RICE & MICE will periodically review injuries that are common, uncommon or just plain unique in hockey. I hope to provide some insight to the “how’s, why’s, and when’s” of the injuries that might keep players out of the lineup.
Shoulder separations, otherwise known as acromioclavicular (AC) joint sprains are another one of those very common injuries in ice hockey. So common, in fact, that it would be challenging to find a skater in the NHL that didn’t suffer this injury at one point or another in his hockey career. The AC joint consists of the clavicle (aka collarbone), the scapula (aka shoulder blade) and the two ligaments that connect the pieces. The acromioclavicular (AC) ligament attaches the end of the clavicle to a part of the shoulder blade called the acromion and the coracoclavicular (CC) ligament connects the clavicle to another part of the shoulder blade called the coracoid process. The collarbone is the bone that connects the shoulder to the rest of the skeletal body.
I know there is almost always some confusion with the terminology used in describing this injury, but regardless of how you choose to refer to this injury, whether it be A-C sprain or separated shoulder or any combination of those descriptors, it is not the same injury as a shoulder dislocation or a shoulder subluxation. Calling the injury a “separated shoulder” is accurate, because in the quick discussion of the anatomy above we know that the collarbone is involed and it is that bony that links the shoulder complex to the rest of the body. An acromioclavicular sprain or A-C sprain is also correct because it involves an injury to ligaments. You say tomato and I say tomato; you say AC sprain and I say shoulder separation.
This injury has the potential to occur anytime a player is checked by an opponent. A hockey player skating alongside the boards that receives that clean shoulder to shoulder contact from an opponent might end in a separated shoulder. As the player makes contact with the boards (or glass), one shoulder is compressed by the glass and the other shoulder is compressed by the blow from the opponent; a separation may occur to either shoulder (or both). We saw Danny Syvret suffer a grade 3 shoulder separation last season from a check into the boards. Shoulder pads protect the players to a certain extent, though they do not offer much protection to the blows from the side. Another mechanism of injury here has a fun acronym FOOSH or fall onto out-stretched hand.
Like any other ligament sprain, the AC separation injuries are graded 1 through 6, however separations graded 4-6 are generally from more extensive trauma like car accidents. Grades 1-3 are commonly seen in hockey and other contact sports. They may also be referred to as mild, moderate or severe, respectively.
A grade I separation is the most common. There is a stretching or mild tearing of the AC ligament. There is tenderness, along with the possibility of mild swelling on the top of the shoulder at the AC joint, and at the end of the collarbone. There may or may not be tenderness over the CC ligament as well. There will be some pain with arm motion and some weakness as well. The player can go back to play as soon as they have full range of motion and strength. This will vary for individual players and can range from not missing a shift to being out for a week to allow for the pain to decrease. Most grade 1 sprains are diagnosed without needing xrays.
With a grade II injury, there is more significant tearing of the ligaments and the AC ligament is usually completely torn and the CC ligaments are usually stretched. There can be significantly more swelling and pain with arm movement. Both the AC and CC joints are very tender and there is significant weakness when lifting the arm away from the body to the front or side. There may be a bump where end of the collarbone is elevated and pushing down on the middle of the collarbone may cause the end of the collarbone to move up and down. The moderate sprain will likely show up on an x ray and may be exaggerated if the player is holding a hand weight with their arm to the side. A sling can be worn by the athlete if needed to reduce pain. Sports therapy is started immediately to maintain range of motion and regain the strength of the shoulder as their pain allows. In most cases it will take 4-6 weeks for the athlete return to play pain free and with full strength and mobility.
A grade III injury is more severe with complete tearing of the AC ligament as well as significant tearing of the CC ligaments. This lack of support between the shoulder blade and the collarbone causes the shoulder complex to drop and the collarbone to lift. The collarbone will be very elevated and unstable. The shoulder complex will drop down. it is definitely a pronounced deformity and easily spotted on a player. A Grade III injury will be quite painful. There is more swelling, pain and tenderness with grade 3 separations. The shoulder will also look deformed because the clavicle is totally separated from the shoulder. Once upon a time grade 3 separations were treated surgically, however the consensus today is athletes with grade 3 separations will return to play sooner with more strength and less pain if treated non-surgically. Of course, there is a longer recovery time of 6-8 weeks for most players to return with full range of motion and full strength.
Moderate and severe sprains are quite noticeable from the moment they happen on the ice or field as most players will come off the ice or field holding their injured arm to support it and lift it back up into place. Grade 1-3 injuries are usually treated with RICE and in grade 2 and 3 sprains, a sling may be used to reduce pain. Slings may be simple and function to stabilize and lift the arm or they can be a bit more specialized and function to lift, stabilize and apply downward pressure on the collarbone. Therapy will progress from RICE to MICE when the player can tolerate mobility exercises. Strength is vitally important to protect the shoulder and be effective in their sport again. Even after return to play, it is not unusual for the athlete to experience periods of discomfort for up to several months and most hockey players will have the telltale bump at the top of their shoulder from past shoulder separations.
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