder surgeon. This case is dependant on age, work demanding, pain belief, past injury history.
Why is that?
The older, the less successful rate of operation. If high level athletic, then surgery can be a good option. If he believes that the operation is the only option, yes! Surgery can be a good option. However, grade 3 can be treated by physio rehab.
If it is not traumatic, then, I will definetly recommend physio. When I say “recommend it”, it means that you have to find a way to imporve its symptoms by assisting in the scapular movement, posterior rotation of the clavicle, activating rotator cuff muscles, increasing thoracic extension and rotation, involving kinetic chain, etc.
This is not about strength problem but altered muscular activity. Once you enhance its movement patterns, then its symptoms will decrease.
I also use taping to depress the clavicle. Once a true clavicle instability due to the disruption of ACJ ligament or CC ligament, then taping to depress the clavicle can be helpful, which can last for 2 or 3 days. Therefore, the important key is to accelerate the rotator cuff activation.
Once pain occurs, it will alter the cortical regions of the brain, deceasing the preconception. This can cause the immediate atrophy of the Gray and white matters of the central nervous system according to some high quality evidence. In other words, if YOU DON'T USE IT, YOU LOSE IT.
ACJ injury can increase the risk of OA. What does it mean to you? Yes! It can cause ACJ stiffness.
It sounds kinda good for the ACJ instability following the ACJ ligament disruption. You definitely need some stiffness that can stabilise the injured ACJ. However this can cause another problem. What is it? Yes! During shoulder movement above 90 degrees, the clavicle has to posteriorly rotate, in order for the scapula to posteriorly tilt. What posterior rotates the scapula? Yes! Lower trap! But if it is stiff, yes! Anterior scapular tilt can be observed, incinerating the activation of pecs, lats, teres major, biceps and brachialis.
What are special tests for ACJ injury?
Yes! I know! I always mention that there are no special tests for accurate diagnosis. Why is that? Sorry to repeat this but I have still seen people using one ?special test to diagnose everything which is impossible.
There are many small and large structures crossing each other with a lot of nociceptors. Once applying the special tests, you are not isolating the affected tissues but pain provocation.
However, a combination of relevant tests with a good history taking can help you with your clinical reasoning.
What tests?
1. horizontal shoulder flexion
2. manual stress over ACJ
3. Horizontal extension with flexed elbow against resistance
4.O’Briens test with internally rotated shoulder but less pain during external rotated shoulder against inferior direction of resistance.
The pain should be locally in the ACJ. No where else!
Sorry for spelling mistakes and stuff.
When I post articles here, I always do this on the move. I am just walking back home while typing this.
Why is this so common?
The common population with the ACJ injury is mostly contact sport athletes in terms of rugby players. Why is that?
Rugby involves a lot of tackling that exposes a shoulder joint to heavy trauma. Yes! The ACJ injury is mostly direct traumatic.
Not to mention, it is also present in non sporty people who fall over the tip of their shoulder. On top of that, putting overload over the ACJ can be a contributing factor such as benching a heavy weight, overhead activity, carrying a heavy bag, etc.
its common symptoms is pain located in the ACJ. If worse, it can result in referred pain through the lateral side of the neck. It is very rare to have referred pain below the affected shoulder. This is a key difference to cervical radiculopathy.
What is cervical radiculopathy?
Yes! It is the result of nerve root compression in the cervical region. The common affected levels in the Cx are C5, 6 and 7. Just letting you know that cervical area has 7 vertebrates but 8 cervical nerves from C1 to C8. Just came across someone who got confused with this today. Just letting you know:)
Anyways, once the nerve roots are compressed, you should expect neurological symptoms in terms of altered strength, sensation or/and relfex. Why is that? Yes! A nerve contains sensory and motor axons. Imagine! If one of them or both of them are impinged, their axons’ nerve conduction is blocked. Get me?
if this is not the case then, don't worry about the cervical radiculopathy. However, do not underestimate peripheral nerve entrapment. Again, if the cervical region is not involved, that does not mean that it is more likely a shoulder injury. Why is that?
Yes! Thoracic outlet syndrome (TOS) is one of the reasons that you can have shoulder pain, especially, the lower brachial plexus that passes in between the clavicle and 1st rib after running through the inter-scalene triangle. If somewhere in those spots are entrapping the brachial plexus, you are more likey to have neurological symptoms. Why is that? Yes! The brachial plexus is compressed.
However, how do you differentiate between cervical radiculopathy and TOS?
Yes! Think of where the origin of the problem. Ipsilateral rotation and a combination of cervical extension and ipsilatera rotation will surely narrow the affected cervical foramen, impinging Cx nerve root.
What about tests for the Cx radiculopathy apart from Cx rotation and Cx compression test?
Yes! Cx distraction test to take pressure off the nerve roots can decrease the affected arm symptoms. However, in TOS, this test can irritate the brachial plexus. Why is that? Yes! You are overstretching it. This can be a good test. What else? Yes! Hyper shoulder abduction test is my favourite one? Again. 1 test can not give you 100% accurate diagnosis but a combination of relavent tests all together with a good history taking. Right? Anyways, why do I use this test much?
Think of where the nerve root impingement is.
Cervical nerve root impingement occurs in the cervical area. What does it mean to you during hyper-shoulder abduction test?
Yes! This shoulder abduction will shorten the nerve root rather than lengthening it, being able to reduce the neural tension. If dropping your affected shoulder and arm, this position will overstretch the affected nerves. Right?
BUT this same test can aggravate TOS symptoms. Why is that? Yes! Think of where the brachial plexus perpetrate?
Where about?
Yes! In between the clavicle and 1st rib. Right? So hyper-abduction of the shoulder joint can over-lengthen it even more, impinged in that small space. The worse scenario is the depressed 1st rib which will eventually impinge it. Get me?
What other tests? There is a lot. But the importance of differentiate diagnosis is based on how you interpret your assessment findings.
It is not about using the “best” diagnostic test.
Back to ACJ injury.
How severe is the ACJ injury?
There are 6 grades! Thats a lot right?
Grade 1: sprain of the AC ligament.
Grade 2: disruption of the AC ligament
Grade 3: disruption of the CC ligament.
Hang on! What is the CC ligament? Yes! It is costoclavicular ligament that is made of trapezoid and conoid ligament.
Grade 4: posterior dislocation of the clavicle
Grade 5: superior dislocation of the clavicle
Grade 6: inferior dislocation of the clavicle (this is very rare!) this means surgery required if present.
Anyways, why do we have to know its grades?
According to research, its grade 1 and 2 recover well by a conservative physio rehab.
What about grade 3? as said earlier, CC and AC ligaments have been all ruptured. Does it need operation?
I recommend a second opinion from a shoulder surgeon. This case is dependant on age, work demanding, pain belief, past injury history.
Why is that?
The older, the less successful rate of operation. If high level athletic, then surgery can be a good option. If he believes that the operation is the only option, yes! Surgery can be a good option. However, grade 3 can be treated by physio rehab.
If it is not traumatic, then, I will definetly recommend physio. When I say “recommend it”, it means that you have to find a way to imporve its symptoms by assisting in the scapular movement, posterior rotation of the clavicle, activating rotator cuff muscles, increasing thoracic extension and rotation, involving kinetic chain, etc.
This is not about strength problem but altered muscular activity. Once you enhance its movement patterns, then its symptoms will decrease.
I also use taping to depress the clavicle. Once a true clavicle instability due to the disruption of ACJ ligament or CC ligament, then taping to depress the clavicle can be helpful, which can last for 2 or 3 days. Therefore, the important key is to accelerate the rotator cuff activation.
Once pain occurs, it will alter the cortical regions of the brain, deceasing the preconception. This can cause the immediate atrophy of the Gray and white matters of the central nervous system according to some high quality evidence. In other words, if YOU DON'T USE IT, YOU LOSE IT.
ACJ injury can increase the risk of OA. What does it mean to you? Yes! It can cause ACJ stiffness.
It sounds kinda good for the ACJ instability following the ACJ ligament disruption. You definitely need some stiffness that can stabilise the injured ACJ. However this can cause another problem. What is it? Yes! During shoulder movement above 90 degrees, the clavicle has to posteriorly rotate, in order for the scapula to posteriorly tilt. What posterior rotates the scapula? Yes! Lower trap! But if it is stiff, yes! Anterior scapular tilt can be observed, incinerating the activation of pecs, lats, teres major, biceps and brachialis.
What are special tests for ACJ injury?
Yes! I know! I always mention that there are no special tests for accurate diagnosis. Why is that? Sorry to repeat this but I have still seen people using one ?special test to diagnose everything which is impossible.
There are many small and large structures crossing each other with a lot of nociceptors. Once applying the special tests, you are not isolating the affected tissues but pain provocation.
However, a combination of relevant tests with a good history taking can help you with your clinical reasoning.
What tests?
1. horizontal shoulder flexion
2. manual stress over ACJ
3. Horizontal extension with flexed elbow against resistance
4.O’Briens test with internally rotated shoulder but less pain during external rotated shoulder against inferior direction of resistance.
The pain should be locally in the ACJ. No where else!
Sorry for spelling mistakes and stuff.
When I post articles here, I always do this on the move. I am just walking back home while typing this.
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