AC Joint Sprains & Separated Shoulders: Symptoms, Management, & Rehab
AC Joint sprains account for 40% of all shoulder injuries, and nearly 10% of all injuries in hockey, football, lacrosse, and other collision sports.
Because these injuries are so common, it’s important to know the basics about an AC joint sprain and how to manage it, particularly if you or your child is playing a collision sport like those listed above. In this article, we’re covering the basics about AC joints, how they get injured, and how to manage and rehabilitate an AC joint post-injury.
What Is The AC Joint?
The acromioclavicular (AC) joint forms the “point” of your shoulder, created by your clavicle (collar bone) and the acromion of your scapula (shoulder blade). This joint, along with the sternoclavicular joint, serves as the only direct connection between your arms and your upper body - your scapula lays on your rib cage, but it’s not directly connected by a joint. Without the clavicle, the SC joint, and the AC joint, the shoulder is significantly less stable and can fall inward.
Beyond connecting your arm and shoulder to the rest of your body, the AC joint is also essential for the large range of motion of your shoulder. Most movements of the shoulder happen through a synchronized movement of your humerus (upper arm bone) and your scapula. As you move your arm, the AC joint acts as a pivot point for the scapula, allowing it to rotate and pivot as required to allow a full range of motion in the shoulder.
There are a number of ligaments that help to keep the joint intact, including the acromioclavicular ligament, the coracoacromial ligament, the coracoclavicular ligament, and the joint capsule itself. Basically, all of these ligaments work to keep the scapula and the clavicle close together, so that the AC joint stays intact and undamaged. These ligaments are also the structures that get damaged when you separate your shoulder or sprain your AC joint.
What Is An AC Joint Sprain/Separated Shoulder?
A sprain occurs when a ligament in your body sustains a force that’s too large for it to handle, causing it to stretch, tear, or rupture (tear completely through). The most common sprain you’d think of is the ankle, but sprains can happen at just about every joint in your body.
With the AC joint, these sprains usually occur as a result of direct trauma to the point/tip of the shoulder, often from getting hit or falling onto it. These injuries can also happen after a fall onto an outstretched hand or onto an elbow, but this is less common. A separated shoulder is essentially the same thing as an AC joint sprain, but usually, this terminology is used when the sprain is more severe, causing a ligament rupture and a deformity/dislocation of the clavicle. Most commonly, these injuries occur after a collision or hit in sports like hockey or football, but they can also occur after a fall during other sports like downhill skiing or biking.
AC joint sprains are typically graded based on severity, going from grade 1 to grade 6. A grade 1 sprain is the mildest type, with just some stretching and small tearing of the ligament structure, without any significant deformity or dislocation. Grade 2 sprains are slightly more severe, with some ligament rupture and a mild deformity or dislocation of the clavicle. Sprains from grade 3 to grade 6 involve complete ligament ruptures and significant dislocation of the clavicle; due to the dislocation, these injuries are pretty obvious in most cases.
Symptoms of an AC joint sprain typically include:
Pain near the point/tip of the shoulder, or generally around the shoulder
Pain that radiates into the neck or down the arm from the shoulder
Pain that gets worse when moving the arm to the side (abduction) or to the front (flexion)
Shoulder that feels sore when touched or pushed on
Limited movement in the shoulder
Swelling & Bruising
Deformity, bulge, or change in the shoulder’s shape (compared side to side)
Diagnosing these injuries can be very straightforward, or it can be a little more challenging. More severe AC joint sprains are often pretty easy to diagnose, as the shoulder has separated and the clavicle is often displaced, making it easy to see the injury. With less severe sprains (which are more common), the clavicle is still in the right place and there may not be a significant amount of laxity in the joint, so everything might look normal; in these cases, some further orthopedic testing and imaging may be required.
For a less severe AC joint sprain, there are a few tests we can do to tell us if the AC joint is actually the structure that’s injured:
Cross-Body Adduction Test - Bring your injured arm across your chest, placing your hand behind your opposite shoulder. If this causes pain near your AC joint and shoulder, this can indicate an AC joint sprain.
AC Shear Test - This one requires a partner. Have your partner place the heels of their hands on the front and back of the injured shoulder, then squeeze them together gently. If this causes pain, it can indicate an AC joint sprain.
AC Joint Differential Test - Lift your injured arm straight up to 90 degrees in front of you, with your palm facing inward. Repeat again, with your palm and arm facing outward. If there is more pain with your palm facing outward than inward, it can indicate an AC joint sprain.
If any of these tests cause pain, it can indicate an AC joint sprain/separated shoulder. Typically, if 2 or 3 of these tests cause pain, then we’d be very suspicious of an AC joint sprain. If your symptoms match and you recently had a fall or direct blow to the shoulder, an AC joint sprain is very likely.
If one only of the tests causes pain, it might be an AC joint injury, but it could also be something else, like a rotator cuff issue.
If you’re uncertain or these tests are unclear, schedule a visit with us today. We’ll help you clear things up, do a detailed history and examination, and help you get on the right path toward recovery and return to activity.
In addition to these orthopedic tests, we might recommend an x-ray to get a look at the AC joint and clavicle, allowing us to rule out a possible clavicular fracture while also getting a look at the AC joint itself to evaluate the degree of separation.
Important Note - If your shoulder has a deformity (something is sticking up or out in a weird direction), you should see a healthcare provider as soon as possible to determine your next steps; in this scenario, a surgical consult might be warranted, though conservative management may still be possible. If you are experiencing numbness, tingling, change in temperature (hot or cold), or any other symptoms down your arm, you should visit an emergency room, as the injury might be compromising nerves and blood vessels near the clavicle.
How Do I Manage An AC Joint Sprain?
Currently, the recommended way to manage most musculoskeletal injuries is represented by this acronym: PEACE & LOVE. In the following bullet points, we’ll break this down for AC joint sprains and separated shoulders.
(Side note - chiropractic care can be a good addition at any point throughout this healing and rehabilitation process. Beyond helping to guide and direct you through the process, we can also help to manage your pain, promote mobility, and overall provide a resource for you to ask questions that come up as you go along. Schedule your visit with us by clicking here.)
PEACE is for immediate management (0-72 hours after injury), and LOVE guides recovery after 72 hours and how to return to activity.
Protection - Avoid activities and movements that cause pain for 24-72 hours after injury. Resting for longer than 72 hours can lead to an extended recovery time
Elevation - Since your shoulder is naturally above your heart, this happens naturally. If you want, you can avoid laying completely flat. You should also avoid laying on the injured side, but that will likely be too painful to do anyways.
Avoid Anti-inflammatories and Icing - Ice and anti-inflammatory medications like ibuprofen or other NSAIDs can impair healing, especially in the first few days. You NEED inflammation for your ankle to recover properly. They should only be used for pain relief if the pain is unmanageable otherwise.
Compression - Compression sleeves for the shoulder and certain taping patterns can reduce pain and mitigate swelling. If you have an ACE wrap, a shoulder spica wrap can help with compression and support as well. Elevation and Compression both decrease some of the annoyance of inflammation without totally getting rid of the inflammation needed to promote healing.
Education - Knowing about your injury and the best ways to treat it can improve your recovery. Reading this blog, watching some videos, and doing some more reading about AC joint injuries are good ways to learn about your injury and how to manage it.
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Load - Using your pain as a guide, gradually start to use your shoulder, moving it around in a larger range of motion. The sooner your start using the injured shoulder (without increasing pain too much), the better tissue repair and recovery will go. When your ligaments are healing, they form scar tissue. If you don’t use your shoulder early, then the injured tendons and ligaments will form disorganized scar tissue, which is less mobile and less functional than the organized scar tissue that develops when you start using it earlier.
Optimism - Confidence, positivity, and a manageable level of stress are key to recovering well. Injuries can be stressful, especially in sports where you have pressure from your coach, team, classmates, and parents. Confidence and positivity help you to recover faster, and maintaining a manageable stress level can reduce the risk of chronic pain and problems. AC joint sprains are usually quite manageable, particularly if you incorporate these PEACE & LOVE methods, early rehabilitation, and chiropractic care.
Vascularization - Pain-free cardiovascular exercise increases blood flow and promotes healing in your injured shoulder. Biking and walking can both be good ways to get some cardio in without straining your shoulder too much.
Exercise - After an injury, you need to be active to restore mobility, strength, and proprioception (position sense) in the injured area. Specific rehabilitative exercises can help you get back to where you were and reduce the risk of reinjury. We’ll cover how to rehab an AC joint sprain in our next section.
Exactly how long the healing and recovery process takes will depend on the severity of the initial injury, whether or not you have any flare-ups, and the steps you take to promote your health and healing. Typically, a low-grade AC joint sprain will take about 10-20 days to heal enough to get you back to regular activity. A more severe sprain can up take two or three months to get back to that point. If you take action early, your recovery time will tend to be shorter and it will be easier for you to get back to your normal activity. The average time out of the game with an AC joint sprain is 18 days, so most people are back to doing what they love within a couple of weeks.
How Do I Rehab An AC Joint Sprain?
Rehabilitation of your AC joint should start early, within a week after your injury in most cases, sometimes as soon as three or four days for a milder sprain. As a general rule, your shoulder should be mostly pain-free at rest before starting rehab exercises, and you should be able to move it around a little bit without severe pain.
When doing these exercises, note that some pain is okay, particularly if you’re feeling a soreness that you might otherwise associate with a workout or exercise. If you’re experiencing sharp pain, particularly if you’d rate it at 4-5/10 or more, consider stopping and giving your shoulder another day to rest before continuing. Pay attention to your pain and symptoms the day following each new exercise as well; if the symptoms get significantly worse, give yourself a day to recover before continuing.
To start with, we use the Shoulder Pendulum exercise to build and retain mobility of the shoulder joints.
Shoulder Pendulum - Stand with your uninjured side next to a table, chair, counter, or something else you can lean on (i.e. if your left arm is injured, stand with your right side near a solid surface). Lean forward slowly, allowing your injured arm hang down and supporting yourself with on the stable surface by leaning on it or placing your free arm on it. Move your body, allowing your arm to swing around in all directions (specifically, front to back, side to side, and both clockwise and counterclockwise circles). Start with very small swings, then build up as you get a feel for your level of pain and if any movements aggravate it. Swing your arm in each direction (front-back, side-side, clockwise circles, counterclockwise circles) for about 15-20 seconds each, 1-3 times per day.
Do this shoulder pendulum exercise for a couple of days, and if the pain in your shoulder stays at a manageable level, continue on.
Once we’re confident that your shoulder is mobile and has a bit of pain-free motion, we move on to strengthening and stabilizing the shoulder and scapula.
Scapular Clocks - Place your hands on a wall in front of you, about shoulder width apart. Squeeze your shoulder blades down and back, and keep them here throughout the exercise. Starting on the injured side, slide your hand down to the 6 o’clock position, then proceed around the half of the clock until you reach the 12 o’clock position (so you’ll start by going counterclockwise with your right hand or clockwise with your left hand). (See a video of this exercise here.) Continue around the clock (swtich between hands at the 6 and 12 o’clock positions) in one direction for 2-3 circles, then reverse directions for another 2-3 circles. Repeat this exercise 2 times per day. If this is easy, place a resistance band around your wrists for an added challenge.
Isometric Low Rows - Place the hand on your injured side against a table or a wall, pushing slightly into it. Bring your shoulder blade down and back without moving your arm, and hold for 5-10 seconds. Repeat this exercise 5-10 times on each side, 2-3 times per day.
Isometric Protraction - Place your hands on the wall in front of you about shoulder width apart, leaning into them slightly. Keep your elbows straight, then push out with your hands, feeling your shoulder blades slide forward around your body, and hold this position for 5-10 seconds. Repeat 5-10 times, 2-3 times per day.
Once you can comfortably bring your arm straight up in front of you, you can progress to the next exercises, which are designed to build coordination and strength. (But continue doing the isometric exercises, at least a couple of times per week. Ideally, add two or three sets of an exercise or two in with every workout.)
Shoulder PNF - Start with your left arm across your body near your right hip, palm facing in and hand clenched like a fist. Slowly bring your arm up and across, like you’re drawing a sword, while slowly opening your hand and rotating your palm to face up. Repeat 20-30x on this right side, then repeat again on the other side; do this 2-3 times per day, or as a warmup before using your shoulders. Level this up by adding a small dumbbell or a resistance band; if you add resistance/weight, you can do fewer reps if needed.
ITYW - Lay facedown with your arms at your sides. Lift them off the ground and pulse 5-10x. Draw your arms straight out to a T position and pulse 5-10x. Bring your arms up towards your ears to form a Y and pulse 5-10x. Draw your elbows down and in to form a W, then bring them back out to a Y, and repeat this Y to W transition 5-10x. Do 2-3 sets of this whole progression per day.
Internal/External Rotations - Standing or laying on one side, tuck your elbow into your side and bend it to 90°, then lay your hand across your stomach near your belly button. Keeping your elbow tucked in tight to your body, rotate your arm and hand outward as far as you can without untucking your elbow or moving the rest of your body. Then bring it back into your belly, again not untucking your elbow. Repeat 20-30 times, then repeat on the other side. Do this 2-3 times per day. Level this up with a dumbbell or resistance band, reducing the number of reps if you add weight or resistance if needed.
Click here for a video demonstrating these 3 exercises!
Continue doing these or other exercises to strengthen the shoulder 1-3 times per week to maintain strength, coordination, and stability in the shoulder. You could also consider adding targeted rotator cuff exercises to your routine. There are many videos on YouTube or elsewhere on the internet walking you through these exercises; click here for one such example.
If you've done this and don’t feel like you’re all the way back, these exercises may not be addressing your individual imbalances, weaknesses, or movement dysfunctions. If this is the case, schedule a visit with us, and we’ll help you build a plan to get you back to where you want to be.
Parting Thoughts
AC Joint injuries are incredibly common, both in sports and in regular life.
While most AC joint sprains are mild and can be managed conservatively, addressing the pain and rehabilitating the shoulder are essential to ensuring that problems don’t arise later on. Without proper management and rehabilitation, issues like reduced strength and range of motion can arise, which limit your ability to perform at your best, whether that’s in your sport or just in your life.
If the sprain is more severe or there’s a deformity, a visit with a healthcare provider is always a good idea to rule out fractures, evaluate the stability of the shoulder, and provide you with information about possible next steps.
Overall, the outcomes for mild to moderate AC joint sprains are very good, with many athletes back to their sport within 18 days.
If you’re looking to get back faster, chiropractic care can be a good addition at any point throughout your healing and rehabilitation process. Beyond helping to guide and direct you through the process, we can also help to manage your pain, promote mobility, and overall provide a resource for you to ask questions that come up as you go along.
At Northbound Chiropractic, we are here to help you get on the right path. Whether it’s improving your sports performance, managing or preventing an injury, or just getting rid of pain, we’re here for you. Click the button below or call or text us at (763) 373-9710 to learn more about scheduling an appointment with us.
Giving you my best,
Dr. Nicholas Carlson
Northbound Chiropractic
Serving Delano, MN, Maple Plain, and the rest of Wright and West Hennepin Counties
**Note: These recommendations do not replace advice given by your healthcare provider. Always consult your healthcare provider for personalized medical advice. These are general recommendations, not specific to any one person or condition. Never perform any stretch or exercise that causes pain or discomfort. If you have physical discomfort or pain, stop immediately and contact your healthcare provider. Recommendations and Information provided are designed for informational purposes only, they are not intended to diagnose, treat, or cure any disease.