This 17 year old male football player injured his shoulder following being tackled during football game. Based on your impression of this image what are the possible injuries that could be shown here? What other injuries might you want to rule out based on his mechanism of injury? Based on your impression how would you proceed with therapy during the first several weeks if he came to see you one week after this injury?
This looks like an AC joint separation. Need to do a neurological screen of the upper quarter to rule out any neuropraxia to the brachial plexus and subsequent nerves or compression vascular structures leading to other issues. Other tests should be done to rule out a rotator cuff tear or a SLAP injury; patient may also have impingement of the joint due to possible abnormal positioning of the shoulder, impingement tests should also be completed. His arm is hopefully in a sling the first week when he comes to see you and he has already been to the medical doctor and they have decided to do conservative care and not surgical repair. Therapy should consist of: education; modalities for pain relief (ice, e-stim); AROM of fingers/wrist/elbow; gentle ROM of the shoulder; shoulder and scapular isometrics progressing as tolerated with no pain; mobilization of the AC joint as indicated if joint motion is limited; and reduction of muscle spasm in the upper trap/levator if present. If injury remains painful for several weeks more, he needs further evaluation by the doctor.
ReplyDeleteI would agree with Zach that this looks like an AC joint separation. You can see the space between the Acromion and the Clavicle as well as the depression of the scapula and GH joint. Possible nerve injury could be possible due to the traction force on the arm during the MOI and these need to be ruled out as well as looked for during the first few weeks. You are obviously seeing this patient after the radiograph so hopefully any fractures have been ruled out but like Zach said above neurological symptoms and vascular symptoms need to be observed and have any issues with these systems ruled out. Some base line tests and measures should be taken to help show progression. Special tests including impingement, RTC, and labrum tests can be done as well as strength of both UEs. Grade I/II mobs can be done to help with any pain but grade III/IV would probably be avoided due the hypermobility of the AC joint. Protected ROM and strength can be initiated early with focus on maintaining ROM and strength focusing on the RTC and scapular muscles to maintain correct shoulder girdle motions. The patient needs to understand that their arm needs to be protected but they also need to continue to use it in certain ways to not add more problems to the one they already have.
ReplyDeleteThe main possible injury that I see here is an AC joint separation. Based off just this image it is hard to tell exactly how much separation there is, but by looking at it I would guess this is a Grade II or III sprain. With a direct blow there is the potential for various soft tissue injuries and injuries to other bones that are possible and may be shown on this image, but the AC sprain is the main one I see. Based on his mechanism of injury I would want to rule out any fractures to the humerus, clavicle, or scapula. The treatment of an AC separation is very varied, but if it was a Grade III sprain they may be immobilized for 3-4 weeks. If it was a Grade II sprain they would often be out of the sling after 1 week, so I would begin with gentle pendulum exercises as well as gentle PROM and AAROM. I would use ice as needed for pain and swelling. As the pain allowed I would also start them on shoulder and scapular strengthening. I would have them perform I’s, Y’s and T’s and rows in prone with weight as tolerated for 3 sets of 15. I would also work on strengthening the rotator cuff muscles in a pain free range.
ReplyDeleteI believe that this xray is showing a AC joint separation and maybe a fracture of the acromion. Other injuries that I would want to rule out would include a fracture of the acromion, fracture of the end of the clavicle, rotator cuff tear based on the Essentials of Musculoskeletal Care book from Jon Harris’ class. Also from this book it says that a type III injury shows complete displacement of the clavicle above the superior border of the acromion with a 30% to 100% increase in the CC interspace. For treatment, the book says that many type III injuries can be treated nonsurgically with good functional results. Since this patient is only 17, I would wonder if they would choose to do surgery or not. If they didn’t do surgery, then I would start with a HEP that would include sidelying ER, sidelying IR and prone scapular retraction /protraction and have him participate in AAROM in pain free range in the clinic. I agree with Zach to include ROM for elbow, wrist and hand. I might do some modalities based off how much swelling and pain that he has. I’d also tell him to not play football for a couple of weeks. The next couple of weeks would depend on how he presents back in the clinic on subsequent sessions. Hopefully I’d be able to increase the AAROM to AROM without pain and start strengthening all of the shoulder muscles including the rotator cuff.
ReplyDeletePiano Key sign (AC joint separation) A grade II or III. With trauma you should screen for possible other injuries such as a fx or RC tear depending on how the fall occurred. Making sure there are no neurological issues as well as obstruction of an artery such TOS. I would suggest immobilizing for 3-4 weeks to allow proper healing time and not put anymore stress on a grade III sprain, grade II 1 week and begin pendulum exercises along with PROM and AARoM. You could use ice as need for increased swelling in the area and pain, if pain is significant apply electrical stim for relief. While in the sling focus on maintaining good elbow and wrist and finger strength/ROM. Then once d/c from the sling work on slowly progress the patient from PROM, AAROM, AROM, strength and stability exercises. Focus on RC and do I, Y’s and T’s starting with no weight and progressing to the weight as tolerated increasing strength while still stabilizing the AC joint.
ReplyDeleteI would agree with everyone else on the AC joint separation. You can clearly see the separation and the depression of the scapula. I can't get the x-ray larger so from this picture that is all that I can tell. I would also want to do a neurological screen to see if there was any injury to the nerve of the shoulder. I would also look for any fractures or torn tissue such as RTC tears. I would assume that when they came to see the PT the Dr had cleared them for therapy. I would start them off with PROM, AAROM and modalities to decrease pain and regain motion loss, education on what to expect and the use of ice if needed for decreased swelling. The next step would to begin some light strengthening. I would probably start them with isometrics to strengthen shoulder and scapular muscles and then work up to more resistance.
ReplyDeleteLike my fellow classmates, I also believe this radiograph indicates this patient sustained an acromioclavicular joint or shoulder separation. The mechanism of injury indicates downward force applied through the acromion process from direct blow which could occur if a football tackle is performed correctly. I would likely call this a type II or type III injury because there is disruption of the AC ligaments and the AC joint space is wider due to disruption. Other injuries that I would want to rule out based on the MOI include any possible fractures of the scapula, humerus, or clavicle, neurological involvement like TOS, a rotator cuff tear, glenoid labrum tear, and impingement syndrome. I would treat this patient initially with a sling (most likely prescribed by the physician), education to avoid any and all activities that impart compression to the AC joint, modalities such as ice and e-stim to manage pain, possibly taping to provide additional stability and decrease pain, and functional range of motion for the entire shoulder girdle. Once this patient has regained the majority of their shoulder motion (approximately 75% of opposite shoulder) and their pain level is minimal, I would continue with more ROM activities and begin to incorporate strengthening exercises to help increase AC joint and shoulder girdle stability. As long as the patients pain level is minimal and the physician agrees the pt can discontinue use of the sling and perform ROM and strengthening exercises including rotator cuff strengthening exercises such as IR, ER, shoulder flexion and extension to 45 degrees, I’s, Y’s, and T’, bicep curls, tricep kickbacks (not overhead), forward, scapular, and abduction raises, serratus punches, bear hug, chest press, rows, horizontal abduction, D1 and D2 flexion and extension. With further progression of strength and ROM I would begin to incorporate closed chain upper extremity activities including plantigrade and quadruped activities, planks, planks with step ups, and push-ups. All of these exercises would be performed only if no pain is present and with low weight/resistance (dumbbell and/or theraband) and higher repetition to increase endurance of the muscles as well as stability of the scapular and shoulder girdle musculature.
ReplyDeleteSimilar to my classmates, I suspect a sprain of the acromioclavicular joint in this particular patient. I think we also need to look into rotator cuff pathology, as well as brachial plexus contusion, or other upper extremity nerve injuries. Labral pathology is not out of the question either, and would warrant further investigation. Since I assume this patient is probably going to be in some sort of pain, modalities like ice and IFC/TENS would be a good place to start for pain modulation. I would then proceed with gentle PROM exercises to patient tolerance, and I think gentle active-assisted exercises within pain-free ROM (i.e. pulleys, wand exercises) would also be a good plan. Once the patient was pain-free with ROM, I would begin some gentle isometrics. At the beginning I might do these exercises with the patient's arm supported, then progress to against gravity. I think a HEP to continue ROM exercises at home is a good plan, as well as cryotherapy and modalities as needed, then wean off of these as patient continues to be able to do more activities with less increases in pain.
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ReplyDeleteI agree with my classmates, this image clearly shows an AC joint separation (piano key sign). If I were assessing this injury without the use of imaging I would want to rule out any kind of clavicle fracture, or AC sprain. This mechanism of injury could possible implicate torn musculature in the rotator cuff, further testing could be useful to determine the extent of muscle involvement. With this image I would favor a grade III sprain and my first step would be for immobilization for 3-4 weeks, definitely remove the patient from participation in football. We would begin activities without resistance for pendulum exercises, AAROM activities with a cane or pullies. Progress toward strengthening with resistance exercises then move toward closed chain activities for pushups and overhead resistance activies. Using modalities as needed for pain and swelling throughout treatment. Ultimately progressing toward return participation in football.
ReplyDeleteBased on the image, it appears that the patient has separated his AC joint. It is evident that there is space between the distal end of his clavicle and the acromion and could be either a grade II or III separation. Other pathology that should be ruled out include fractures, nerve damage or impingement, RTC and labrum. For the first few weeks o therapy, it should include pain and swelling management including cryotherapy since his is an acute injury. Begin with PROM progressing towards AAROM and then to AROM. Activities could include pulleys, finger ladder, or wall clocks. I would focus on isometric strengthening first, particularly with scapular retraction to provide dynamic stability of the AC joint. Other initial strengthening options include rhythmic stabilization, rhythmic initiation, contract-relax, and hold-relax. I would progress the patient into progressive resistance exercises with the theraband and eventually to weights. Soon after, I would work on functional activities and implement a home exercise program.
ReplyDeleteI agree with my classmates that this injury radiograph shows AC joint separation or a piano key sign. If the patient presented to me, a week after injury, I would assume he already had been evaluated by a physician and was placed in a sling for at least 1 week with a type II sprain. If type III sprain was suspected, 3-4 weeks of sling use would be appropriate. I would want to rule out the possibility of other injuries including scapular, humeral, and clavicular fractures, rotator cuff tear, SLAP lesion, and impingement syndrome. To begin therapy, I would complete AROM and light strengthening exercises for the hand, wrist, and elbow to maintain functional strength and motion in those joints. Pain relief modalities would be applied as indicated to the AC joint such as ice and E-STIM. I would assess PROM, in a non-painful range and progress to AAROM as tolerated by the patient. After discontinuing use of the sling, progression would be towards AROM exercises and scapular and overhead strengthening including I's, Y's, T's, eccentric pulleys, closed chain serratus strengthening, and return to sport conditioning drills.
ReplyDeleteThe imaging shows a very clear AC joint separation, probably a Grade 3 and this diagnosis would seem to be in line with the mechanism of injury. I am not sure if this patient opted for surgery but that would impact testing and treatment. However, I would do a neurological screening of the bilateral UE, check for vascular compromise in the bilateral UE, screening examination for the cervical region, and check the mobility of the SC joint. I would also run through the tests for a rotator cuff injury and SLAP. As noted by my classmates, Grade 3 AC joint separation generally requires the patient to be in sling for 3-4 weeks during this time therapy focus would be on pain relief with modalities (IFC and ice), hand, wrist, and elbow light strengthening exercises, scapular isometrics, possibly some mobilizations to the SC joint or cervical spine as indicated and gentle PROM of shoulder in pain free range progressing toward AAROM and then AROM. Once out of the sling I would begin slightly more aggressive scapular, inferior and posterior mobilizations of the glenohumeral joint and rotator cuff strengthening. More than likely any exercise that approaches the close-packed position of the AC joint will increase their pain and will likely be gradually worked toward.
ReplyDeleteI also agree with my classmates that this patient is presenting with an AC joint separation. Assuming this patient has already seen his PCP and obtained this x-ray to confirm this and hopefully rule out any fractures. Based on his MOI, I would also want to complete special tests to rule out any other pathologies such as rotator cuff tear, SLAP lesion or impingement syndromes. With an understanding that this injury may be associated with a Neuropraxia, I would want to check integrity of the nerves by checking sensation and any muscle atrophy. I would start out by educating pt on the importance of continue use of sling until d/c by doctor to prevent further injury. Then I would start out with PROM if tolerable by patient. I would also work AROM and strengthening exercises for the hand, wrist and elbow to maintain current function of those joints. Depending on pt's pain level, I would utilize e-stim and ice to help reduce any pain. In the coming weeks, I would progress to AAROM an AROM along with gradually employing strengthening activities to regain the lost stability and strength. I would focus on scapular muscles beginning with gentle scap squeezes and progressing "Y","T","I"s, utilizing theraband and weights as appropriate. I would also incorporate stabilization activities such as supine stabilization with a weight a body blade or therabar. Eventually working into sport specific exercises to ensure appropriate strength, stability and function for return to sport.
ReplyDeleteMy impression of the type of injury involved is an AC injury. I agree with Rhonda that it is either a type II or type III. It is hard to see with the x-ray whether it is just the coracoacromial ligament that is disrupted or both the coracoacromial and coracoclavicular ligaments. I would want to do a neurological and vascular screening to ensure that nothing else was injured with the tackle. I would include special testing for any labral tears or rotator cuff injury due to the supraspinatus and infraspinatus passing under the AC joint. I might also screen for impingement later on as the AC joint heals. As several of my classmates said, I hope he comes into the clinic wearing a sling, and that the doctor has already informed him of the importance wearing it for one to two weeks. My therapy would also include educating him on the importance of wearing his sling and joint protection. I would also start with gentle exercises for the hand, wrist, elbow, and scapula. PROM and AAROM exercises would be given to the involved shoulder. Ice and compression can be used to decrease the swelling with electrical stimulation either interferential for pain relief or high volt to expedite the healing process. Exercises would be progresses as tolerated to include AROM, and glenohumoral and scapulothoracic stabilization exercises would be given within two to three weeks when the patient has full ROM.
ReplyDeleteI too, believe that the image shows an AC joint separation, noted by the displacement of the clavicle with the depressed acromion. Fractures and nerve injuries would need to be ruled out prior to or during the initial evaluation. It would also be good to evaluate any damage to or limitations of the rotator cuff. Impingement is possible with this injury as well, therefore special tests should be performed. This patient will most likely come to PT in a UE sling. PT would be limited to gentle PROM and modalities (ice, e-stim) initially, however progressing to (A)AROM and strengthening (isometrics, resistance) as the patient progresses. The patient can preform wrist and hand strengthening exercises while in the sling. Scapular strengthening and joint stabilization exercises would be beneficial as the patient progresses. Joint mobilizations can be performed once the sling has been discontinued and restrictions have been lifted.
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ReplyDeleteThe radiograph images displays an AC joint separation of either Type II or III judging by the wider separation of the AC joint. When first seeing this patient I would want to rule out any other possible injuries including rotator cuff issues, nerve entrapment or injuries, or possible fractures. The patient would initially be in a sling for about 1 week with a Type II or 3-4 weeks for a Type III injury. Gentle PROM should be started at 1 week as well as beginning to allow the patient to use the arm for ADLs and using modalities as needed for pain modulation. The patient would then progress to functional AROM, postural education, and joint mobilizations if no hypermobility noted in the AC joint, and strengthening of the trapezius, deltoid, rotator cuff, and all scapular muscles with isometrics, rhythmic stabilization,resistance bands, closed chain exercises, etc and would be progress as tolerated with increased difficulty. Since the patient is an athlete, I would try to incorporate more sport specific activities towards the end of therapy.
ReplyDeleteI believe that the X ray indicates an AC joint separation, probably a type 3 injury due to the amount of separation. Upon initial eval the patient would probably complain of point tenderness/pain over the AC joint especially when lifting the arm, and with a type 3, there will be a visible deformity of the AC joint with the clavicle displaced superiorly from the acromion. The pt will most likely after the arm supported in an adducted position due to instability and because abduction is painful. It would be important to rule out any other traumatic fractures that may have occurred with this injury, nerve or vascular injuries, and possible RTC injuries or impingement due to displacement that may have occurred. Considering this is a young athlete I would hope that they would do surgery to repair this so he could avoid future dislocation injuries if he continues to play football. However, if they didn't do surgery, I would expect the patient to use a sling for 4-7 days since it is a large separation. I would start the patient with gentle PROM but not pushing end range yet and the use of any modalities to help reduce pain and inflammation at the site of the injury, along with postural re education. Pt would progress to AAROM with pulleys and UE ergometry and start strengthening the scapular muscles to help build back up the dynamic stability of the entire shoulder complex. If the AC joint demonstrated any kind of stiffness I would perform joint mobs. Next I would progress to AROM and RTC strengthening, eventually progressing to more sport activity related exercises and drills. Towards the end of treatment I would want the pt to start working out with their team again, not maxing out, to see how the patient tolerates it and eventually, with doctor release, release them to full work outs.
ReplyDeleteThis is clearly an acromioclavicular joint separation possibly a grade II or III. If I didn't have access to the radiograph I would want to rule out humerus, clavicle, and scapula fractures due to the MOI. I would also want to perform a full neuro exam and evaluate the integrity of the vascular structures. I would access soft tissue structures to rule out RC pathology, labral impairments, and other ligamentous injuries. During the initial weeks of therapy I would start out with gentle PROM and AAROM utilizing ice to help control pain and inflammation along with AROM of elbow and wrist, progressing to light isometrics to promote scapular stabilization and increase strength of RC.
ReplyDeleteAs my classmates have said, I believe this radiograph displays an acromioclavicular sprain. There is a clear separation of the distal portion of the clavicle and the acromion. The scapula and the glenohumeral joint are clearly inferior to the clavicle. Due to the mechanism of injury I would want to do an UE neuro exam, test for vascular injury/compromise, RTC injury, Labral injury, rib injury, cervical spine injury and I would also want to check the stability of the SC joint. If the patient was in a sling (as ordered by the doctor) I would focus on ROM of the elbow and wrist and take initial goniometric and strength measurement. I would also focus on pain/swelling control by using ice and electrical stimulation if warranted. I would work on PROM and progress the AAROM and the AROM. Progression would be based on patients ability to do the exercises in a pain-free ROM. For strengthening I would start with exercises such as rhythmic stabilization, scapular stabilization exercises, RTC strengthening exercises, and postural re-education exercises. As the patient progressed I would want to start incorporating sport specific exercises to make sure that the patient was able to handle sport type exercises prior to discharge.
ReplyDeleteIt looks like a AC joint separation from the X-ray, there is a clear separation: the inferior distal aspect of the clavicle is above the superior aspect of the acromion, it would be Grade III, it is hard to tell the soft tissue integrity but based on this plain film and the degree of separation: the AC and CC ligaments are probably disrupted. Based on this mechanism of injury: I would do a screening to rule out fractures of this area. A neuro exam will be needed to rule out any brachial plexus involvement from reflex testing and nerve tension test and strength test as well as subjective report of pain, tingling/numbness and/or loss of strength. Check the surrounding soft tissue: muscle stains including: RTCs, biceps: long head,, and PROM and AROM for GH joint and capsule integrity. Early interventions: pain management from pain relieving exercises with some modality (i.e IFC/TENS), PROM to AAROM to AROM to promote movement and stabilization exercises if patient able to tolerate, PNF and rhythmic stabilization would be a safe start. Later on introducing to global exercise cooperating T/S mobility and muscle stabilization of the area.
ReplyDeletePossible injuries that could be shown include AC joint separation. Based on this mechanism of injury I would also want to rule out clavicle, acromion, or coracoid fractures or rotator cuff tear. I would proceed with therapy in the first few weeks with care. I would first work on getting pain under control with modalities to decrease pain/swelling and gentle PROM. After that I would focus on increasing pain free ROM followed by easy strengthening. Some exercises included might be scapular protraction/retraction, shoulder ER and IR rotation, Is, Ys, Ts, and posture training. Ultimately I would want to work this patient back to football related activities but depending on how the patient responds to treatment this may take more than a few weeks.
ReplyDeleteI would say that the player has AC joint separation with possible clavicle fracture.
ReplyDeleteI would want to make sure that the individual’s nerve (brachial plexus) and vascular systems were intact. Also I would want to rule out a concussion and possibly cervical injuries.
I would start him out with ball squeezes, elbow ROM with his arm at his side, scapular retractions, pendulums, and modalities as needed to reduce pain and swelling.
From the radiograph image it looks like he suffered an acromioclavicular joint separation. He may also have a number of ligamentous tears and fractures of the clavicle, scapula, humerus, and possibly ribs. Because of the high impact cause of his injury it would be important to do a full UE screening for neurological and arterial/venous injuries. To proceed with therapy, I would start with very light exercises of the hand/wrist and elbow to keep his strength. I would also have to be very cautious of pain and utilize modalities like ice and ESTIM. After one week I would try to incorporate more shoulder passive range of motion exercises, not many going well over the head though depending on pain. As pain subsides I would work into isometric strengthening of the shoulder at the side of the body and scapular strengthening. Slowly I would progress to more active motion of the shoulder with wall climbs and pulleys again watching out for pain. As the patient progresses more dynamic functional activities would be utilized including lifting low weights above shoulder height.
ReplyDeleteFrom the image it appears to me to be an AC joint separation with possible acromion fracture. You can see the piano key deformity when you look at the soft tissue outline. Based on his MOI you would want to rule out any other fractures, subluxation/dislocation, RC tear, SLAP tear, and a Bankart lesion labrum tear (TUBS). A more detailed history of exactly which way he was going and where he was hit would be beneficial to determining the injury based on subjective information. This is something my last CI did a very good job of: asking very detailed questions for the subjective portion of acute injuries. You would also want to check both subjectively and objectively for any nerve or vascular involvement due to the traumatic nature of the injury. Judging by the severity that appears in the radiograph I would guess that he was probably in a sling for the week between injury and my evaluation and may need to remain in one for a while after the first week depending on physician preference and the actual severity of the separation or if there is an acromion fracture or not. I would begin acutely with modalities prn for pain and PROM/AAROM. Then I would progress to isometrics of the RC and shoulder muscles as well as the scapular muscles. As the patient makes progress, AROM and resisted exercises can be performed for shoulder and scapular muscles with emphasis on decreasing any compensatory patterns. If he is a linemen I would be sure to include CKC exercises (would include them anyway but may focus more if he is a lineman) as part of his return to sport regimen.
ReplyDeleteThis image shows a very distinct piano key sign indicating an AC joint separation. I would call this a grade III separation according to the amount of space between the clavicle and acromion. Due to the stated mechanism of injury I would perform a complete upper extremity exam including special tests to rule out a rotator cuff tear or a labral pathology, and check for TOS or other neurological pathologies. I would also check for further fractures of the upper extremity specifically of the clavicle, scapula or humerus. If this patient presented 1 week post injury with a referral, I would assume he was in a sling already, and if this were a grade II sprain I would assess the patient further to determine if he was able to discontinue his sling, but if this were a grade III separation I would leave him in the sling at least another week or two. I would perform modalities such as e-stim and ice to decrease pain and inflammation and work on wrist/elbow mobility as well as PROM of the shoulder in a non-painful range and weaning of the sling while using postural education to increase endurance of the muscles to prevent muscle spasm or tension post immobilization. Progression to AAROM (pulley, UBE, cane AAROM, ranger) to increase scapular strength and stability as well as mobility of the rotator cuff muscles. I would then progress the patient to shoulder isometrics and very light AROM activities (prone I,Y,T, scapular rows, supine punches) as tolerated by the patient. I would continue to progress AROM with greater repetitions, then move to less reps/increased weight. Once the pt. gained enough strength and control we would begin further proprioception activities as tolerated and endurance/perturbation exercises. I would then move forward to return to sport activities.
ReplyDeleteBased on my impressions of this image, I feel that this patient has suffered an AC joint sprain. This is based on the fact that the acromion process is visibly inferior to the clavicle. I would use the information provided by the image combined with the mechanism of injury to confirm the diagnosis. If the patient were tackled with the arm adducted to the side and driven onto the shoulder, this would coincide with the idea of the AC joint sprain. Based on this injury it would be important to rule out any neurological conditions such as a brachial plexus injury. You would also want to MMT to check for any strain or tear of the RTC musculature. During the initial evaluation, base level strength and ROM of the contralateral elbow/wrist/hand would want to be documented in order to insure the patient has returned to baseline following therapy. Depending on the severity of the sprain vs. dislocation, early treatment would consist of pain and inflammation control with a transition into maintaining/improving ROM and finally transitioning into strengthening. The strengthening process would begin with isometric exercises progressing to concentric/eccentric exercises following decreased pain and adequate ROM.
ReplyDeleteIt is obvious from the image that there is acromioclavicular joint separation, possibily grade II or III based on the piano key sign. Because of the contact MOI I would want to rule out other fractures and dislocations (possibly of the proximal clavicle), and any other muscular injuries such as a SLAP injury, rotator cuff tear, or Bankart lesion.
ReplyDeleteBased on your impression how would you proceed with therapy during the first several weeks if he came to see you one week after this injury?
One week after injury the goal of therapy would be to gain all information on MOI and perform a thorough evaluation. Assuming that the patient would still be in great pain I would focus therapy on pain management to decrease swelling and develope a POC that would work up this patient to full use and eventually coming back to football. Initially, in the first few weeks, I would educate the patient on resting the arm, but not letting it become stiff, as well as on posture. I would reinforce sling use that the doctor would have likely given them. For hands on work I would perform PROM in a non painful arc for the shoulder and have the patient perform AROM at the elbow and wrist. I would use modalities such as e-stim to decrease pain. I would then progress to isometric strengthening of the surrounding scapular and upper extremity muscles. His pain would be a guide as to how far we progessed him in the first few weeks.
Based off the image it is apparent that there has been trauma sustained to the AC joint. It has a significant amount of gapping and is likely a grade II –III injury. There could also be fracturing around the damage site that we are unable to see. I would likely want further imaging with a CT scan or an MRI to help rule out other damage done if they were not seeing significant progress in 3-4 weeks with pain. I would not proceed with a large amount of therapy for the first few weeks. With this image, I would like the physician to clear him for activity. I would progress PROM as tolerated keeping pain minimal. The HEP would consist of pain management and patient education on how to prevent further damage to the joint.
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ReplyDeleteThe picture clearly shows an AC joint separation. It is hard to tell what grade of separation it is, but if its grade II or III separation then there could be disruption of the coracoclavicular ligaments and AC ligaments. There could be a fracture of the AC joint. Palpate to check for tenderness of the AC and CC ligaments. Perform an upper quarter neuro screen to assess damage to nerves in the area. Also examine the vascular structures as well. Perform special tests to rule out damage to the RTC or other soft tissue structures surrounding the shoulder. Further imaging such as an MRI maybe needed to rule out soft tissue damage. Start off with conservative treatment consisting of gentle PROM and mobililzations with IFC and ice. Progress the patient to AAROM consisting of cane exercises in supine progressing to standing. Eventually progress to AROM and isometrics. Perform scapular and shoulder stabilization exercises consisting of rhythmic stabilization and other PNF strengthening techniques.
ReplyDeleteThe radiograph appears to show an AC joint separation possibly a grade II or III. I would want to do an upper quarter screening to make sure all neuro and vascular systems are intact, especially with the brachial plexus running right through the affected area this can be done by testing the patients sensation ( sharp/dull), blood flow to the affected arm (allen’s test), and reporting a pain number and description to see if any abnormalities arise. Testing of the rotator cuff, labrum, ROM and MMT of the GH joint on both sides, and the stability of the right scapula would also need to be tested to see if any muscular imbalances occurred. Initial treatment would depend on the severity of the separation with rest, ice, and compression initiated immediately along with education to continue elbow and wrist ROM. As therapy progressed I would add shoulder pendulums, gentle PROM and AAROM with pulley’s, seated table flex and horiz ABd/ADD using a rolling stool for the patient to move the body instead of actively moving the arm, and/or supine wand exercises. To progress I would add more scapular stability/strengthening exercises and gravity eliminated exercises for the rotator cuff muscles until adequate strength is obtained then progress to against gravity and/or free weighs.
ReplyDeleteThis radiograph suggests a possible AC joint separation as the distal end of the clavicle is elevated as compared to the acromion. This is very common during football as a player is tackled and their shoulder driven into the ground disrupting the AC and coracoclavicular ligaments. The elevation of the clavicle is called a piano key sign. This would suggest a possible grade II or grade III type of AC joint separation as evidenced by the elevation of the clavicle on the acromion. This type of injury would cause possible damage to the AC ligament, and trapezoid and conoid ligaments as well which are collectively known as the coracoclavicular ligament. Other possible injuries that are common with his MOI include: shoulder impingement, clavicle fracture, rotator cuff tear, TOS, shoulder dislocation and labral tear. With this extent of an injury, if he would like to play contact sports in the future I am sure that he would have surgery such as surgical fixation of the AC joint and coracoclavicular ligament. He could also opt for a conservative approach which would consist of a lengthy time in immobilization. Either way, I would be very conservative in my rehab approach. Day 1 I would spend a considerable amount of time educating the patient on his injury and on the importance of immobilization and avoidance of hard impact or demanding activities on his shoulder to let the ligaments heal properly. I would also use TENS, ICE and possibly cold/compression to reduce swelling and pain. I would also focus on postural education, elbow and hand AROM, gentle shoulder PROM progressing to AAROM. I would also focus on scapular strengthening and GH strengthening starting with isometrics and progressing as tolerated. I would also focus on decreasing muscle tension in the upper traps and levator scap as this produces a painful shrug during GH elevation. I would also work on RTC strengthening and lower trap for scapular stabilization.
ReplyDeleteI believe that this is an AC joint separation. The patient could have possible nerve damage to his brachial plexus, vascular structures, muscle contusions, or labral injuries. You would want to do special test for SLAP, rotator cuff tears, impingement, thoracic outlet test, and neurological screens to rule out those possible injuries. You would also want to rule out fractures to others structures such as the scapula and clavicle with radiographs. For treatment I would start conservatively with patient education about proper positioning and precautions, modalities to address their pain and any swelling, gentle ROM to the shoulder without pain, active ROM to the elbow and fingers, progressing to isometrics as tolerated without pain, joint mobilizations for pain and then increased motion, progress to increased AROM and strengthening exercises for rotator cuff muscles and scapular stabilizers.
ReplyDeleteThe radiograph appears to be a grade II or III AC joint separation. Based on what a surgeon told me last summer I would assume that this patient would be a surgical candidate due to the role that clavicle plays with glenohumeral mechanics being compromised. With an impact injury I would want to rule out a hil sachs injury, SLAP or bankart. I would also screen the for neurovascular involvement to rule out traction or brachial plexus injury. I would do a full shoulder exam checking fro impingment, RTC tear or labral tear as tolerated by the patient but the shoulder is likely not going to tolerate a lot of movement early on. For treatment I would start with PROM as tolerated at the shoulder and focus on restoring scapular mechanics and strength depending on the findings from the evaluation, as well as active range of motion of motion/strengthening of the lower arm.
ReplyDeleteThis image clearly shows an acromioclavicular separation. It is a type III AC joint separation which involve complete disruption of the acromioclavicular and coracoclavicular ligaments, resulting in 100% superior displacement of the clavicle. You may want to rule out medial or distal clavicle fracture, acromial process or coracoid process fracture. Rotator cuff tear be also be present. You may also want to check for a SLAP tear. The pt will present into the clinic with sling to immobilize the upper extremity to reduce pain and inflammation. Initial rehab focus on PROM and closed chain scapular activities, scapular squeeze, horizontal abduction with external rotation and prone horizontal extension with arm at 100 degrees. Pt may progress to rowing exercises with theraband or resistance machines. Then progress to open chain exercises to enhance shoulder function, such as lawn movers.
ReplyDeleteCote PC, Wojcik KE, Gomlinski G, Mazzocca AD. Rehabilitation of Acromioclavicular Joint Separations: Operative and Nonoperative Considerations. Clinic in Sports Medicine. 2010. 29(2):213-228
Based on this image it look lack the patient suffered an AC joint separation due to the increased AC joint space distance and the increased coracoclavicular distance as well as the relative depression of the scapula and GH joint. Due the increased distances and the contour of the soft tissue, I would say this patient mostly likely has a piano key sign and that this is a grade III injury, but AP stress films could be used to better evaluate coracoclavicular distance and the acromioclavicular distance. With this patient other fractures must be ruled out especially of the distal clavicle, acromion, and head of the humerus. In this image something doesn’t look quite right in the area of the coracoid process so that would need further investigation. Due to the MOI and the appearance of the subacromial space, I would check for neurological symptoms, vascular supply, and RTC injuries. I would also screen the cervical spine. Based on my impression, if the patient does have a grade III injury the first several weeks of therapy should focus on education and decreasing pain. Initially while he is immobilized, I would start with exercises for the elbow, wrist and fingers to maintain ROM and increase circulation. After the period of immobilization, gentle shoulder PROM can begin progressing to AROM as tolerated with no pain.
ReplyDeleteThis image clearly shows a separated AC joint. Things to rule out would be fractures, impingement, vascular or neurological compromise, RTC tear, or SLAP lesion. Therapy should include education of preventing further damage, and pain modalities. To prevent decreased mobility AROM should be done of the wrist and elbow as well as passive shoulder ROM within a pain free range. These can be progressed as the patient can tolerate. Eventually isometric scapular strengthening can be added as well.
ReplyDeleteThe radiograph taken reveals separation of the R AC joint. The degree of involvement would be either a Grade II or III. A grade II involvement would require the use of a sling for atleast 1 week and a grade III from 2-4 weeks. Differential diagnosis to rule out while performing the patient exam would be: Colle's fracture (with a fall onto outstretched arm), scapular/humeral/clavicular fractures, labral tears, RTC tears, vascular/neurological involvement, and sternoclavicular joint. Initial interventions should include educating the patient on the specifics of the injury and how to protect it, PROM and AAROM in a pain-free range to prevent any further decrease in mobility, and modalities as needed for pain. As patients symptoms decrease, treatment will progress to light isometric strengthening of the RTC and scapular stabilzing musculature.
ReplyDeleteNot to sound like a broken record player but it's a separated AC joint. I am guessing the Acromioclavicular ligament is completely ruptured and possibly the coracoclavicular as well, so type II or III needs further evaluation. I would want to rule out glenohumeral dislocations, rotator cuff tears, scapula fractures, avulsion fractures at the sight of the AC joint split, proximal dislocation of the clavical. Biceps tendon, SLAP tear, any other labrum damage. If the patient has not already visited his primary care giver or an orthopedic surgeon I would recommend they pay them a visit for surgical consult. The patient will need a neuro screen of the UE to check for nerve apraxia. Since the patient lived a week post this injury I am guessing their were no major blood vessels torn. This patient will need a sling to improve shoulder stability and decrease pain from instability. I would imagine a football player might want to get the shoulder repaired surgically in order to continue his football career or at least have a better functioning shoulder since he is so young. Post surgery he will still need to be immobilized in a sling for several weeks with gentle PROM, progressing to isometrics and AAROM. Elbow and wrist strength and mobility will need to be maintained. Scapular stability strengthening as well as rotator cuff strengthening in the subacute phase.
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