It’s a shallow life that doesn’t give a person a few scars.
-Garrison Keillor
I have a bump on top of my right shoulder that tells a good story. I got
it when I was thirteen on my dirt bike - a red Honda XR100r that I mowed
a lot of lawns to pay for myself. The bike was nothing fancy, but it could
be rode
hard and put up wet, and the next day or even the next month, it would
still start up on the first kick. I loved that bike and named it Speedy,
a name that became emblazoned on all the vehicles throughout my childhood
and is even now displayed on the fishing skiff in my garage.
The day of my injury was a scorcher in July; one of those stifling, 100
percent humidity days when the air was completely still and smelled of
turpentine oozing from the pine trees as the cicadas buzzed. My buddy
and I carved a few trails along Frederica River that would link up with
a couple of hunting roads heading toward Cannon’s Point. I remember
it was so hot that even
travelling
fast just felt like a blow dryer in my face. I was coming out of one of
the small trails to hit the main road. During that turn, there was a slight
berm to hit the main road, so I had to gear down and get low as I took
the turn, making it one of my favorite sections to ride. Normally, I would
right myself and speed up down the road, but that day, as I leaned down
to make the turn, I noticed there was something large laying across the
road in the sun.
Immediately after I saw it, I hit it. My front tire met squarely with the
front shoulder of a six to
eight foot
alligator that had picked my dirt road as his choice sunning spot. My
memory of that instant is quite a blur. My bike went out from underneath
me, the sky went below me, and I heard a big splash. When I came to, my
dirt bike was upside down against a tree and luckily, the gator was long
gone into the swamp. I also had one heck of a headache and pain coming
from a new bump at the tip of my shoulder. Reliably, Speedy started on
the first kick, but the handlebars were askew; I had to ride back home
sidesaddle with an aching shoulder.
The following day, my shoulder still ached, the bump was now more prominent,
and off to the
pediatrician
I went. After the X-rays were taken, the pediatrician kept poking at the
bump, asking me to lift my shoulder and finally proclaiming, “You
have an AC separation. Put some ice on it. It’ll be fine in a few
weeks.” I didn’t know then what that meant, but I did as I
was told. It wasn’t until my residency that I learned what a common
injury it is and how that story would come to mind again and again as
I saw patients in my practice with similar injuries. Here is an overview
in case you ever find yourself in the same precarious situation I did
back then:
AC separation overview
An
acromioclavicular joint separation, or
AC separation, is not truly an injury to the shoulder joint. This injury actually involves the
AC joint where the collarbone (clavicle) meets up with the highest point of the
shoulder blade or scapula, called the acromion. It is a very frequent
injury among physically active people, like the adolescent boy I was.
It is commonly caused by a fall directly on the tip of the shoulder or
a direct blow to the area. AC joint separations are most common in contact
sports such as football and with bikers or ATV riders who flip over their
handlebars. In either incident, the shoulder blade is driven downwards,
causing an injury to the joint capsule of the
AC joint and, if it’s severe enough, the underlying coracoclavicular ligaments
that help tether the collarbone to the shoulder blade. These can be mild
to severe injuries depending on the degree of impact to the supporting
structures leading to greater deformity at the AC joint.
Simple AC injuries are classified in three grades ranging from mild dislocations
to a complete separation:
-
Grade I – A slight to no displacement of the joint. The acromioclavicular
joint may be stretched or slightly torn. The underlying ligaments remain
intact. This is the most common type of AC joint injury.
-
Grade II – A partial dislocation of the AC joint with some prominence of the
end of the clavicle. The AC ligaments are torn but the underlying coracoclavicular
ligaments remain intact.
-
Grade III – A complete separation the AC joint. The joint capsule that surrounds
the AC joint and the underlying coracoclavicular ligaments are torn.
Deformity
is obvious as the shoulder falls under the weight of the arm and the clavicle
is pushed up, causing a bump on the shoulder.
There are a total of six grades of severity in AC separations. Grades I-III
are the most common. Grades IV-VI are less common and are usually the
result of a very high-energy injury as in a motor vehicle accident or
falling from a height. Grades IV-VI are all treated surgically to avoid
any lasting deformity of the shoulder’s function.
Non-operative treatment
The treatment of an AC separation depends on the grade of the injury.
Most Grade I-III AC separations are treated successfully with non-operative
treatment that may include:
- Ice to reduce pain and swelling
-
Rest and sling until
pain
subsides, usually one to two weeks
- Pain and anti-inflammatory medications
-
A rehabilitation program to restore normal motion and strength
.
Depending
on the grade of injury, most patients heal within two to three months
without surgical intervention. The patient is allowed to return to sports
when there is
full
painless range of motion without tenderness at the AC joint. This usually
takes about two weeks for Grade I injuries, six weeks for Grade II injuries
and up to 12 weeks for a grade III injury. A small prominence of the AC
joint is usually evident but usually does not cause any long-term functional
deficit. In a study assessing operative vs. non-operative treatment for
Grade III separations in NFL quarterbacks, Dr. “Ted” Schlegel,
team physician for the Denver Broncos, found that the results of non-operative
vs. operative treatment are the same.
Operative treatment
Operative treatment is necessary for all Grade IV-VI AC injuries. Surgery
may also be necessary for those patients with AC separations that do not
respond to conservative treatment. If, after two to three months, pain
continues with overhead activity or with contact sports then surgery may
be necessary. There are some select patient populations with Grade III
AC separations that may benefit from early surgical fixation. A variety
of surgical methods exist to stabilize the AC joint.
Usually
these consist of reconstructing the coracoclavicular ligaments with a
tendon graft and excising a small portion of the distal end of the clavicle
while repairing the AC joint capsule. The rehab for these types of procedures
can easily be three to four months and usually require six to eight months
to get back to full activity.
In retrospect
Thirty years after I hit that alligator, I still have a bump on my shoulder.
In the past thirty years, I have played thousands of tennis games, moved
more azalea bushes around my grandmother’s yard than I can count,
played catch with all of my boys until the sun sets, and never had a single
limitation that I can say is a result of my own AC separation. When someone
notices the bump, I get to tell a great story. And I never tire of hearing
the ones other people tell when they step in my exam rooms with the same
injury, though I have not yet heard one tell of hitting an alligator on
a dirt bike. I’m grateful for that bump and that it was not serious
enough to necessitate surgery and leave a scar. But mostly, I’m
grateful that alligator was more scared of me that I was of it. Get out
there, and do something fun.