AC Joint Sprain (Shoulder Separation) Rehab

This blog aims to discuss AC joint sprains, also known as shoulder separations, review the different treatments for them, and go through a comprehensive rehab program.

Looking to improve your strength, range of motion, and power to enhance your function and performance? Check out our Shoulder Resilience program!

AC Joint Anatomy

The acromioclavicular joint, or AC joint, is one of the main joints that make up the shoulder. It is composed of the acromion of the scapula and the lateral end of the clavicle. It is supported by three ligaments, the conoid and trapezoid, which make up the coracoclavicular ligament, and lastly the acromioclavicular, or AC, ligament.

AC Joint Sprain Types

There are six types of AC joint injuries, which vary based on the degree of injury and tissue involvement. 

  • Type 1 consists of a partial tear of the AC ligament, with no involvement of the coracoclavicular ligament or shoulder muscles.
  • Type 2 increases to a complete tear of the AC ligament, with a partial tear of the coracoclavicular ligament, but no muscular involvement.
  • Type 3 has a complete tear of all of the involved ligaments, with no muscular involvement.
  • Type 4 has muscular involvement with the distal end of the clavicle displaced posteriorly into or through the trapezius.
  • Type 5 has a high probability of the deltoid and trapezius being detached from the distal clavicle.
  • And Type 6 has an inferior displacement of the clavicle with a range of muscular involvement.

AC Joint Sprain Mechanism Of Injury

The most common mechanism of injury for an AC joint injury is a fall on an outstretched arm. Other mechanisms are falling on the shoulder and a collision to the shoulder.

AC Joint Injury Presentation

The typical symptoms for AC joint injuries are pain at the AC joint and loss in range of motion, particularly when taking your arm overhead, across your body, or behind your back. 

Holding objects or hanging on your arm may be painful, as well as weight bearing on your hands or arms. You may present with a piano key sign, where your clavicle has elevated in relation to the acromion.

AC Joint Injury Management Options

There are two primary management options for an AC joint injury, surgery and non-surgical management.

The type of AC joint injury sustained has traditionally been used to determine which option should be the first choice of treatment. Historically non-surgical management has been advised for type 1 and 2 AC joint injuries. Verstift 2021 found that after about 7 years, individuals with a type 1 or 2 AC joint injury did have slightly lower function of their shoulder, however, this finding was not clinically meaningful.

In contrast, surgical management was previously advised for types 4, 5, and 6, while type 3 had mixed recommendations. The Canadian Orthopaedic Trauma Society completed a (large multicenter) randomized clinical trial and found that non-surgical management had superior results for shoulder function in the short term, and no significant difference in the long term, for types 3, 4, and 5.

Murray et al 2018 found similar results, concluding that surgery provided “no functional benefit over nonoperative treatment at 1 year following type-III or IV AC joint injuries”

A 2019 Cochrane review of all of the research summarizes this topic well: “surgical intervention may have no additional benefits in terms of function, return to former activities, and quality of life at one year.” subsequently stating “consequently, whilst these results favour a non-operative approach, possible benefits of surgery cannot be ruled out, including for more complex, high-grade injuries.”

As such, non-surgical management should be the first line of treatment for AC joint injuries. Non-surgical management should be followed for a minimum of 3-6 months. After that time period, if there isn’t the desired improvements in pain or function, then surgery may be considered.

AC Joint Injury Non-operative Management Options

The rehab process will be broken down into two primary phases, with a third optional phase for those looking to return to sports.

Phase 1 – AC Joint Sprain Rehab

The first phase is focused on having things calm down, getting your pain managed, and begin regaining range of motion and strength. You should look to limit painful motions and positions, modifying activities to decrease the demand on your shoulder.

To assist in calming things down, a shoulder sling is advised to reduce the load on the AC joint. This should be worn as much as possible, ideally only removed for performing rehab and showers.

The duration of sling use varies on the type of AC joint injury and degree of pain. For type 1, a sling should be used for a minimum of 3-7 days. For type 2 3-10 days, and for type 3 and higher, 7-14 days.

This will allow time for your shoulder pain to reduce and for the recovery process to begin. A sling can be used for longer durations if removing it leads to your pain interfering with daily activities.

Additional options for pain management during this phase are ice or heat, medications, and modalities. If you find using ice or heat reduces your pain, then feel free to do so. Medications such as NSAIDs or acetaminophen might be utilized, however, this should be discussed with your doctor. Finally, various modalities such as massage may help in reducing your pain. These are not a necessity and do not expedite your recovery.

Shoulder Range of Motion & Strength

After sustaining an AC joint injury, you may have decreased shoulder range of motion and strength. The initial goal of rehab will be to restore these.

Range of motion deficits might vary based on the severity of the injury. Initially, you should aim to regain the range of motion required to perform activities of daily living such as brushing your teeth, eating, and caring for yourself. Here are two options to begin with. You can perform these exercises daily, staying within a range of motion that is tolerable.

Option 1 – Elevation – you can perform this either in sitting or laying on your back, holding onto a dowel with your uninvolved arm and your involved arm resting on the end of the dowel. Raise the dowel, then return down gradually.

Option 2 – Rotation – you can perform this either in sitting or laying on your back, holding onto a dowel with one hand, and your involved arm holding on the end, with your elbow by your side, push the dowel out slowly, then pull back in.

Aim to perform 2-3 sets of 8-15 repetitions per day for each motion.

Two ranges of motion which are more challenging following an AC joint injury are horizontal adduction and extension. These motions may be more painful initially due to their demand on the AC joint, so you may wait a few days, or longer, before performing them. 

Option 3 – Horizontal Adduction – you can perform this either in sitting or laying on your back, have your arm straight out with your non-involved arm grabbing your involved arm’s wrist. Bring your involved arm across your midline, then return.

Option 4 – Extension – you can perform this either in standing or sitting. Hold a dowel in front with your non-involved arm, and your involved arm down by your side on the end of the dowel. Gently guide your involved arm back, then return forward.

Begin performing all of these movements with your involved arm being taken through the motion passively. As your symptoms subside, start using your involved arm to assist in the motion. Over time, using your non-involved arm less and less, transitioning to an active range of motion.

Along with improving your range of motion, you should also work on regaining strength. Here are three movements to start with:

Shoulder Abduction Isometric – Stand next to a wall with your elbow bent 90 degrees. Place a towel between your elbow and the wall and then push your elbow into the wall, trying to raise your arm. 

External Rotation Isometric – Stand next to a wall with your elbow bent 90 degrees. Place a towel between your wrist and the wall and then push your wrist into the wall, trying to rotate your arm outward. 

Internal Rotation Isometric – Stand beside a doorway with your elbow bent 90 degrees. Place a towel between your wrist and the wall and then rotate your wrist into the wall. 

Aim to perform 2-3 sets of 30-45 seconds per day for each motion.

There isn’t a strict timeline for this phase. Once you no longer need the shoulder sling, have minimal to no symptoms with daily activities and can perform range of motion actively through most shoulder ranges with minimal symptoms, progress to the next phase. This will range from a few days to a few weeks depending upon your degree of injury and the severity of symptoms. For instance, if you sustained a type one AC joint injury, and have minimal pain or loss in range of motion, then you may progress within a week. In contrast, if you sustained a type five AC joint injury, have significant pain, loss in range of motion and difficulty using your arm, then this phase may last three to four weeks. Monitor your symptoms and progress when you are confident.

Phase 2 – AC Joint Sprain Rehab

The goal for this phase is to progress your strength and range of motion, better preparing your shoulder for your needs and activities. You should select exercises that will address motions that need to improve for yo ur needs and activities. I will review three isolated categories and a fourth compound category which cover the major motions you may find are limited following an AC joint injury, providing multiple options within each one so you can scale it to your ability level. You may not perform every category. Given that you have a different starting point and different end goal than another person, your exercise choices should reflect that. I’ll discuss this more in the programming section.

Shoulder Protraction & Upward Rotation Strength

Being able to protract and upwardly rotate is often impaired following a shoulder separation. Therefore, strengthening specific muscles can improve this deficit. Here are three options.

Option 1: Band or Cable Protraction – Stand holding a cable or band in one hand. With your arm straight, reach your arm forward without twisting your shoulders. Return under control.

Option 2: Hands Elevated Push-Up Plus – Start in a tall plank with your hands elevated. Push your chest away from your hands, spreading your shoulder blades apart. Let your shoulders come back together and repeat. To make it harder, lower your hands over time.

Option 3: Wall Slide – Place your hands inside a pillowcase with your palms facing you and your forearms on the wall. Rotate your arms out against the sides of the pillowcase and begin sliding your arms up. Think about pushing the wall away from you. Return down. 

Shoulder Horizontal Abduction Strength

Moving your arm horizontally out and across your body may become sensitive, therefore exercises can be used to improve your tolerance and capacity in these directions. Here are two options:

Option 1: Cable or band reverse fly – Holding a cable or band with your arm straight, take your arm straight out to the side. Return slowly. If you tolerate it, you can let your hand cross your midline to increase the range of motion worked through. 

Option 2: Side Lying Reverse Fly – Laying on your side, holding a DB with your arm straight out in front. Raise the DB so your arm points to the roof, then return down. If you tolerate it, you can lower the DB further down, letting your hand cross your midline.

Shoulder Elevation Strength

This category will address any limitations in strength and range of motion with overhead movements. Here are 2 options:

Option 1: Lateral raise – Have your arms relatively straight and raise your arms to around shoulder height, then control down. Over time, as your symptoms reduce, gradually take your arms further overhead. 

Option 2: Pullover – Laying on your back on a bench with your arms straight holding a dowel, begin slowly raising your arms overhead. Over time, as your symptoms reduce, gradually take your arms further overhead.

Shoulder Compound Exercises

These can be broken into two primary categories: pressing and pulling. There are a plethora of options that could be selected, however, I want to provide three factors to consider as you’re choosing exercises.

Factor 1: Angle of movement

You can divide pressing and pulling exercises into three main groups – horizontal, angled, and vertical. For instance, with pressing, you have dumbbell bench press, landmine press, and dumbbell overhead press. None of these exercises are inherently better than the others, although you may find that at first, you are better able to tolerate horizontal directed movements. As you begin to work overhead, you w ill challenge the AC joint more. This isn’t a bad thing, but it is something to consider as early on you may not tolerate angled or vertical movements.

Factor 2: Range of motion

You may find a certain part of a range of motion particularly bothersome. For instance, the bottom range of dumbbell bench press may be irritable. You could replace it with dumbbell floor press, and then as your symptoms reduce, transition back to dumbbell bench press.

Factor 3: Open vs closed chain

Open chain is when your hand is moving and your torso stays in place, such as a cable row, whereas closed chain is when your hand is fixed and your torso is moving, like an inverted row. One is not superior to the other, though you may find that an open chain is more tolerable at first, or vice-versa. Experiment and see if you notice that one is more tolerable, then gradually integrate the other over time as you desire.

Example Progressions

Here are two example progressions you may utilize:

Example 1 – pressing – you could begin with a DB floor press, then transition DB bench press, then to a half kneeling landmine press, then to a DB overhead press.

Example 2 – pulling – you could begin with a cable row, then transition to a high to low row, and then to a half kneeling 1-arm pulldown.

Programming & Timeline

You can consider your exercise selection on a continuum. On the far left you have more severe injuries with more limitations, whereas on the far right you have less severe injuries with less limitations. If you’re on the far left, you’ll benefit from performing more exercises to address you limitations. If you’re on the far right, you don’t need to perform as many exercises. For those on the far left, as your symptoms improve, you could reduce the number of exercises you perform.

To optimize your improvements in strength and range of motion, it will be beneficial to perform exercises two to three days per week, having at least one day of rest in between days. Perform 2 to 4 sets of 10 to 15 repetitions each session for your selected movements. Over time look to progress your movements either through performing more reps, more sets, more weight, using more range of motion, or a higher level of exertion.

Similar to the first phase, there isn’t a strict timeline for this phase as it will depend upon your severity of symptoms and your level of the desired function. As such, this phase may last only a couple of weeks, whereas for a different individual it may last a few months.

Phase 3 – AC Joint Sprain Rehab

If you’re looking to return to sporting activities, then you may need to incorporate other exercises that prepare your shoulder for higher-level demands. I’ll present two categories and then discuss returning to sport.

Shoulder Power Training

In returning to sports, you will need to generate force quickly. These three options will help you develop power.

Option 1 – MB Push throws – standing close to a wall with a medicine ball between your hands. Push the medicine ball with intent into the wall. Aim for 3-5 throws per set.

Option 2 – MB slam – Holding a medicine ball, raising it overhead and then slamming it down with intent. Aim for 3-5 throws per set.

Option 3 – MB shot put – In a shoulder-width stance, holding a medicine ball in your rear hand, and other supporting, rotate back with your elbow in line with your shoulder, then explosively rotate forward. Aim for 3-5 throws per set.

Shoulder Stability Training

This progression will help in Improving your tolerance of weight bearing and increasing your shoulder stability. 

Level 1 – Shoulder Taps – Set up in a tall plank position. Push down with one arm as you raise the other and tap your opposite shoulder. Go slow and minimize motion at your hips and shoulders. Elevate your hands if the floor is too challenging. Perform 30-60 seconds per set.

Level 2  – Drags – In a tall plank, reach and drag a weight across your body with one hand, then switch hands and drag it back. Keep your hips and shoulders level throughout. Perform 30-60 seconds per set.

Level 3 – Wide Grip Alternating Hand Taps – In a tall plank, open up your hands wider than usual, then reach one hand and tap your opposite hand. Return it and switch hands, repeating back and forth for time. Continue working your grip wider until you can perform with hands about 3 feet apart. Perform 20-30 seconds per set.

Programming

During this phase, you should continue training exercises discussed in the prior phase, further increasing your capacity. You can incorporate these exercises into your training sessions, placing them at the start of your session. You can select one exercise from each category and complete two to four sets.

Gradual Return To Sport

In addition to dedicated exercises for power and stability, performing a gradual return to your sport is important. Start with restricted practices where you and your coach adjust your volume and intensity of practice to a tolerable level and then increase those variables until you are up to unrestricted practices. At that stage, begin introducing restricted games and follow a similar format until you are up to unrestricted games. Monitor your symptoms along the way. If you find your symptoms are reducing, continue with your plan. If your symptoms are increasing, you may need to decrease the demands and give yourself more time.

Shoulder AC Joint Sprain Rehab Summary

An AC joint injury, or shoulder separation, is where the acromioclavicular joint of the shoulder gets injured. There are 6 types of AC joint injuries, with varying severity levels and ligament and muscle involvement. AC joint injuries are often able to be managed well conservatively. Starting by undergoing a period of reduced loading to allow a decrease in pain and begin the recovery process is ideal. From there, performing a progressive rehab program that targets movements that you are limited in is beneficial in returning to your full functional abilities. If you plan to return to sports, incorporate a plan where you incrementally increase your sporting activities that challenge your shoulder, allowing yourself time to adapt to the demands. Thank you for watching, be sure to like the video and leave any questions in the comments!

Do you want to read other similar blogs? Check out these topics:

How to Improve Your Shoulder Range Of Motion, Rotator Cuff Exercises, Goldilocks Principles Of Rehab

Thanks for reading. Check out the video and please leave any questions or comments below.

Leave a Reply

Your email address will not be published.

Fill out this field
Fill out this field
Please enter a valid email address.
You need to agree with the terms to proceed

Menu