playing career when the injury can be treated opera-
tively if the former player is still symptomatic.- Type I and II injuries
- These are treated with ice, rest, and immobilization
for 7–14 days. Gradual resumption of full activities
can then progress as the patient tolerates. - Heavy lifting and contact sports is avoided for
8–12 weeks, especially in the case of type II
injuries.
- These are treated with ice, rest, and immobilization
- Type III injuries
- There is little, if any, agreement as to the best treat-
ment of these injuries. A prospective, randomized
study was performed accessing operative versus non-
operative treatment revealed no difference between
the two groups; however, this study combined two
types of operative fixation: coracoclavicular lag
screw fixation and transacromial pin fixation. There
were a significant number of failures in the
transacromial fixation group; whereas, there were no
failures in the lag screw fixation group. Taken
together, the average failure was the same as nonop-
eratively treated patient; however, this would seem to
support lag screw fixation as being superior to non-
operative treatment of these injuries. - This author has found the cross-body adduction radi-
ograph to be the most helpful in differentiating these
patients: if there is no evidence of medial instability,
most of these patients do fine with nonoperative
treatment. If there is medial instability, this repre-
sents a more severe injury and these patients typi-
cally will do better with operative intervention.
- There is little, if any, agreement as to the best treat-
- Type IV, V, and VI injuries: Most authors agree that
due to the severity of these injuries, operative inter-
vention is indicated (Rowe, 1968). - Operative intervention can be broken down into three
types:- Transacromial fixation: Pins are passed through
the acromion into the distal clavicle to hold it
reduced. The primary limitation with this proce-
dure is that it can be difficult to pass pins accu-
rately through the acromion, especially in a patient
with a thin acromion. Furthermore, the joint sur-
faces of the distal clavicle and acromion are dis-
rupted by the pins and, as noted earlier, smooth
pins can migrate.
2.Coracoclavicular lag screw fixation: a screw is
passed through the distal clavicle into the base of
the coracoid to hold the joint reduced. This is by
far the strongest fixation; however, the technique
can be rather demanding for an inexperienced
surgeon, as the exact placement of the screw into
the coracoid can be difficult to obtain. Furthermore,
the screw needs to be removed because of the
risk of hardware breakage and reabsorption of
- Transacromial fixation: Pins are passed through
the bone around the screw (Weaver and Dunn,
1972).
3.Coracoclavicular circlage fixation: Sutures are
passed around the clavicle and coracoid to hold the
AC joint reduced. This is probably the easiest to per-
form and does not require fluoroscopy in the oper-
ating room; however, permanent sutures can saw
through the clavicle or coracoid while absorbable
sutures may not last long enough to achieve ade-
quate healing (Martell, 1992). Furthermore, if
weaved sutures are used, the fixation is less stable
due to the bungee cordnature of the sutures and this
can interfere with ligament healing.- These procedures and be combined with or without
distal clavicle resection and with or without ligament
transfer, typically the acromioclavicular ligament.
RETURN TO PLAY CRITERIA- Type I injuries:Activities can be advanced after
7 days of rest and ice. Return to full, unrestricted
activity can occur when the player has full, pain-free
range of motion. This usually occurs after 2 weeks. - Type II injuries:Ice, rest, and immobilization for
7–14 days or until symptoms subside. Activities of
daily living can then be started and activities are grad-
ually progressed as tolerated; however, due to the risk
of exacerbation of the injury, most contact sports
should be avoided for 8 to 12 weeks. - Type III injuries:Nonoperative treatment—same as
type II injuries. - Type III (operative) and Type IV–VI injuries:Sling
for 4–6 weeks followed by 6 weeks of simple activities
of daily living. The fixation can be removed after 8–12
weeks and then activities slowly progress over the fol-
lowing 6 weeks to allow the repaired ligament to
strengthen. Once they have full, painless range of
motion and strength, they can return to sports.
REFERENCES
Basamania CJ: Medial instability of the shoulder: A new concept
of the pathomechanics of acromioclavicular separations.
Presented at American Orthopaedic Society for Sports
Medicine Specialty Day Meeting, Orlando, FL, 2000.
Basamania CJ, Craig EV, Rockwood CA, Jr: Fractures of the
clavicle, in Rockwood CA, Jr, Matsen FA, III (eds.): The
Shoulder. Philadelphia, PA, Saunders, 2003.
Bergfeld JA Andrish JT, Clancy WG: Evaluation of the acromio-
clavicular joint following first- and second-degree sprains. Am
J Sports Med6:153–159, 1978.280 SECTION 4 • MUSCULOSKELETAL PROBLEMS IN THE ATHLETE