Welcome to the Deep Dive. Today we're focusing
on a specific and actually fairly common shoulder
issue, the acromioclavicular joint or the AC
joint. That's right. Often called a shoulder
separation. Exactly. And while it might sound
minor, it can really affect daily life and particularly
athletic function. We often see it in high impact
sports, don't we? Indeed. Rugby, cycling falls,
horse riding, quite common. And the impact on
function can be, well, profound. So our goal
in this deep dive is to really get under the
skin of AC joint injuries. We want to provide
you, our audience of mid -senior medical professionals,
with a solid, practical understanding, moving
beyond the basics to the kind of detailed insights
that help in clinic. Looking at everything from
diagnosis, classification, right through to the
latest thinking on treatment and recovery. Precisely.
So let's start at the beginning. An AC joint
disruption isn't the same as a typical shoulder
dislocation, is it? Can you clarify that distinction?
Yes, that's a really crucial point. People often
use shoulder dislocation quite loosely, but usually...
That refers to the glenohumeral joint, the main
ball and socket. Where the humerus comes out
of the sock. Exactly. An AC joint disruption,
though, is different. It's a separation right
at the top, the apex of the shoulder. It's specifically
where the collarbone, the clavicle, meets the
acromeon, which is the highest point of the shoulder
blade. So the injury is a traumatic separation
of those two bones. The ligaments holding them
together get damaged to varying degrees. And
you mentioned it's common in sports. Very. Especially
contact sports or activities where falls directly
onto the shoulder are a risk. Think rugby tackles,
falls in motorsports, equestrian sports. And
it causes significant pain and limitation. Absolutely.
It's not just a minor niggle. It can be genuinely
debilitating, affecting simple daily tasks, let
alone high level sport or manual work. So understanding
the anatomy is key then. What makes this small
joint so important for shoulder function and
yet seemingly so vulnerable? Well, functionally,
it's critical. It's technically a diarthrodial
joint, a synovial joint, but its main job is
to link the entire arm and shoulder blade assembly,
the upper limb, to the main trunk, the axial
skeleton. It's the strip connecting the arm to
the body, essentially. You could think of it
like that, yes. It allows the scapula to move
properly, which is vital for everything from
reaching up to throwing. Without that stable
connection, shoulder function is severely compromised.
And what keeps it stable? It sounds like a complex
setup. It is. It relies on both static and dynamic
stabilizers. First, you have the acromioclavicular
ligaments themselves. They form the joint capsule.
These are key for horizontal stability, stopping
the clavicle, moving too far forwards or backwards
relative to the acromion. Okay, so front -to
-back stability. Precisely. But arguably even
more important, especially for vertical stability,
stopping the collarbone popping up, are the coracuclavicular
ligaments, the CC ligaments. Ah, yes, the cornoid
and trapezoid. Exactly, the cornoid and the trapezoid.
They run from the coracoid process, that hook
-like bit of bone on the scapula, up to the underside
of the distal clavicle. Think of them as really
strong suspension cables. Holding the clavicle
down. Essentially, yes. Preventing superior displacement.
If these are torn, that's when you typically
see that characteristic bump on the shoulder
in more severe injuries. Their integrity is absolutely
vital. So those are the static ligamentous restraints.
What about muscles? Good point. We also have
crucial dynamic stabilizers. The large deltoid
and trapezius muscles drape over the shoulder.
While their main job is movement, they also provide
dynamic compression and stability to the AC joint.
Especially if the ligaments are injured. Yes,
their role becomes even more important then,
although they can't fully compensate if the main
ligaments, particularly the CCs, are completely
ruptured. Is there anything else within the joint
itself? Well, sometimes there's a meniscal disc,
a small fibrocardilage pad between the bone ends.
It's not present in everyone, but when it is,
it helps with load distribution and acts as a
bit of a shock absorber. So, quite an intricate
structure. Given this anatomy, what usually causes
these ligaments to tear? What are the typical
mechanisms of injury? It's almost always down
to trauma, a significant force applied to the
joint that overcomes the strength of those ligaments.
The most common mechanism, by far, is direct
trauma. This is usually a fall directly onto
the point of the shoulder, hitting the acromeon,
often with the arm tucked into the side, adducted.
Like in a rugby tackle or falling off a bike?
Exactly that scenario. The force drives the shoulder
blade downwards, but the clavicle stays put,
creating this massive sheer force across the
AC joint, tearing the ligaments. OK, that makes
sense. Are there other ways it can happen? Yes.
Less commonly, you can get indirect trauma. The
classic example is a foosh injury, a fall on
an outstretched hand. Ah, yes, foosh. The force
travels up the arm, through the humerus and scapula,
and ultimately stresses the AC joint. Yeah. We
also see some cases of repetitive microtrauma,
maybe in weightlifters or overhead athletes,
but that's usually a lower grade issue managed
differently. You mentioned earlier it's common.
Are there specific groups more at risk? Yes,
there's a really striking demographic pattern.
Males are affected much more often than females.
The ratio is something like five to one. Five
to one, that's significant. It is, and it's particularly
prevalent in the 20 to 35 age group. This strongly
correlates with higher participation rates in
those high -risk contact sports and activities
we discussed. It really highlights that link
between activity levels and injury risk. That
5 .1 ratio certainly reflects what we tend to
see clinically. So once an injury happens, classifying
it correctly is the next vital step for management.
The Rockwood classification is the standard,
isn't it? Absolutely. Classification is fundamental
in orthopedics. It gives us a common language
and guides treatment. The Rockwood system from
1998 is the most comprehensive and widely used
for AC joint injuries. And it goes beyond just
mild, moderate, severe. It does. It defines six
distinct types based on exactly which ligaments
are torn, the AC and the crucial cc ligaments,
and importantly, the direction and degree of
clavicle displacement relative to both the acromion
and the coracuate process. It provides a really
robust framework for prognosis and deciding on
treatment. Okay, let's walk through them then.
Starting with the mildest. Type 1. Right. Type
I is essentially a sprain of the AC ligament
only. The fibers are stretched, maybe some minor
tearing, but crucially, the ligament is intact
overall and the joint remains stable. So no displacement.
No displacement. Yeah. Radiographically, it looks
normal. The CC ligaments are completely unharmed.
Patients present with localized tenderness, but
it typically settles well with conservative management
within a few weeks. OK. Moving up to type 2.
In type 2, the AC ligament is completely torn.
That's the key difference. However, the CC ligaments,
while they might be sprained, are still intact
and functional. Ah, so the main vertical stabilizers
are okay. Correct. Because the CCs are intact,
you only get partial displacement or subluxation
of the joint. On an X -ray, you'll see the clavicle
slightly elevated relative to the acrimine, maybe
some overlap, but it's not a complete dislocation.
And management is usually non -operative for
type 2 as well? Generally, yes. Because the crucial
cc ligaments are holding things relatively stable,
non -operative treatment with structured rehab
usually yields good results. Now, type 3. This
is often where the debate starts, isn't it? How
does Rockwood define it? And perhaps more interestingly,
how do you approach these clinically? You're
absolutely right. Type 3 is the controversial
one. According to the strict Rockwood definition,
a type 3 injury involves a complete rupture of
both the AC ligaments and the CC ligaments. So
everything's torn? Anatomically, yes. This results
in a complete dislocation of the joint. The clavicle
displaces superiorly, often quite significantly,
because there's nothing holding it down anymore.
This is when you see that obvious step -off deformity
or the piano key sign on examination. Right.
Now clinically, This is where nuance comes in.
While Rockwood says both are completely torn,
in my practical experience managing these, I
sometimes view a grade 3 as perhaps having a
complete AC tear, but maybe only a significant
sprain or partial tear of the CC ligaments. Ah,
so not always a complete CC rupture in practice
for what gets called a type 3. Well, the displacement
is there, as per Rockwood 3 definition, implying
significant CC injury. But the absolute necessity
for surgery isn't always clear -cut for every
single patient who fits the type 3 x -ray picture.
It allows us to consider the patient's needs
more closely. I see. So you'd weigh other factors.
Absolutely. What are the patient's functional
demands? Are they a high -level overhead athlete?
A manual laborer needing maximum shoulder stability?
In those cases, Even with a standard type 3 appearance,
surgery might be the better option to restore
optimal mechanics. Versus someone more sedentary.
Exactly. A less active individual might do perfectly
well functionally with non -operative management,
despite the radiographic appearance. This contrasts
sharply with what I might term category three
injuries in my thinking, encompassing rockwood
types for V insects. The more severe types. Yes.
In those, there's absolutely no doubt both ligament
complexes are completely disrupted, the displacement
is far more dramatic, and the instability is
profound. Surgery is almost always required for
those higher grades. So for type 3, it's about
bridging that gap between the strict anatomical
classification and the individual patient's context.
That's a really helpful clinical perspective.
Okay, let's look at those higher grades then,
starting with type 4. What's the defining feature
there? Type 4 is defined by posterior displacement.
The clavicle doesn't just go up, it goes backwards,
often getting trapped behind or even punching
through the trapezius muscle. Button -holing
through the muscle. That's the term, yes. This
makes it incredibly unstable and very difficult
to reduce and hold non -operatively. Because
of this inherent instability and the soft tissue
damage, early surgical stabilization is pretty
much always necessary to avoid long -term problems.
Right. And type V, how much worse does it get?
Type V represents a very severe superior displacement.
We're talking significant vertical distance between
the clavicle and the acromeon, often 100 % or
more displacement compared to the normal side.
Wow. This indicates not just complete AC and
CC ligament rupture, but also extensive stripping
of the muscle attachments, the deltoid and trapezius
fascia from the distal clavicle. The deformity
is usually very obvious. And surgery is mandatory.
Almost invariably, yes. The instability is profound.
The functional deficit is huge. Non -operative
management simply doesn't work for type V. You
need surgery to restore function and stability.
And finally, the rare type VI. Type VI is indeed
very uncommon. Here, the clavicle displaces inferiorly,
downwards, getting lodged underneath the acromand,
or even more rarely, the coracoid process. Downwards?
How does that happen? Usually requires a very
specific high energy impact. Like the higher
grades of IV and V, it represents profound instability
due to massive ligamentous and muscular disruption.
Surgery is required here too. So that covers
the adult classifications. But you sometimes
see these in children. Are there special considerations
for pediatric AC injuries? Ah, yes. A very important
distinction. Children aren't just small adults,
especially skeletally. The key difference is
the periosteum around the distal clavicle in
a child's that fibrous sleeve covering the bone.
It's stronger in kids. It's relatively much thicker
and stronger compared to the ligaments themselves.
So when a child sustains a force that would tear
ligaments in an adult, in the child, it's more
likely to cause an injury through the bone's
growth plate. or cause the periosteal sleeve
to tear or avulse off the bone rather than a
pure mid -substance ligament tear. So the injury
pattern is different. Exactly. The periosteal
sleeve can sometimes even remain partially intact,
acting like a natural tether or hinge, which
can influence the degree of displacement and
often leads to better healing potential and remodeling
capacity compared to adults. While you can still
see injuries resembling the higher rockwood types
in children, the underlying pathology and healing
response are different. That's fascinating. Okay,
let's shift to diagnosis. We suspect an AC joint
injury. How does the patient typically present
and what's the diagnostic pathway? Well, the
presentation really mirrors the severity, the
walk would type. For lower grades, type I and
II, the main feature is localized pain right
over the AC joint. It's often quite tender to
touch. And worst with certain movements? Definitely.
Bringing the arm across the chest, horizontal
adduction usually provokes it. Lying on that
side at night is often very uncomfortable, too.
You might see some mild swelling, but usually
no obvious deformity. And for the higher grades,
three and above? It's usually much more obvious.
Besides more intense pain, you'll likely see
that visible deformity, the step off or bump
where the clavicle is riding high. The whole
arm might hang slightly lower on the affected
side. So the visual inspection is key. What about
the hands -on clinical examination? What are
you specifically looking for? The physical exam
is crucial. First, visual inspection for that
asymmetry or step -off deformity. Then, careful
palpation directly over the AC joint itself tenderness
is a very consistent sign. And testing stability.
Yes. We gently assess for abnormal movement.
Can you press the clavicle down? Does it reduce?
Does it spring back up when you release pressure?
Panache sign. That indicates instability. Do
you ever hear or feel anything? Sometimes. Yes.
During testing, or even with a patient's own
movement, you might hear or feel a painful clunk
as the joint subluxes or reduces. That's a strong
indicator of significant ligament damage. We
also check range of motion, noting pain on specific
movements like adduction or elevation. Okay,
so a clinical exam gives you a strong suspicion.
How does imaging confirm things and help classify
the injury accurately? Let's start with x -rays.
X -rays are the first -line investigation. Absolutely
essential. They confirm the diagnosis by showing
the relationship between the clavicle and the
acromion, revealing the degree of displacement.
They also crucially rule out associated fractures.
Are there specific views you need? A standard
AP view is useful, but often a Zonka view is
preferred. It's angled slightly to give a clearer,
unobstructed view of the AC joint itself. What
about stress views? You hear about those. Yes,
stress x -rays can be very helpful, especially
if you suspect a type 3 injury. But the resting
films look only mildly displaced, or perhaps
like a type 2. The patient holds weights in each
hand. To pull the arm down. Exactly. The weight
stresses the joint, pulling the scapula and arm
down, which exaggerates any underlying instability
and makes the clavicle displacement much more
obvious if the CC ligaments are indeed torn.
It helps differentiate between stable type 2
and unstable type 3 injuries sometimes. Right.
When might you use a CT scan? CT gives much better
bony detail than x -rays. It's particularly useful
if you suspect an associated fracture, maybe
of the distal clavicle, the acromeon, or, importantly,
the coracoid process. It can also show the degree
of static displacement very clearly, especially
any posterior displacement seen in type 4. An
MRI. Is that commonly used? MRI isn't usually
the first -line test for an acute, straightforward
AC separation. Its strength isn't showing soft
tissues in great detail. So the ligaments themselves?
Precisely. MRI is excellent for visualizing the
ligaments directly, assessing the extent of tearing,
partial versus complete, and identifying any
associated injuries to other soft tissues like
the rotator cuff or labrum. It's most useful
when the diagnosis is uncertain after x -rays,
perhaps in lower grade injuries with persistent
symptoms or if you suspect complications later
on. Okay, that clarifies the imaging pathway.
So diagnosis made, classification determined.
Now we face the treatment decision non -operative
versus operative. Let's start with the non -operative
route. What's the approach and who's it best
suited for? Non -operative management is definitely
the mainstay for lower grade injuries. Rockwood
type I and II, and often considered for type
III, as we discussed. The initial focus is purely
on symptom control. How do you achieve that?
Rest is key, initially. Using an arm sling provides
comfort and support, ideally a broad arm sling
that supports the elbow and takes the weight
off the shoulder, rather than a simple collar
and cuff. We also use ice therapy frequently
in the acute phase to reduce swelling and pain,
alongside NSAIDs, nonsteroidal anti -inflammatory
drugs. And how long does that initial phase last?
It depends. For a type Y, the sling might only
be needed for comfort for a week or so. For type
2, maybe longer, perhaps four to six weeks for
symptoms to really settle. Once the acute pain
starts to subside, the focus shifts very quickly
towards rehabilitation. So rehab starts quite
early then. Can you walk us through the typical
phases? Yes. Rehab shouldn't be delayed. It's
a structured, phased process. Phase one is the
acute phase. Pain control, protecting the joint,
but starting gentle range of motion exercises,
often passive or active assisted, and isometric
exercises, contracting muscles without moving
the joint much. Keeping things moving gently.
Exactly. Then phase two is about strengthening.
As pain allows, we introduce isotonic exercises,
moving against resistance, initially keeping
movements below shoulder height to avoid stressing
the joint too much. We focus on strengthening
the rotator cuff, the scapular stabilizers, the
bigger shoulder muscles, building back the support
system, precisely. Phase three involves progressing
to more functional movements, increasing strength,
power, endurance, and crucially, neuromuscular
control, teaching the muscles to work together
effectively again, getting ready for more demanding
tasks. And the final phase. Phase 4 is the return
to activity. This is highly individualized, focusing
on sport -specific or work -specific drills,
gradually reintroducing the demands the patient
needs to meet. For example, return to contact
sports might be considered around 6 -12 weeks,
depending on progress and injury severity. That
sounds very thorough. What are the typical outcomes
for non -operative treatments, say for type I
and 2, and maybe select a type 3? For type I
and 2, the outcomes are generally excellent.
Most patients get significant pain relief within
a few weeks, and many athletes can return to
sport quite quickly, sometimes within 2 -4 weeks
for type 2. Full recovery might take up to 12
weeks, perhaps a bit longer, for some type 3s
managed this way. Are there any potential downsides
or long -term issues with non -operative management?
While most do very well, a minority might experience
persistent symptoms. This could be some residual
ache, discomfort with specific activities, or
potentially developing AC joint arthritis down
the line. There's also some evidence suggesting
a slight reduction in things like bench press
strength. In some individuals, although most
don't find it functionally limiting, if symptoms
are still significant at six months, they're
more likely to persist beyond a year. Okay. So
when does surgery become the recommendation?
What are the main indications and the goals of
operating? Surgery is generally reserved for
the higher grade injuries, definitely types 4,
V, and 6. And it's strongly considered for type
3 injuries, particularly in active individuals
with high demands or when non -operative treatment
for a type 3 has failed to provide satisfactory
function or pain relief. And what are you trying
to achieve with surgery? The main goals are,
firstly, an anatomical reduction, getting the
clavicle back into its proper position relative
to the acromion and coracoid. Secondly, secure
a fixation to hold it there while the tissues
heal. And thirdly, restoring stability both horizontally
and vertically to allow for good long -term function.
Ultimately, we want a stable, pain -free shoulder.
How have surgical techniques changed over the
years? Oh, considerably. Older techniques, like
the Weaver Dun procedure, often involved resecting
the end of the clavicle and using local tissues
like the coracoacromial ligament for reconstruction.
Now, the trend is much more towards anatomical
reconstruction, often using stronger fixation
methods. Like what? Things like suspensory fixation
devices have become very popular. These use strong
sutures or synthetic tapes passed around the
coracoid and through tunnels in the clavicle
to replicate the function of the native cc ligaments.
Some techniques involve plates or screws, though
these often require removal later. In chronic
cases, sometimes biological grafts are used to
augment the repair. You mentioned there are over
a hundred techniques described. That suggests
there isn't one single best way. That's absolutely
right. The sheer number of techniques reflects
the ongoing challenge and the lack of universal
consensus on the perfect repair. Options range
from direct ligament repair, if possible acutely,
using local tissue transfers, synthetic ligaments,
suture button devices, hook plates. The list
goes on. The choice depends on the injury pattern,
the surgeon's preference and experience, the
patient's needs, and whether the injury is acute
or chronic. It's fascinating though that even
with surgery aiming for perfect anatomical reduction,
research hasn't always shown a direct link between
that perfect x -ray and better pain or function
outcomes. That's a really key observation in
the field. While we strive for anatomical correction,
the correlation between radiographic appearance
and patient -reported outcomes isn't always straightforward.
So a perfect x -ray doesn't guarantee a perfect
result for the patient? Not necessarily. You
can have a patient with a radiographically flawless
reduction who still has some pain or functional
limitation. And conversely, someone with slight
residual displacement on x -ray might be completely
asymptomatic and function at a very high level.
Why is that? It's complex. Factors like muscle
strength, neuromuscular control, individual pain
perception, biological healing response, and
the demands placed on the shoulder all play a
huge role. It underscores that our ultimate goal
isn't just to fix the x -ray image, but to achieve
a stable, painless shoulder that allows the patient
to return to their desired activities. Patient
function and satisfaction are the real measures
of success. A very important perspective. So,
looking at the bigger picture of prognosis, how
do the recovery paths and long -term outcomes
generally compare between non -op and surgical
approaches? Well, for types 1 and 2, non -op
is the clear winner, good outcomes, quicker return
to activities generally. Sling use is short.
maybe 7 -10 days for type 1, perhaps 4 -6 weeks
for type 2 protection. Long -term studies show
good results, though as mentioned, a few might
have lingering issues or develop arthritis later.
If symptoms persist at 6 months, they might linger
longer. And for the higher grades where surgery
is more common? For types 3 and above, surgery
generally provides better anatomical reduction
and stability. However, it comes with a higher
risk of complications compared to non -operative
treatment. What kind of complications are we
talking about? Things like mild residual instability
can still occur, despite the surgery. Hardware
issues are possible migration, prominence needing
removal. Infection is a risk, though thankfully
low, maybe around 1%. Nerve injury is rare, but
possible. Stiffness or soft tissue ossification
can also occur. So there are definite trade -offs?
Absolutely. Non -operative might mean quicker
initial recovery, but potentially more residual
instability or cosmetic deformity for higher
grades. Surgery aims for better anatomical stability,
but has a longer recovery and carries those surgical
risks. Despite the risks though, meta -analyses
show high return to sport rates, around 94%,
for patients having surgery for type 3 or higher
injuries. And rehabilitation after surgery is
presumably just as crucial. Even more so, arguably.
Post -surgical rehab is absolutely vital to protect
the repair, regain motion safely, build strength,
and ultimately optimize the outcome. It's carefully
progressed. What does that involve initially?
Initially, there might be restrictions, perhaps
limiting abduction above 90 degrees for a period.
Gentle pendulum exercises are often started early
to maintain some motion and prevent stiffness
without stressing the repair. And then building
up. Yes, then progressively introducing range
of motion followed by strengthening exercises
for the rotator cuff, deltoid, and scapular muscles.
It's all about providing dynamic support to the
reconstructed joint. The protocol needs tailoring
to the specific surgery performed. So, summing
up the long -term picture. It really hinges on
the initial injury, severity, and the chosen
management. But regardless of whether it's non
-op or surgical, a meticulously planned patient
-specific rehabilitation program is paramount.
That tailored rehab, considering the patient's
individual goals and activity levels, is probably
the single most important factor in achieving
the best possible long -term function. Okay,
that leads us nicely into modern approaches.
Many listeners will be keen to hear about current
thinking on reconstruction. Could you share your
management philosophy, particularly how you differentiate
acute versus chronic injuries when deciding on
intervention? Certainly. My approach is very
much guided by the timing, the acuity of the
injury. I generally define acute as less than
about one week from injury. And how does that
guide your initial steps? For most acute injuries,
one week after diagnosis, my preference is usually
to start with conservative management. That means
a sling, but mainly just for comfort. not strict
immobilization, analgesia for pain, and crucially
starting rehabilitation with early active mobilization
as soon as the patient feels able. So give conservative
treatment a chance first in most acute cases.
In many, yes, but the initial inflammation settles
see how the patient progresses functionally.
However, there are definite exceptions where
I'd recommend early surgery even in the acute
phase, such as cases with really severe pain,
especially if the clavicle is clearly buttonholed
through the trapezius, a type 4. Also, high -level
overhead athletes often benefit from early surgery
to restore mechanics optimally. Any associated
neurovascular injury or an open fracture are,
of course, immediate surgical indications. What's
your follow -up strategy, then, for those managed
conservatively initially? I typically review
them at three weeks. If they're improving well,
symptoms settling, function returning, we continue
with the symptomatic management and gradual return
to activity plan in another review around three
months. And if they're not doing well at three
weeks? If they're still really struggling with
pain or instability or just not coping functionally,
then I'd offer early surgical reconstruction
at that point. No sense in delaying further if
it's clearly not working. And the three month
review? At three months, if they've successfully
returned to their activities with minimal issues,
fantastic. They could be discharged. If they're
still not coping despite extended rehab, then
surgery is offered as the definitive solution.
It's a pathway that allows for non -operative
management where appropriate but ensures timely
intervention if needed. That makes good clinical
sense. When surgery is the path chosen, what
constitutes an ideal reconstruction technique
today? What are the key goals? Ah, the ideal
technique. That's what we're all striving for.
Based on current understanding, I think there
are about six key criteria we aim for. One, anatomical
restoration. We want to recreate both the CC
and AC ligament anatomy as closely as possible.
Right, putting things back where they belong.
Two, strength plus flexibility. The repair needs
to be strong enough immediately, but also allow
some natural physiological motion at the AC joint.
Two, rigid isn't good either. Makes sense. Three,
allow early rehabilitation. The construct must
be stable enough to let patients start moving
relatively early to prevent stiffness and speed
up recovery. Get them gone and quickly. 4. Biological
integration. Ideally, the repair encourages the
body's own tissues to heal into it, providing
long -term, durable stability. Less reliance
on artificial materials long -term. 5. Avoid
donor site morbidity. If using the patient's
own tissue, Autographed. We want to minimize
any problems from the harvest site. That's an
advantage of good synthetic options. And six,
eliminate routine hardware removal. We want techniques
where implants don't routinely need a second
operation just to take them out. That's a very
clear checklist. With those criteria in mind,
can you tell us about your preferred approach
to the triple anatomical technique? What does
it involve? Yes, this technique is designed to
hit those criteria, aiming for anatomical restoration
with biological potential, creating a strong
construct that allows early mobilization. It
has three main parts. Triple technique, three
parts. Makes sense. First is an anatomic corcoclavicular
ligament reconstruction. I use a strong synthetic
ligament, specifically the Lars ligament, which
is polyethylene tetrafasolate, because it's incredibly
strong, stronger than the native CC ligaments,
providing immediate stability. Its braided structure
also encourages tissue ingrowth, aiming for that
biological integration over time. We pass it
anatomically through tunnels in the clavicle
at the ligament footprints and then secure it
around or through the coracoid. Okay, so that
replaces the CC ligaments. What's the second
part? Second is an acromoclavicular ligament
reconstruction, often using a transfer of the
nearby coraco -chromial ligament. This directly
addresses the AC joint capsule and ligament,
restoring horizontal stability, which the CC
reconstruction alone doesn't fully address. Got
it. And the third component. The third part is
a delto -tripetal fascia repair. This involves
carefully repairing the torn fascia of the deltoid
and trapezius muscles where they attach to the
clavicle and acromion. This is especially important
in higher grade injuries, like type V, where
the fascia is often ripped off. It adds significant
reinforcement and dynamic stability to the whole
construct. So you're rebuilding the CCs, the
ACs, and reinforcing the muscle envelope. Exactly.
It's a comprehensive belt and braces approach.
We also believe transferring a ligament like
the CA ligament might help restore some proprioception
that joint position sends. Overall, we find it
safe, reproducible, and very effective at restoring
stability, which allows for that crucial early
recovery and return to sport. It certainly sounds
robust. Finally, for those patients, especially
athletes undergoing this kind of reconstruction,
how do you manage their return to sport? What
are realistic timelines? Return to sport is always
a gradual, criterion -based process, not just
about time. It absolutely requires teamwork between
me, the physiotherapist, and often strength and
conditioning coaches. Everyone has to be on the
same page. Completely. We need to see the patient
meet specific functional milestones, strength,
range of motion, stability, sport -specific movements
before they progress. But based on our experience,
contact athletes like rugby players usually take
around three to four months post -op before returning
to full contact. They need that time for solid
healing and to rebuild the strength to withstand
impacts. And overhead athletes, pitchers, tennis
players. They typically need longer, often six
to nine months. Their sports require extreme
ranges of motion, power and fine motor control.
Rushing them back risks re -injury or poor performance.
Any activities that allow a quicker return. Interestingly,
we find horse riders and cyclists can often get
back sooner, sometimes in less than three months,
while falls can cause the initial injury. The
actual activity itself doesn't usually place
the same high -impact repetitive stress on the
AC joint as contact or overhead sports. And sport
-specific rehab is key throughout. Absolutely
critical. A rugby player needs drills with a
ball, controlled contact simulation. A swimmer
needs pool -based rehab. Tailoring the exercises
to mimic the demands of their specific sport
ensures they are truly ready and confident when
they return to competition. Professor, this has
been incredibly insightful. We've covered a huge
amount from the basic anatomy right through to
your specific advanced surgical technique for
AC joint disruptions. Thank you for clarifying
so much complexity. It's been a real pleasure.
These are common injuries, and getting the management
right based on a detailed understanding really
does make a difference for our patients. Absolutely.
Just as a final thought for our listeners, as
our understanding of biomechanics and biology
continues to advance, perhaps with things like
better biological augmentation or even more refined,
minimally invasive techniques, how do you see
the approach to AC joint stability and recovery
evolving further in the future? That's the exciting
part, isn't it? Always looking ahead. Indeed.
If this deep dive has sharpened your perspective
on AC joint injuries, please do consider rating
and sharing it with your colleagues. Thank you
for joining us. Thank you.