A “separated shoulder” is a common term for an injury affecting the acromioclavicular (AC) joint, which is distinct from a dislocated shoulder (glenohumeral joint). The AC joint connects the collarbone (clavicle) to the acromion, a part of the shoulder blade. Separation occurs when the stabilizing ligaments are stretched or torn, usually following a direct blow or a fall. Treatment depends on the extent of the ligament damage and the severity of the clavicle’s displacement.
Defining the Injury and Grading Severity
The AC joint is stabilized by two sets of ligaments: the acromioclavicular ligaments, which surround the joint capsule, and the coracoclavicular (CC) ligaments, which anchor the clavicle to the coracoid process of the shoulder blade. An injury to the AC joint causes a progressive tearing of these structures, leading to the “separation.” The Rockwood Classification system is the standard method doctors use to grade the severity of this injury, ranging from Type I to Type VI.
Type I is the least severe, involving only a mild sprain or stretch of the AC ligaments with the CC ligaments remaining intact, showing normal joint alignment on X-ray. A Type II injury involves a complete tear of the AC ligaments, but only a partial tear or sprain of the CC ligaments, resulting in slight upward displacement of the clavicle. Type III represents a complete tear of both the AC and CC ligaments, causing a visible bump and significant displacement of the clavicle.
The higher-grade injuries (Types IV, V, and VI) involve increasingly severe displacement and soft tissue disruption. Diagnosis relies on a physical examination for tenderness and instability, combined with upright X-rays to visualize the extent of the clavicle’s displacement relative to the acromion. Types I and II are generally treated without surgery, while Types IV through VI almost always require surgical intervention due to the severity of the displacement. Management of Type III injuries remains the most debated, often starting with non-surgical care.
Immediate Care and Conservative Treatment
Conservative management is the standard approach for Type I and Type II separations, and for the majority of Type III injuries, especially in non-high-performance athletes. The initial focus is on controlling pain and inflammation and protecting the injured joint. This acute phase typically involves the RICE protocol: Rest, Ice, Compression, and Elevation.
Rest is achieved by avoiding any movements that cause pain, particularly lifting the arm overhead or across the body. A sling is commonly used for comfort to support the weight of the arm and limit movement, especially for Type II and Type III injuries. Ice packs should be applied for 15 to 20 minutes several times a day to the top of the shoulder to reduce swelling and pain.
Pain management often includes Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) like ibuprofen, which help reduce both pain and inflammation. Sling immobilization is usually short, lasting about one to three weeks, since prolonged use can lead to shoulder stiffness. Once the initial sharp pain subsides, gentle, pendulum-style range-of-motion exercises are introduced to prevent stiffness. Activity modification is maintained, avoiding heavy lifting or contact until the joint is stable and pain-free, which may take six to twelve weeks for a Type III injury.
Surgical Intervention for Severe Separations
Surgery is typically reserved for high-grade separations (Types IV, V, and VI), and for Type III injuries where conservative treatment has failed to relieve persistent pain or instability in active patients. These severe injuries cause significant displacement of the clavicle, which cannot be adequately stabilized without surgical repair. The primary goal of any surgical procedure is to reduce the displaced clavicle back into its correct anatomical position and reconstruct the torn CC ligaments to restore vertical stability.
The surgical techniques fall into a few general categories, with the choice often depending on whether the injury is acute or chronic. One approach involves the temporary use of a fixation device, such as a hook plate or screws, to hold the joint in place while the body heals; this hardware typically requires a second surgery for removal. A more common modern technique is Coracoclavicular (CC) ligament reconstruction, often performed arthroscopically or with minimal open incisions.
This reconstruction frequently uses strong synthetic materials or a tendon graft (autograft or allograft), often secured with a suture-button suspension device between the clavicle and the coracoid process. These methods aim to mimic the function of the native CC ligaments, providing long-term stability. Following surgery, a period of rigid immobilization is necessary to protect the reconstruction, which differs from the early mobilization used in low-grade separations.
Long-Term Recovery and Rehabilitation
Regardless of whether the injury was treated conservatively or surgically, a structured rehabilitation program is essential for a full recovery and to prevent chronic issues like instability or pain. The long-term recovery phase focuses on gradually restoring the shoulder’s full range of motion and rebuilding muscle strength.
Physical therapy begins by addressing any residual stiffness with passive and active range-of-motion exercises, ensuring the shoulder can move fully without pain. This is followed by a progressive strengthening program that specifically targets the rotator cuff muscles and the muscles responsible for scapular stabilization. Strengthening these muscles helps dynamically support the AC joint and compensate for any residual ligament laxity.
The overall timeline for recovery varies significantly based on the initial injury grade and treatment. Patients with Type I or II separations often return to full activity within six to eight weeks. Recovery for a conservatively managed Type III separation may take up to three months. A surgically repaired separation typically requires four to six months before a full return to contact sports or heavy overhead work is possible. The final phase of rehabilitation involves functional and sport-specific exercises, ensuring the shoulder is conditioned for the patient’s specific demands.