WEBVTT 00:00:00.000 --> 00:00:02.200 Welcome to the Deep Dive. Today we're focusing 00:00:02.200 --> 00:00:05.040 on a specific and actually fairly common shoulder 00:00:05.040 --> 00:00:08.439 issue, the acromioclavicular joint or the AC 00:00:08.439 --> 00:00:10.519 joint. That's right. Often called a shoulder 00:00:10.519 --> 00:00:13.279 separation. Exactly. And while it might sound 00:00:13.279 --> 00:00:16.339 minor, it can really affect daily life and particularly 00:00:16.339 --> 00:00:19.000 athletic function. We often see it in high impact 00:00:19.000 --> 00:00:22.320 sports, don't we? Indeed. Rugby, cycling falls, 00:00:22.600 --> 00:00:26.160 horse riding, quite common. And the impact on 00:00:26.160 --> 00:00:29.679 function can be, well, profound. So our goal 00:00:29.679 --> 00:00:32.000 in this deep dive is to really get under the 00:00:32.000 --> 00:00:34.960 skin of AC joint injuries. We want to provide 00:00:34.960 --> 00:00:37.899 you, our audience of mid -senior medical professionals, 00:00:38.380 --> 00:00:40.880 with a solid, practical understanding, moving 00:00:40.880 --> 00:00:43.259 beyond the basics to the kind of detailed insights 00:00:43.259 --> 00:00:45.359 that help in clinic. Looking at everything from 00:00:45.359 --> 00:00:47.740 diagnosis, classification, right through to the 00:00:47.740 --> 00:00:50.189 latest thinking on treatment and recovery. Precisely. 00:00:50.409 --> 00:00:52.090 So let's start at the beginning. An AC joint 00:00:52.090 --> 00:00:54.509 disruption isn't the same as a typical shoulder 00:00:54.509 --> 00:00:56.810 dislocation, is it? Can you clarify that distinction? 00:00:57.710 --> 00:01:00.170 Yes, that's a really crucial point. People often 00:01:00.170 --> 00:01:03.450 use shoulder dislocation quite loosely, but usually... 00:01:03.340 --> 00:01:05.859 That refers to the glenohumeral joint, the main 00:01:05.859 --> 00:01:08.140 ball and socket. Where the humerus comes out 00:01:08.140 --> 00:01:10.280 of the sock. Exactly. An AC joint disruption, 00:01:10.340 --> 00:01:13.180 though, is different. It's a separation right 00:01:13.180 --> 00:01:15.900 at the top, the apex of the shoulder. It's specifically 00:01:15.900 --> 00:01:19.079 where the collarbone, the clavicle, meets the 00:01:19.079 --> 00:01:21.159 acromeon, which is the highest point of the shoulder 00:01:21.159 --> 00:01:24.099 blade. So the injury is a traumatic separation 00:01:24.099 --> 00:01:26.579 of those two bones. The ligaments holding them 00:01:26.579 --> 00:01:29.180 together get damaged to varying degrees. And 00:01:29.180 --> 00:01:31.780 you mentioned it's common in sports. Very. Especially 00:01:31.780 --> 00:01:34.760 contact sports or activities where falls directly 00:01:34.760 --> 00:01:37.939 onto the shoulder are a risk. Think rugby tackles, 00:01:38.159 --> 00:01:40.680 falls in motorsports, equestrian sports. And 00:01:40.680 --> 00:01:43.900 it causes significant pain and limitation. Absolutely. 00:01:44.079 --> 00:01:46.480 It's not just a minor niggle. It can be genuinely 00:01:46.480 --> 00:01:49.780 debilitating, affecting simple daily tasks, let 00:01:49.780 --> 00:01:53.060 alone high level sport or manual work. So understanding 00:01:53.060 --> 00:01:56.340 the anatomy is key then. What makes this small 00:01:56.340 --> 00:01:58.640 joint so important for shoulder function and 00:01:58.640 --> 00:02:02.659 yet seemingly so vulnerable? Well, functionally, 00:02:02.780 --> 00:02:04.780 it's critical. It's technically a diarthrodial 00:02:04.780 --> 00:02:07.420 joint, a synovial joint, but its main job is 00:02:07.420 --> 00:02:09.659 to link the entire arm and shoulder blade assembly, 00:02:09.879 --> 00:02:12.259 the upper limb, to the main trunk, the axial 00:02:12.259 --> 00:02:15.500 skeleton. It's the strip connecting the arm to 00:02:15.500 --> 00:02:17.520 the body, essentially. You could think of it 00:02:17.520 --> 00:02:20.419 like that, yes. It allows the scapula to move 00:02:20.419 --> 00:02:22.699 properly, which is vital for everything from 00:02:22.699 --> 00:02:25.340 reaching up to throwing. Without that stable 00:02:25.340 --> 00:02:28.520 connection, shoulder function is severely compromised. 00:02:28.819 --> 00:02:30.879 And what keeps it stable? It sounds like a complex 00:02:30.879 --> 00:02:34.159 setup. It is. It relies on both static and dynamic 00:02:34.159 --> 00:02:38.060 stabilizers. First, you have the acromioclavicular 00:02:38.060 --> 00:02:40.740 ligaments themselves. They form the joint capsule. 00:02:41.199 --> 00:02:43.759 These are key for horizontal stability, stopping 00:02:43.759 --> 00:02:47.000 the clavicle, moving too far forwards or backwards 00:02:47.000 --> 00:02:49.659 relative to the acromion. Okay, so front -to 00:02:49.659 --> 00:02:52.740 -back stability. Precisely. But arguably even 00:02:52.740 --> 00:02:54.840 more important, especially for vertical stability, 00:02:55.340 --> 00:02:58.460 stopping the collarbone popping up, are the coracuclavicular 00:02:58.460 --> 00:03:01.539 ligaments, the CC ligaments. Ah, yes, the cornoid 00:03:01.539 --> 00:03:03.840 and trapezoid. Exactly, the cornoid and the trapezoid. 00:03:03.860 --> 00:03:06.539 They run from the coracoid process, that hook 00:03:06.539 --> 00:03:09.219 -like bit of bone on the scapula, up to the underside 00:03:09.219 --> 00:03:11.819 of the distal clavicle. Think of them as really 00:03:11.819 --> 00:03:14.120 strong suspension cables. Holding the clavicle 00:03:14.120 --> 00:03:17.860 down. Essentially, yes. Preventing superior displacement. 00:03:18.199 --> 00:03:20.819 If these are torn, that's when you typically 00:03:20.819 --> 00:03:22.979 see that characteristic bump on the shoulder 00:03:22.979 --> 00:03:26.319 in more severe injuries. Their integrity is absolutely 00:03:26.319 --> 00:03:29.479 vital. So those are the static ligamentous restraints. 00:03:29.639 --> 00:03:33.539 What about muscles? Good point. We also have 00:03:33.539 --> 00:03:36.780 crucial dynamic stabilizers. The large deltoid 00:03:36.780 --> 00:03:38.960 and trapezius muscles drape over the shoulder. 00:03:39.300 --> 00:03:41.620 While their main job is movement, they also provide 00:03:41.620 --> 00:03:44.240 dynamic compression and stability to the AC joint. 00:03:44.479 --> 00:03:47.080 Especially if the ligaments are injured. Yes, 00:03:47.419 --> 00:03:49.719 their role becomes even more important then, 00:03:49.939 --> 00:03:51.939 although they can't fully compensate if the main 00:03:51.939 --> 00:03:54.460 ligaments, particularly the CCs, are completely 00:03:54.460 --> 00:03:56.419 ruptured. Is there anything else within the joint 00:03:56.419 --> 00:03:58.840 itself? Well, sometimes there's a meniscal disc, 00:03:59.240 --> 00:04:01.659 a small fibrocardilage pad between the bone ends. 00:04:01.979 --> 00:04:04.060 It's not present in everyone, but when it is, 00:04:04.139 --> 00:04:05.919 it helps with load distribution and acts as a 00:04:05.919 --> 00:04:08.240 bit of a shock absorber. So, quite an intricate 00:04:08.240 --> 00:04:11.560 structure. Given this anatomy, what usually causes 00:04:11.560 --> 00:04:13.479 these ligaments to tear? What are the typical 00:04:13.479 --> 00:04:16.259 mechanisms of injury? It's almost always down 00:04:16.259 --> 00:04:19.079 to trauma, a significant force applied to the 00:04:19.079 --> 00:04:21.459 joint that overcomes the strength of those ligaments. 00:04:21.959 --> 00:04:24.800 The most common mechanism, by far, is direct 00:04:24.800 --> 00:04:28.079 trauma. This is usually a fall directly onto 00:04:28.079 --> 00:04:30.680 the point of the shoulder, hitting the acromeon, 00:04:30.959 --> 00:04:33.100 often with the arm tucked into the side, adducted. 00:04:33.180 --> 00:04:35.560 Like in a rugby tackle or falling off a bike? 00:04:35.839 --> 00:04:38.480 Exactly that scenario. The force drives the shoulder 00:04:38.480 --> 00:04:40.860 blade downwards, but the clavicle stays put, 00:04:41.439 --> 00:04:43.660 creating this massive sheer force across the 00:04:43.660 --> 00:04:46.300 AC joint, tearing the ligaments. OK, that makes 00:04:46.300 --> 00:04:48.800 sense. Are there other ways it can happen? Yes. 00:04:49.060 --> 00:04:51.600 Less commonly, you can get indirect trauma. The 00:04:51.600 --> 00:04:54.300 classic example is a foosh injury, a fall on 00:04:54.300 --> 00:04:57.420 an outstretched hand. Ah, yes, foosh. The force 00:04:57.420 --> 00:04:59.860 travels up the arm, through the humerus and scapula, 00:05:00.120 --> 00:05:02.600 and ultimately stresses the AC joint. Yeah. We 00:05:02.600 --> 00:05:04.800 also see some cases of repetitive microtrauma, 00:05:04.920 --> 00:05:06.740 maybe in weightlifters or overhead athletes, 00:05:07.079 --> 00:05:09.480 but that's usually a lower grade issue managed 00:05:09.480 --> 00:05:11.459 differently. You mentioned earlier it's common. 00:05:11.879 --> 00:05:14.500 Are there specific groups more at risk? Yes, 00:05:14.720 --> 00:05:16.699 there's a really striking demographic pattern. 00:05:16.899 --> 00:05:18.899 Males are affected much more often than females. 00:05:19.519 --> 00:05:21.519 The ratio is something like five to one. Five 00:05:21.519 --> 00:05:24.639 to one, that's significant. It is, and it's particularly 00:05:24.639 --> 00:05:28.420 prevalent in the 20 to 35 age group. This strongly 00:05:28.420 --> 00:05:30.879 correlates with higher participation rates in 00:05:30.879 --> 00:05:32.839 those high -risk contact sports and activities 00:05:32.839 --> 00:05:35.019 we discussed. It really highlights that link 00:05:35.019 --> 00:05:37.800 between activity levels and injury risk. That 00:05:37.800 --> 00:05:40.920 5 .1 ratio certainly reflects what we tend to 00:05:40.920 --> 00:05:43.740 see clinically. So once an injury happens, classifying 00:05:43.740 --> 00:05:46.459 it correctly is the next vital step for management. 00:05:46.899 --> 00:05:48.839 The Rockwood classification is the standard, 00:05:48.980 --> 00:05:51.639 isn't it? Absolutely. Classification is fundamental 00:05:51.639 --> 00:05:53.839 in orthopedics. It gives us a common language 00:05:53.839 --> 00:05:56.209 and guides treatment. The Rockwood system from 00:05:56.209 --> 00:05:59.250 1998 is the most comprehensive and widely used 00:05:59.250 --> 00:06:01.949 for AC joint injuries. And it goes beyond just 00:06:01.949 --> 00:06:05.170 mild, moderate, severe. It does. It defines six 00:06:05.170 --> 00:06:07.730 distinct types based on exactly which ligaments 00:06:07.730 --> 00:06:10.029 are torn, the AC and the crucial cc ligaments, 00:06:10.310 --> 00:06:12.189 and importantly, the direction and degree of 00:06:12.189 --> 00:06:14.470 clavicle displacement relative to both the acromion 00:06:14.470 --> 00:06:17.189 and the coracuate process. It provides a really 00:06:17.189 --> 00:06:19.629 robust framework for prognosis and deciding on 00:06:19.629 --> 00:06:21.350 treatment. Okay, let's walk through them then. 00:06:21.410 --> 00:06:23.579 Starting with the mildest. Type 1. Right. Type 00:06:23.579 --> 00:06:25.620 I is essentially a sprain of the AC ligament 00:06:25.620 --> 00:06:28.740 only. The fibers are stretched, maybe some minor 00:06:28.740 --> 00:06:31.759 tearing, but crucially, the ligament is intact 00:06:31.759 --> 00:06:35.680 overall and the joint remains stable. So no displacement. 00:06:35.959 --> 00:06:38.060 No displacement. Yeah. Radiographically, it looks 00:06:38.060 --> 00:06:41.040 normal. The CC ligaments are completely unharmed. 00:06:41.480 --> 00:06:43.579 Patients present with localized tenderness, but 00:06:43.579 --> 00:06:46.040 it typically settles well with conservative management 00:06:46.040 --> 00:06:48.980 within a few weeks. OK. Moving up to type 2. 00:06:49.220 --> 00:06:51.639 In type 2, the AC ligament is completely torn. 00:06:51.839 --> 00:06:55.019 That's the key difference. However, the CC ligaments, 00:06:55.360 --> 00:06:57.720 while they might be sprained, are still intact 00:06:57.720 --> 00:07:00.980 and functional. Ah, so the main vertical stabilizers 00:07:00.980 --> 00:07:03.540 are okay. Correct. Because the CCs are intact, 00:07:03.879 --> 00:07:06.500 you only get partial displacement or subluxation 00:07:06.500 --> 00:07:09.199 of the joint. On an X -ray, you'll see the clavicle 00:07:09.199 --> 00:07:11.759 slightly elevated relative to the acrimine, maybe 00:07:11.759 --> 00:07:14.500 some overlap, but it's not a complete dislocation. 00:07:15.000 --> 00:07:16.839 And management is usually non -operative for 00:07:16.839 --> 00:07:20.220 type 2 as well? Generally, yes. Because the crucial 00:07:20.220 --> 00:07:22.680 cc ligaments are holding things relatively stable, 00:07:23.319 --> 00:07:25.439 non -operative treatment with structured rehab 00:07:25.439 --> 00:07:30.439 usually yields good results. Now, type 3. This 00:07:30.439 --> 00:07:32.800 is often where the debate starts, isn't it? How 00:07:32.800 --> 00:07:35.459 does Rockwood define it? And perhaps more interestingly, 00:07:35.680 --> 00:07:38.310 how do you approach these clinically? You're 00:07:38.310 --> 00:07:40.110 absolutely right. Type 3 is the controversial 00:07:40.110 --> 00:07:42.709 one. According to the strict Rockwood definition, 00:07:42.910 --> 00:07:45.730 a type 3 injury involves a complete rupture of 00:07:45.730 --> 00:07:48.550 both the AC ligaments and the CC ligaments. So 00:07:48.550 --> 00:07:52.129 everything's torn? Anatomically, yes. This results 00:07:52.129 --> 00:07:55.490 in a complete dislocation of the joint. The clavicle 00:07:55.490 --> 00:07:58.050 displaces superiorly, often quite significantly, 00:07:58.449 --> 00:08:00.209 because there's nothing holding it down anymore. 00:08:00.730 --> 00:08:03.370 This is when you see that obvious step -off deformity 00:08:03.370 --> 00:08:05.689 or the piano key sign on examination. Right. 00:08:05.850 --> 00:08:08.579 Now clinically, This is where nuance comes in. 00:08:08.800 --> 00:08:10.600 While Rockwood says both are completely torn, 00:08:11.040 --> 00:08:13.519 in my practical experience managing these, I 00:08:13.519 --> 00:08:16.459 sometimes view a grade 3 as perhaps having a 00:08:16.459 --> 00:08:19.420 complete AC tear, but maybe only a significant 00:08:19.420 --> 00:08:21.939 sprain or partial tear of the CC ligaments. Ah, 00:08:22.000 --> 00:08:24.500 so not always a complete CC rupture in practice 00:08:24.500 --> 00:08:27.019 for what gets called a type 3. Well, the displacement 00:08:27.019 --> 00:08:30.160 is there, as per Rockwood 3 definition, implying 00:08:30.160 --> 00:08:33.519 significant CC injury. But the absolute necessity 00:08:33.519 --> 00:08:36.259 for surgery isn't always clear -cut for every 00:08:36.259 --> 00:08:38.919 single patient who fits the type 3 x -ray picture. 00:08:39.559 --> 00:08:41.639 It allows us to consider the patient's needs 00:08:41.639 --> 00:08:44.559 more closely. I see. So you'd weigh other factors. 00:08:44.799 --> 00:08:47.000 Absolutely. What are the patient's functional 00:08:47.000 --> 00:08:49.700 demands? Are they a high -level overhead athlete? 00:08:50.279 --> 00:08:52.519 A manual laborer needing maximum shoulder stability? 00:08:53.320 --> 00:08:56.399 In those cases, Even with a standard type 3 appearance, 00:08:56.919 --> 00:08:58.580 surgery might be the better option to restore 00:08:58.580 --> 00:09:01.519 optimal mechanics. Versus someone more sedentary. 00:09:01.740 --> 00:09:04.279 Exactly. A less active individual might do perfectly 00:09:04.279 --> 00:09:06.240 well functionally with non -operative management, 00:09:06.759 --> 00:09:09.519 despite the radiographic appearance. This contrasts 00:09:09.519 --> 00:09:11.620 sharply with what I might term category three 00:09:11.620 --> 00:09:14.019 injuries in my thinking, encompassing rockwood 00:09:14.019 --> 00:09:17.519 types for V insects. The more severe types. Yes. 00:09:18.139 --> 00:09:20.740 In those, there's absolutely no doubt both ligament 00:09:20.740 --> 00:09:23.320 complexes are completely disrupted, the displacement 00:09:23.320 --> 00:09:25.919 is far more dramatic, and the instability is 00:09:25.919 --> 00:09:29.080 profound. Surgery is almost always required for 00:09:29.080 --> 00:09:32.700 those higher grades. So for type 3, it's about 00:09:32.700 --> 00:09:35.240 bridging that gap between the strict anatomical 00:09:35.240 --> 00:09:38.259 classification and the individual patient's context. 00:09:38.419 --> 00:09:40.840 That's a really helpful clinical perspective. 00:09:41.240 --> 00:09:42.940 Okay, let's look at those higher grades then, 00:09:43.000 --> 00:09:45.259 starting with type 4. What's the defining feature 00:09:45.259 --> 00:09:48.100 there? Type 4 is defined by posterior displacement. 00:09:48.500 --> 00:09:50.480 The clavicle doesn't just go up, it goes backwards, 00:09:50.740 --> 00:09:52.799 often getting trapped behind or even punching 00:09:52.799 --> 00:09:55.039 through the trapezius muscle. Button -holing 00:09:55.039 --> 00:09:57.720 through the muscle. That's the term, yes. This 00:09:57.720 --> 00:10:00.080 makes it incredibly unstable and very difficult 00:10:00.080 --> 00:10:03.139 to reduce and hold non -operatively. Because 00:10:03.139 --> 00:10:05.360 of this inherent instability and the soft tissue 00:10:05.360 --> 00:10:07.980 damage, early surgical stabilization is pretty 00:10:07.980 --> 00:10:10.519 much always necessary to avoid long -term problems. 00:10:10.779 --> 00:10:13.399 Right. And type V, how much worse does it get? 00:10:13.539 --> 00:10:16.340 Type V represents a very severe superior displacement. 00:10:16.919 --> 00:10:19.480 We're talking significant vertical distance between 00:10:19.480 --> 00:10:22.500 the clavicle and the acromeon, often 100 % or 00:10:22.500 --> 00:10:24.580 more displacement compared to the normal side. 00:10:24.740 --> 00:10:28.129 Wow. This indicates not just complete AC and 00:10:28.129 --> 00:10:30.889 CC ligament rupture, but also extensive stripping 00:10:30.889 --> 00:10:34.070 of the muscle attachments, the deltoid and trapezius 00:10:34.070 --> 00:10:36.629 fascia from the distal clavicle. The deformity 00:10:36.629 --> 00:10:39.110 is usually very obvious. And surgery is mandatory. 00:10:39.289 --> 00:10:41.990 Almost invariably, yes. The instability is profound. 00:10:42.110 --> 00:10:44.830 The functional deficit is huge. Non -operative 00:10:44.830 --> 00:10:47.230 management simply doesn't work for type V. You 00:10:47.230 --> 00:10:49.110 need surgery to restore function and stability. 00:10:49.389 --> 00:10:52.470 And finally, the rare type VI. Type VI is indeed 00:10:52.470 --> 00:10:55.889 very uncommon. Here, the clavicle displaces inferiorly, 00:10:56.009 --> 00:10:58.309 downwards, getting lodged underneath the acromand, 00:10:58.330 --> 00:11:01.370 or even more rarely, the coracoid process. Downwards? 00:11:01.409 --> 00:11:03.350 How does that happen? Usually requires a very 00:11:03.350 --> 00:11:06.080 specific high energy impact. Like the higher 00:11:06.080 --> 00:11:09.240 grades of IV and V, it represents profound instability 00:11:09.240 --> 00:11:12.340 due to massive ligamentous and muscular disruption. 00:11:12.860 --> 00:11:14.980 Surgery is required here too. So that covers 00:11:14.980 --> 00:11:17.500 the adult classifications. But you sometimes 00:11:17.500 --> 00:11:20.419 see these in children. Are there special considerations 00:11:20.419 --> 00:11:24.159 for pediatric AC injuries? Ah, yes. A very important 00:11:24.159 --> 00:11:26.559 distinction. Children aren't just small adults, 00:11:27.039 --> 00:11:29.980 especially skeletally. The key difference is 00:11:29.980 --> 00:11:32.559 the periosteum around the distal clavicle in 00:11:32.559 --> 00:11:35.220 a child's that fibrous sleeve covering the bone. 00:11:35.279 --> 00:11:38.200 It's stronger in kids. It's relatively much thicker 00:11:38.200 --> 00:11:40.860 and stronger compared to the ligaments themselves. 00:11:41.360 --> 00:11:43.559 So when a child sustains a force that would tear 00:11:43.559 --> 00:11:46.779 ligaments in an adult, in the child, it's more 00:11:46.779 --> 00:11:48.820 likely to cause an injury through the bone's 00:11:48.820 --> 00:11:51.769 growth plate. or cause the periosteal sleeve 00:11:51.769 --> 00:11:54.809 to tear or avulse off the bone rather than a 00:11:54.809 --> 00:11:57.350 pure mid -substance ligament tear. So the injury 00:11:57.350 --> 00:11:59.730 pattern is different. Exactly. The periosteal 00:11:59.730 --> 00:12:02.190 sleeve can sometimes even remain partially intact, 00:12:02.409 --> 00:12:04.730 acting like a natural tether or hinge, which 00:12:04.730 --> 00:12:06.909 can influence the degree of displacement and 00:12:06.909 --> 00:12:09.210 often leads to better healing potential and remodeling 00:12:09.210 --> 00:12:12.529 capacity compared to adults. While you can still 00:12:12.529 --> 00:12:14.490 see injuries resembling the higher rockwood types 00:12:14.490 --> 00:12:17.330 in children, the underlying pathology and healing 00:12:17.330 --> 00:12:20.129 response are different. That's fascinating. Okay, 00:12:20.129 --> 00:12:23.529 let's shift to diagnosis. We suspect an AC joint 00:12:23.529 --> 00:12:26.450 injury. How does the patient typically present 00:12:26.450 --> 00:12:29.429 and what's the diagnostic pathway? Well, the 00:12:29.429 --> 00:12:31.850 presentation really mirrors the severity, the 00:12:31.850 --> 00:12:34.950 walk would type. For lower grades, type I and 00:12:34.950 --> 00:12:37.990 II, the main feature is localized pain right 00:12:37.990 --> 00:12:41.009 over the AC joint. It's often quite tender to 00:12:41.009 --> 00:12:43.230 touch. And worst with certain movements? Definitely. 00:12:43.850 --> 00:12:46.350 Bringing the arm across the chest, horizontal 00:12:46.350 --> 00:12:48.769 adduction usually provokes it. Lying on that 00:12:48.769 --> 00:12:50.809 side at night is often very uncomfortable, too. 00:12:51.190 --> 00:12:53.129 You might see some mild swelling, but usually 00:12:53.129 --> 00:12:55.629 no obvious deformity. And for the higher grades, 00:12:55.990 --> 00:12:57.850 three and above? It's usually much more obvious. 00:12:58.309 --> 00:13:00.190 Besides more intense pain, you'll likely see 00:13:00.190 --> 00:13:02.730 that visible deformity, the step off or bump 00:13:02.730 --> 00:13:04.649 where the clavicle is riding high. The whole 00:13:04.649 --> 00:13:06.730 arm might hang slightly lower on the affected 00:13:06.730 --> 00:13:09.549 side. So the visual inspection is key. What about 00:13:09.549 --> 00:13:11.529 the hands -on clinical examination? What are 00:13:11.529 --> 00:13:13.710 you specifically looking for? The physical exam 00:13:13.710 --> 00:13:16.710 is crucial. First, visual inspection for that 00:13:16.710 --> 00:13:20.009 asymmetry or step -off deformity. Then, careful 00:13:20.009 --> 00:13:22.809 palpation directly over the AC joint itself tenderness 00:13:22.809 --> 00:13:25.669 is a very consistent sign. And testing stability. 00:13:25.950 --> 00:13:28.830 Yes. We gently assess for abnormal movement. 00:13:29.389 --> 00:13:31.090 Can you press the clavicle down? Does it reduce? 00:13:31.350 --> 00:13:33.389 Does it spring back up when you release pressure? 00:13:33.769 --> 00:13:36.389 Panache sign. That indicates instability. Do 00:13:36.389 --> 00:13:40.009 you ever hear or feel anything? Sometimes. Yes. 00:13:40.350 --> 00:13:42.389 During testing, or even with a patient's own 00:13:42.389 --> 00:13:45.409 movement, you might hear or feel a painful clunk 00:13:45.409 --> 00:13:48.649 as the joint subluxes or reduces. That's a strong 00:13:48.649 --> 00:13:51.309 indicator of significant ligament damage. We 00:13:51.309 --> 00:13:54.090 also check range of motion, noting pain on specific 00:13:54.090 --> 00:13:56.769 movements like adduction or elevation. Okay, 00:13:56.909 --> 00:13:58.769 so a clinical exam gives you a strong suspicion. 00:13:59.330 --> 00:14:02.070 How does imaging confirm things and help classify 00:14:02.070 --> 00:14:04.629 the injury accurately? Let's start with x -rays. 00:14:05.070 --> 00:14:07.610 X -rays are the first -line investigation. Absolutely 00:14:07.610 --> 00:14:10.169 essential. They confirm the diagnosis by showing 00:14:10.169 --> 00:14:11.970 the relationship between the clavicle and the 00:14:11.970 --> 00:14:14.190 acromion, revealing the degree of displacement. 00:14:14.789 --> 00:14:17.330 They also crucially rule out associated fractures. 00:14:17.549 --> 00:14:19.649 Are there specific views you need? A standard 00:14:19.649 --> 00:14:22.210 AP view is useful, but often a Zonka view is 00:14:22.210 --> 00:14:25.090 preferred. It's angled slightly to give a clearer, 00:14:25.289 --> 00:14:27.809 unobstructed view of the AC joint itself. What 00:14:27.809 --> 00:14:30.110 about stress views? You hear about those. Yes, 00:14:30.330 --> 00:14:32.570 stress x -rays can be very helpful, especially 00:14:32.570 --> 00:14:35.149 if you suspect a type 3 injury. But the resting 00:14:35.149 --> 00:14:37.509 films look only mildly displaced, or perhaps 00:14:37.509 --> 00:14:39.950 like a type 2. The patient holds weights in each 00:14:39.950 --> 00:14:42.750 hand. To pull the arm down. Exactly. The weight 00:14:42.750 --> 00:14:45.250 stresses the joint, pulling the scapula and arm 00:14:45.250 --> 00:14:48.230 down, which exaggerates any underlying instability 00:14:48.230 --> 00:14:50.809 and makes the clavicle displacement much more 00:14:50.809 --> 00:14:53.090 obvious if the CC ligaments are indeed torn. 00:14:53.230 --> 00:14:55.629 It helps differentiate between stable type 2 00:14:55.629 --> 00:14:57.870 and unstable type 3 injuries sometimes. Right. 00:14:58.090 --> 00:15:01.919 When might you use a CT scan? CT gives much better 00:15:01.919 --> 00:15:04.779 bony detail than x -rays. It's particularly useful 00:15:04.779 --> 00:15:07.200 if you suspect an associated fracture, maybe 00:15:07.200 --> 00:15:10.340 of the distal clavicle, the acromeon, or, importantly, 00:15:10.519 --> 00:15:13.179 the coracoid process. It can also show the degree 00:15:13.179 --> 00:15:15.679 of static displacement very clearly, especially 00:15:15.679 --> 00:15:18.500 any posterior displacement seen in type 4. An 00:15:18.500 --> 00:15:21.379 MRI. Is that commonly used? MRI isn't usually 00:15:21.379 --> 00:15:23.679 the first -line test for an acute, straightforward 00:15:23.679 --> 00:15:26.480 AC separation. Its strength isn't showing soft 00:15:26.480 --> 00:15:28.620 tissues in great detail. So the ligaments themselves? 00:15:29.019 --> 00:15:32.840 Precisely. MRI is excellent for visualizing the 00:15:32.840 --> 00:15:35.539 ligaments directly, assessing the extent of tearing, 00:15:35.940 --> 00:15:38.340 partial versus complete, and identifying any 00:15:38.340 --> 00:15:40.779 associated injuries to other soft tissues like 00:15:40.779 --> 00:15:43.919 the rotator cuff or labrum. It's most useful 00:15:43.919 --> 00:15:46.379 when the diagnosis is uncertain after x -rays, 00:15:46.820 --> 00:15:48.820 perhaps in lower grade injuries with persistent 00:15:48.820 --> 00:15:51.500 symptoms or if you suspect complications later 00:15:51.500 --> 00:15:54.080 on. Okay, that clarifies the imaging pathway. 00:15:54.779 --> 00:15:57.139 So diagnosis made, classification determined. 00:15:57.480 --> 00:15:59.720 Now we face the treatment decision non -operative 00:15:59.720 --> 00:16:01.919 versus operative. Let's start with the non -operative 00:16:01.919 --> 00:16:04.019 route. What's the approach and who's it best 00:16:04.019 --> 00:16:06.620 suited for? Non -operative management is definitely 00:16:06.620 --> 00:16:09.070 the mainstay for lower grade injuries. Rockwood 00:16:09.070 --> 00:16:11.809 type I and II, and often considered for type 00:16:11.809 --> 00:16:14.570 III, as we discussed. The initial focus is purely 00:16:14.570 --> 00:16:16.629 on symptom control. How do you achieve that? 00:16:16.889 --> 00:16:19.669 Rest is key, initially. Using an arm sling provides 00:16:19.669 --> 00:16:21.929 comfort and support, ideally a broad arm sling 00:16:21.929 --> 00:16:23.470 that supports the elbow and takes the weight 00:16:23.470 --> 00:16:25.490 off the shoulder, rather than a simple collar 00:16:25.490 --> 00:16:28.230 and cuff. We also use ice therapy frequently 00:16:28.230 --> 00:16:30.549 in the acute phase to reduce swelling and pain, 00:16:30.929 --> 00:16:33.830 alongside NSAIDs, nonsteroidal anti -inflammatory 00:16:33.830 --> 00:16:36.559 drugs. And how long does that initial phase last? 00:16:36.879 --> 00:16:39.100 It depends. For a type Y, the sling might only 00:16:39.100 --> 00:16:41.539 be needed for comfort for a week or so. For type 00:16:41.539 --> 00:16:45.059 2, maybe longer, perhaps four to six weeks for 00:16:45.059 --> 00:16:47.740 symptoms to really settle. Once the acute pain 00:16:47.740 --> 00:16:50.679 starts to subside, the focus shifts very quickly 00:16:50.679 --> 00:16:53.159 towards rehabilitation. So rehab starts quite 00:16:53.159 --> 00:16:55.460 early then. Can you walk us through the typical 00:16:55.460 --> 00:16:58.500 phases? Yes. Rehab shouldn't be delayed. It's 00:16:58.500 --> 00:17:01.620 a structured, phased process. Phase one is the 00:17:01.620 --> 00:17:04.319 acute phase. Pain control, protecting the joint, 00:17:04.799 --> 00:17:06.759 but starting gentle range of motion exercises, 00:17:07.160 --> 00:17:09.779 often passive or active assisted, and isometric 00:17:09.779 --> 00:17:11.980 exercises, contracting muscles without moving 00:17:11.980 --> 00:17:14.059 the joint much. Keeping things moving gently. 00:17:14.299 --> 00:17:16.319 Exactly. Then phase two is about strengthening. 00:17:16.650 --> 00:17:19.750 As pain allows, we introduce isotonic exercises, 00:17:19.990 --> 00:17:22.190 moving against resistance, initially keeping 00:17:22.190 --> 00:17:24.730 movements below shoulder height to avoid stressing 00:17:24.730 --> 00:17:27.009 the joint too much. We focus on strengthening 00:17:27.009 --> 00:17:29.309 the rotator cuff, the scapular stabilizers, the 00:17:29.309 --> 00:17:31.269 bigger shoulder muscles, building back the support 00:17:31.269 --> 00:17:34.910 system, precisely. Phase three involves progressing 00:17:34.910 --> 00:17:37.450 to more functional movements, increasing strength, 00:17:37.529 --> 00:17:40.329 power, endurance, and crucially, neuromuscular 00:17:40.329 --> 00:17:42.430 control, teaching the muscles to work together 00:17:42.430 --> 00:17:45.029 effectively again, getting ready for more demanding 00:17:45.029 --> 00:17:48.769 tasks. And the final phase. Phase 4 is the return 00:17:48.769 --> 00:17:51.869 to activity. This is highly individualized, focusing 00:17:51.869 --> 00:17:54.890 on sport -specific or work -specific drills, 00:17:55.470 --> 00:17:57.509 gradually reintroducing the demands the patient 00:17:57.509 --> 00:18:00.390 needs to meet. For example, return to contact 00:18:00.390 --> 00:18:02.769 sports might be considered around 6 -12 weeks, 00:18:03.089 --> 00:18:05.190 depending on progress and injury severity. That 00:18:05.190 --> 00:18:07.809 sounds very thorough. What are the typical outcomes 00:18:07.809 --> 00:18:10.349 for non -operative treatments, say for type I 00:18:10.349 --> 00:18:12.849 and 2, and maybe select a type 3? For type I 00:18:12.849 --> 00:18:14.470 and 2, the outcomes are generally excellent. 00:18:14.680 --> 00:18:16.880 Most patients get significant pain relief within 00:18:16.880 --> 00:18:19.299 a few weeks, and many athletes can return to 00:18:19.299 --> 00:18:21.660 sport quite quickly, sometimes within 2 -4 weeks 00:18:21.660 --> 00:18:24.240 for type 2. Full recovery might take up to 12 00:18:24.240 --> 00:18:26.940 weeks, perhaps a bit longer, for some type 3s 00:18:26.940 --> 00:18:29.559 managed this way. Are there any potential downsides 00:18:29.559 --> 00:18:31.880 or long -term issues with non -operative management? 00:18:32.200 --> 00:18:35.480 While most do very well, a minority might experience 00:18:35.480 --> 00:18:38.579 persistent symptoms. This could be some residual 00:18:38.579 --> 00:18:41.740 ache, discomfort with specific activities, or 00:18:41.740 --> 00:18:44.000 potentially developing AC joint arthritis down 00:18:44.000 --> 00:18:46.210 the line. There's also some evidence suggesting 00:18:46.210 --> 00:18:48.089 a slight reduction in things like bench press 00:18:48.089 --> 00:18:50.430 strength. In some individuals, although most 00:18:50.430 --> 00:18:53.309 don't find it functionally limiting, if symptoms 00:18:53.309 --> 00:18:55.650 are still significant at six months, they're 00:18:55.650 --> 00:18:58.829 more likely to persist beyond a year. Okay. So 00:18:58.829 --> 00:19:00.690 when does surgery become the recommendation? 00:19:00.890 --> 00:19:03.210 What are the main indications and the goals of 00:19:03.210 --> 00:19:05.700 operating? Surgery is generally reserved for 00:19:05.700 --> 00:19:07.819 the higher grade injuries, definitely types 4, 00:19:07.920 --> 00:19:10.420 V, and 6. And it's strongly considered for type 00:19:10.420 --> 00:19:13.140 3 injuries, particularly in active individuals 00:19:13.140 --> 00:19:16.559 with high demands or when non -operative treatment 00:19:16.559 --> 00:19:18.940 for a type 3 has failed to provide satisfactory 00:19:18.940 --> 00:19:21.220 function or pain relief. And what are you trying 00:19:21.220 --> 00:19:24.079 to achieve with surgery? The main goals are, 00:19:24.299 --> 00:19:26.539 firstly, an anatomical reduction, getting the 00:19:26.539 --> 00:19:28.980 clavicle back into its proper position relative 00:19:28.980 --> 00:19:33.160 to the acromion and coracoid. Secondly, secure 00:19:33.160 --> 00:19:35.259 a fixation to hold it there while the tissues 00:19:35.259 --> 00:19:39.180 heal. And thirdly, restoring stability both horizontally 00:19:39.180 --> 00:19:42.019 and vertically to allow for good long -term function. 00:19:42.559 --> 00:19:45.259 Ultimately, we want a stable, pain -free shoulder. 00:19:45.960 --> 00:19:48.319 How have surgical techniques changed over the 00:19:48.319 --> 00:19:51.240 years? Oh, considerably. Older techniques, like 00:19:51.240 --> 00:19:54.079 the Weaver Dun procedure, often involved resecting 00:19:54.079 --> 00:19:56.339 the end of the clavicle and using local tissues 00:19:56.339 --> 00:19:58.940 like the coracoacromial ligament for reconstruction. 00:19:59.200 --> 00:20:01.980 Now, the trend is much more towards anatomical 00:20:01.980 --> 00:20:04.500 reconstruction, often using stronger fixation 00:20:04.500 --> 00:20:07.240 methods. Like what? Things like suspensory fixation 00:20:07.240 --> 00:20:10.059 devices have become very popular. These use strong 00:20:10.059 --> 00:20:12.279 sutures or synthetic tapes passed around the 00:20:12.279 --> 00:20:14.240 coracoid and through tunnels in the clavicle 00:20:14.240 --> 00:20:17.039 to replicate the function of the native cc ligaments. 00:20:17.339 --> 00:20:20.460 Some techniques involve plates or screws, though 00:20:20.460 --> 00:20:23.180 these often require removal later. In chronic 00:20:23.180 --> 00:20:25.599 cases, sometimes biological grafts are used to 00:20:25.599 --> 00:20:27.460 augment the repair. You mentioned there are over 00:20:27.460 --> 00:20:29.900 a hundred techniques described. That suggests 00:20:29.900 --> 00:20:32.539 there isn't one single best way. That's absolutely 00:20:32.539 --> 00:20:34.640 right. The sheer number of techniques reflects 00:20:34.640 --> 00:20:37.000 the ongoing challenge and the lack of universal 00:20:37.000 --> 00:20:40.480 consensus on the perfect repair. Options range 00:20:40.480 --> 00:20:43.700 from direct ligament repair, if possible acutely, 00:20:44.140 --> 00:20:46.619 using local tissue transfers, synthetic ligaments, 00:20:47.000 --> 00:20:49.819 suture button devices, hook plates. The list 00:20:49.819 --> 00:20:52.859 goes on. The choice depends on the injury pattern, 00:20:53.559 --> 00:20:56.019 the surgeon's preference and experience, the 00:20:56.019 --> 00:20:58.819 patient's needs, and whether the injury is acute 00:20:58.819 --> 00:21:01.259 or chronic. It's fascinating though that even 00:21:01.259 --> 00:21:04.259 with surgery aiming for perfect anatomical reduction, 00:21:04.599 --> 00:21:06.700 research hasn't always shown a direct link between 00:21:06.700 --> 00:21:09.559 that perfect x -ray and better pain or function 00:21:09.559 --> 00:21:12.200 outcomes. That's a really key observation in 00:21:12.200 --> 00:21:15.099 the field. While we strive for anatomical correction, 00:21:15.619 --> 00:21:17.880 the correlation between radiographic appearance 00:21:17.880 --> 00:21:20.900 and patient -reported outcomes isn't always straightforward. 00:21:21.259 --> 00:21:23.599 So a perfect x -ray doesn't guarantee a perfect 00:21:23.599 --> 00:21:26.269 result for the patient? Not necessarily. You 00:21:26.269 --> 00:21:28.589 can have a patient with a radiographically flawless 00:21:28.589 --> 00:21:31.430 reduction who still has some pain or functional 00:21:31.430 --> 00:21:34.089 limitation. And conversely, someone with slight 00:21:34.089 --> 00:21:36.609 residual displacement on x -ray might be completely 00:21:36.609 --> 00:21:38.910 asymptomatic and function at a very high level. 00:21:38.990 --> 00:21:41.970 Why is that? It's complex. Factors like muscle 00:21:41.970 --> 00:21:44.930 strength, neuromuscular control, individual pain 00:21:44.930 --> 00:21:48.049 perception, biological healing response, and 00:21:48.049 --> 00:21:50.349 the demands placed on the shoulder all play a 00:21:50.349 --> 00:21:52.980 huge role. It underscores that our ultimate goal 00:21:52.980 --> 00:21:55.660 isn't just to fix the x -ray image, but to achieve 00:21:55.660 --> 00:21:58.500 a stable, painless shoulder that allows the patient 00:21:58.500 --> 00:22:01.329 to return to their desired activities. Patient 00:22:01.329 --> 00:22:03.769 function and satisfaction are the real measures 00:22:03.769 --> 00:22:06.609 of success. A very important perspective. So, 00:22:06.710 --> 00:22:09.430 looking at the bigger picture of prognosis, how 00:22:09.430 --> 00:22:11.910 do the recovery paths and long -term outcomes 00:22:11.910 --> 00:22:14.410 generally compare between non -op and surgical 00:22:14.410 --> 00:22:16.890 approaches? Well, for types 1 and 2, non -op 00:22:16.890 --> 00:22:19.509 is the clear winner, good outcomes, quicker return 00:22:19.509 --> 00:22:21.890 to activities generally. Sling use is short. 00:22:22.079 --> 00:22:25.259 maybe 7 -10 days for type 1, perhaps 4 -6 weeks 00:22:25.259 --> 00:22:27.579 for type 2 protection. Long -term studies show 00:22:27.579 --> 00:22:29.400 good results, though as mentioned, a few might 00:22:29.400 --> 00:22:31.740 have lingering issues or develop arthritis later. 00:22:32.180 --> 00:22:34.279 If symptoms persist at 6 months, they might linger 00:22:34.279 --> 00:22:36.380 longer. And for the higher grades where surgery 00:22:36.380 --> 00:22:39.339 is more common? For types 3 and above, surgery 00:22:39.339 --> 00:22:41.720 generally provides better anatomical reduction 00:22:41.720 --> 00:22:44.279 and stability. However, it comes with a higher 00:22:44.279 --> 00:22:47.119 risk of complications compared to non -operative 00:22:47.119 --> 00:22:48.869 treatment. What kind of complications are we 00:22:48.869 --> 00:22:51.809 talking about? Things like mild residual instability 00:22:51.809 --> 00:22:55.369 can still occur, despite the surgery. Hardware 00:22:55.369 --> 00:22:58.170 issues are possible migration, prominence needing 00:22:58.170 --> 00:23:01.410 removal. Infection is a risk, though thankfully 00:23:01.410 --> 00:23:05.349 low, maybe around 1%. Nerve injury is rare, but 00:23:05.349 --> 00:23:08.410 possible. Stiffness or soft tissue ossification 00:23:08.410 --> 00:23:10.990 can also occur. So there are definite trade -offs? 00:23:11.210 --> 00:23:13.380 Absolutely. Non -operative might mean quicker 00:23:13.380 --> 00:23:15.900 initial recovery, but potentially more residual 00:23:15.900 --> 00:23:18.180 instability or cosmetic deformity for higher 00:23:18.180 --> 00:23:21.660 grades. Surgery aims for better anatomical stability, 00:23:22.000 --> 00:23:24.160 but has a longer recovery and carries those surgical 00:23:24.160 --> 00:23:27.059 risks. Despite the risks though, meta -analyses 00:23:27.059 --> 00:23:30.359 show high return to sport rates, around 94%, 00:23:30.359 --> 00:23:32.539 for patients having surgery for type 3 or higher 00:23:32.539 --> 00:23:34.980 injuries. And rehabilitation after surgery is 00:23:34.980 --> 00:23:37.579 presumably just as crucial. Even more so, arguably. 00:23:37.869 --> 00:23:40.430 Post -surgical rehab is absolutely vital to protect 00:23:40.430 --> 00:23:43.109 the repair, regain motion safely, build strength, 00:23:43.450 --> 00:23:46.329 and ultimately optimize the outcome. It's carefully 00:23:46.329 --> 00:23:48.549 progressed. What does that involve initially? 00:23:49.450 --> 00:23:52.109 Initially, there might be restrictions, perhaps 00:23:52.109 --> 00:23:54.549 limiting abduction above 90 degrees for a period. 00:23:55.369 --> 00:23:57.769 Gentle pendulum exercises are often started early 00:23:57.769 --> 00:24:00.309 to maintain some motion and prevent stiffness 00:24:00.309 --> 00:24:02.990 without stressing the repair. And then building 00:24:02.990 --> 00:24:05.430 up. Yes, then progressively introducing range 00:24:05.430 --> 00:24:07.849 of motion followed by strengthening exercises 00:24:07.849 --> 00:24:10.710 for the rotator cuff, deltoid, and scapular muscles. 00:24:11.289 --> 00:24:13.569 It's all about providing dynamic support to the 00:24:13.569 --> 00:24:16.930 reconstructed joint. The protocol needs tailoring 00:24:16.930 --> 00:24:20.490 to the specific surgery performed. So, summing 00:24:20.490 --> 00:24:22.549 up the long -term picture. It really hinges on 00:24:22.549 --> 00:24:24.769 the initial injury, severity, and the chosen 00:24:24.769 --> 00:24:27.650 management. But regardless of whether it's non 00:24:27.650 --> 00:24:30.690 -op or surgical, a meticulously planned patient 00:24:30.690 --> 00:24:33.190 -specific rehabilitation program is paramount. 00:24:33.710 --> 00:24:35.829 That tailored rehab, considering the patient's 00:24:35.829 --> 00:24:37.950 individual goals and activity levels, is probably 00:24:37.950 --> 00:24:39.809 the single most important factor in achieving 00:24:39.809 --> 00:24:41.930 the best possible long -term function. Okay, 00:24:42.230 --> 00:24:44.650 that leads us nicely into modern approaches. 00:24:45.269 --> 00:24:47.450 Many listeners will be keen to hear about current 00:24:47.450 --> 00:24:50.829 thinking on reconstruction. Could you share your 00:24:50.829 --> 00:24:53.769 management philosophy, particularly how you differentiate 00:24:53.769 --> 00:24:56.890 acute versus chronic injuries when deciding on 00:24:56.890 --> 00:24:59.230 intervention? Certainly. My approach is very 00:24:59.230 --> 00:25:01.410 much guided by the timing, the acuity of the 00:25:01.410 --> 00:25:05.309 injury. I generally define acute as less than 00:25:05.309 --> 00:25:07.390 about one week from injury. And how does that 00:25:07.390 --> 00:25:10.009 guide your initial steps? For most acute injuries, 00:25:10.410 --> 00:25:13.470 one week after diagnosis, my preference is usually 00:25:13.470 --> 00:25:15.890 to start with conservative management. That means 00:25:15.890 --> 00:25:18.880 a sling, but mainly just for comfort. not strict 00:25:18.880 --> 00:25:22.500 immobilization, analgesia for pain, and crucially 00:25:22.500 --> 00:25:25.160 starting rehabilitation with early active mobilization 00:25:25.160 --> 00:25:28.480 as soon as the patient feels able. So give conservative 00:25:28.480 --> 00:25:31.400 treatment a chance first in most acute cases. 00:25:31.480 --> 00:25:34.160 In many, yes, but the initial inflammation settles 00:25:34.160 --> 00:25:36.119 see how the patient progresses functionally. 00:25:36.319 --> 00:25:37.759 However, there are definite exceptions where 00:25:37.759 --> 00:25:39.859 I'd recommend early surgery even in the acute 00:25:39.859 --> 00:25:42.480 phase, such as cases with really severe pain, 00:25:42.819 --> 00:25:45.319 especially if the clavicle is clearly buttonholed 00:25:45.319 --> 00:25:49.200 through the trapezius, a type 4. Also, high -level 00:25:49.200 --> 00:25:51.579 overhead athletes often benefit from early surgery 00:25:51.579 --> 00:25:54.759 to restore mechanics optimally. Any associated 00:25:54.759 --> 00:25:57.579 neurovascular injury or an open fracture are, 00:25:57.579 --> 00:26:00.640 of course, immediate surgical indications. What's 00:26:00.640 --> 00:26:02.880 your follow -up strategy, then, for those managed 00:26:02.880 --> 00:26:05.119 conservatively initially? I typically review 00:26:05.119 --> 00:26:07.730 them at three weeks. If they're improving well, 00:26:08.029 --> 00:26:10.369 symptoms settling, function returning, we continue 00:26:10.369 --> 00:26:12.430 with the symptomatic management and gradual return 00:26:12.430 --> 00:26:14.930 to activity plan in another review around three 00:26:14.930 --> 00:26:16.710 months. And if they're not doing well at three 00:26:16.710 --> 00:26:18.369 weeks? If they're still really struggling with 00:26:18.369 --> 00:26:21.829 pain or instability or just not coping functionally, 00:26:22.210 --> 00:26:24.309 then I'd offer early surgical reconstruction 00:26:24.309 --> 00:26:26.690 at that point. No sense in delaying further if 00:26:26.690 --> 00:26:28.690 it's clearly not working. And the three month 00:26:28.690 --> 00:26:31.630 review? At three months, if they've successfully 00:26:31.630 --> 00:26:33.910 returned to their activities with minimal issues, 00:26:34.289 --> 00:26:37.299 fantastic. They could be discharged. If they're 00:26:37.299 --> 00:26:39.980 still not coping despite extended rehab, then 00:26:39.980 --> 00:26:42.059 surgery is offered as the definitive solution. 00:26:42.440 --> 00:26:44.380 It's a pathway that allows for non -operative 00:26:44.380 --> 00:26:47.359 management where appropriate but ensures timely 00:26:47.359 --> 00:26:49.779 intervention if needed. That makes good clinical 00:26:49.779 --> 00:26:53.319 sense. When surgery is the path chosen, what 00:26:53.319 --> 00:26:55.880 constitutes an ideal reconstruction technique 00:26:55.880 --> 00:26:58.660 today? What are the key goals? Ah, the ideal 00:26:58.660 --> 00:27:00.400 technique. That's what we're all striving for. 00:27:00.980 --> 00:27:02.940 Based on current understanding, I think there 00:27:02.940 --> 00:27:07.029 are about six key criteria we aim for. One, anatomical 00:27:07.029 --> 00:27:09.990 restoration. We want to recreate both the CC 00:27:09.990 --> 00:27:12.730 and AC ligament anatomy as closely as possible. 00:27:12.869 --> 00:27:14.450 Right, putting things back where they belong. 00:27:15.150 --> 00:27:18.329 Two, strength plus flexibility. The repair needs 00:27:18.329 --> 00:27:20.630 to be strong enough immediately, but also allow 00:27:20.630 --> 00:27:23.269 some natural physiological motion at the AC joint. 00:27:23.670 --> 00:27:25.750 Two, rigid isn't good either. Makes sense. Three, 00:27:26.210 --> 00:27:28.799 allow early rehabilitation. The construct must 00:27:28.799 --> 00:27:30.759 be stable enough to let patients start moving 00:27:30.759 --> 00:27:33.000 relatively early to prevent stiffness and speed 00:27:33.000 --> 00:27:36.519 up recovery. Get them gone and quickly. 4. Biological 00:27:36.519 --> 00:27:40.019 integration. Ideally, the repair encourages the 00:27:40.019 --> 00:27:42.299 body's own tissues to heal into it, providing 00:27:42.299 --> 00:27:44.940 long -term, durable stability. Less reliance 00:27:44.940 --> 00:27:48.019 on artificial materials long -term. 5. Avoid 00:27:48.019 --> 00:27:51.059 donor site morbidity. If using the patient's 00:27:51.059 --> 00:27:53.750 own tissue, Autographed. We want to minimize 00:27:53.750 --> 00:27:56.109 any problems from the harvest site. That's an 00:27:56.109 --> 00:27:59.309 advantage of good synthetic options. And six, 00:28:00.210 --> 00:28:03.309 eliminate routine hardware removal. We want techniques 00:28:03.309 --> 00:28:05.349 where implants don't routinely need a second 00:28:05.349 --> 00:28:07.589 operation just to take them out. That's a very 00:28:07.589 --> 00:28:10.380 clear checklist. With those criteria in mind, 00:28:10.480 --> 00:28:12.480 can you tell us about your preferred approach 00:28:12.480 --> 00:28:14.700 to the triple anatomical technique? What does 00:28:14.700 --> 00:28:16.559 it involve? Yes, this technique is designed to 00:28:16.559 --> 00:28:19.380 hit those criteria, aiming for anatomical restoration 00:28:19.380 --> 00:28:22.059 with biological potential, creating a strong 00:28:22.059 --> 00:28:24.599 construct that allows early mobilization. It 00:28:24.599 --> 00:28:26.779 has three main parts. Triple technique, three 00:28:26.779 --> 00:28:30.240 parts. Makes sense. First is an anatomic corcoclavicular 00:28:30.240 --> 00:28:33.299 ligament reconstruction. I use a strong synthetic 00:28:33.299 --> 00:28:35.180 ligament, specifically the Lars ligament, which 00:28:35.180 --> 00:28:38.700 is polyethylene tetrafasolate, because it's incredibly 00:28:38.700 --> 00:28:41.019 strong, stronger than the native CC ligaments, 00:28:41.259 --> 00:28:44.200 providing immediate stability. Its braided structure 00:28:44.200 --> 00:28:46.880 also encourages tissue ingrowth, aiming for that 00:28:46.880 --> 00:28:49.900 biological integration over time. We pass it 00:28:49.900 --> 00:28:51.920 anatomically through tunnels in the clavicle 00:28:51.920 --> 00:28:54.480 at the ligament footprints and then secure it 00:28:54.480 --> 00:28:56.319 around or through the coracoid. Okay, so that 00:28:56.319 --> 00:28:58.299 replaces the CC ligaments. What's the second 00:28:58.299 --> 00:29:00.920 part? Second is an acromoclavicular ligament 00:29:00.920 --> 00:29:03.660 reconstruction, often using a transfer of the 00:29:03.660 --> 00:29:06.660 nearby coraco -chromial ligament. This directly 00:29:06.660 --> 00:29:08.799 addresses the AC joint capsule and ligament, 00:29:09.099 --> 00:29:11.180 restoring horizontal stability, which the CC 00:29:11.180 --> 00:29:13.900 reconstruction alone doesn't fully address. Got 00:29:13.900 --> 00:29:16.900 it. And the third component. The third part is 00:29:16.900 --> 00:29:20.640 a delto -tripetal fascia repair. This involves 00:29:20.640 --> 00:29:23.680 carefully repairing the torn fascia of the deltoid 00:29:23.680 --> 00:29:26.019 and trapezius muscles where they attach to the 00:29:26.019 --> 00:29:29.039 clavicle and acromion. This is especially important 00:29:29.039 --> 00:29:31.559 in higher grade injuries, like type V, where 00:29:31.559 --> 00:29:34.500 the fascia is often ripped off. It adds significant 00:29:34.500 --> 00:29:36.759 reinforcement and dynamic stability to the whole 00:29:36.759 --> 00:29:40.079 construct. So you're rebuilding the CCs, the 00:29:40.079 --> 00:29:43.200 ACs, and reinforcing the muscle envelope. Exactly. 00:29:43.369 --> 00:29:46.049 It's a comprehensive belt and braces approach. 00:29:46.609 --> 00:29:48.589 We also believe transferring a ligament like 00:29:48.589 --> 00:29:51.930 the CA ligament might help restore some proprioception 00:29:51.930 --> 00:29:54.829 that joint position sends. Overall, we find it 00:29:54.829 --> 00:29:57.849 safe, reproducible, and very effective at restoring 00:29:57.849 --> 00:30:00.250 stability, which allows for that crucial early 00:30:00.250 --> 00:30:03.210 recovery and return to sport. It certainly sounds 00:30:03.210 --> 00:30:06.500 robust. Finally, for those patients, especially 00:30:06.500 --> 00:30:08.440 athletes undergoing this kind of reconstruction, 00:30:09.039 --> 00:30:11.180 how do you manage their return to sport? What 00:30:11.180 --> 00:30:14.279 are realistic timelines? Return to sport is always 00:30:14.279 --> 00:30:17.099 a gradual, criterion -based process, not just 00:30:17.099 --> 00:30:20.000 about time. It absolutely requires teamwork between 00:30:20.000 --> 00:30:22.559 me, the physiotherapist, and often strength and 00:30:22.559 --> 00:30:24.319 conditioning coaches. Everyone has to be on the 00:30:24.319 --> 00:30:26.700 same page. Completely. We need to see the patient 00:30:26.700 --> 00:30:29.599 meet specific functional milestones, strength, 00:30:29.740 --> 00:30:32.140 range of motion, stability, sport -specific movements 00:30:32.140 --> 00:30:35.269 before they progress. But based on our experience, 00:30:36.009 --> 00:30:38.049 contact athletes like rugby players usually take 00:30:38.049 --> 00:30:40.410 around three to four months post -op before returning 00:30:40.410 --> 00:30:42.970 to full contact. They need that time for solid 00:30:42.970 --> 00:30:44.910 healing and to rebuild the strength to withstand 00:30:44.910 --> 00:30:48.009 impacts. And overhead athletes, pitchers, tennis 00:30:48.009 --> 00:30:50.650 players. They typically need longer, often six 00:30:50.650 --> 00:30:53.349 to nine months. Their sports require extreme 00:30:53.349 --> 00:30:56.089 ranges of motion, power and fine motor control. 00:30:56.329 --> 00:30:59.569 Rushing them back risks re -injury or poor performance. 00:30:59.930 --> 00:31:02.410 Any activities that allow a quicker return. Interestingly, 00:31:02.829 --> 00:31:05.289 we find horse riders and cyclists can often get 00:31:05.289 --> 00:31:07.690 back sooner, sometimes in less than three months, 00:31:08.390 --> 00:31:10.799 while falls can cause the initial injury. The 00:31:10.799 --> 00:31:13.059 actual activity itself doesn't usually place 00:31:13.059 --> 00:31:15.799 the same high -impact repetitive stress on the 00:31:15.799 --> 00:31:19.180 AC joint as contact or overhead sports. And sport 00:31:19.180 --> 00:31:22.319 -specific rehab is key throughout. Absolutely 00:31:22.319 --> 00:31:24.440 critical. A rugby player needs drills with a 00:31:24.440 --> 00:31:27.099 ball, controlled contact simulation. A swimmer 00:31:27.099 --> 00:31:30.140 needs pool -based rehab. Tailoring the exercises 00:31:30.140 --> 00:31:32.000 to mimic the demands of their specific sport 00:31:32.000 --> 00:31:34.140 ensures they are truly ready and confident when 00:31:34.140 --> 00:31:36.240 they return to competition. Professor, this has 00:31:36.240 --> 00:31:38.380 been incredibly insightful. We've covered a huge 00:31:38.380 --> 00:31:40.319 amount from the basic anatomy right through to 00:31:40.319 --> 00:31:42.420 your specific advanced surgical technique for 00:31:42.420 --> 00:31:45.119 AC joint disruptions. Thank you for clarifying 00:31:45.119 --> 00:31:47.140 so much complexity. It's been a real pleasure. 00:31:47.420 --> 00:31:50.119 These are common injuries, and getting the management 00:31:50.119 --> 00:31:53.339 right based on a detailed understanding really 00:31:53.339 --> 00:31:55.579 does make a difference for our patients. Absolutely. 00:31:56.190 --> 00:31:58.630 Just as a final thought for our listeners, as 00:31:58.630 --> 00:32:01.369 our understanding of biomechanics and biology 00:32:01.369 --> 00:32:03.930 continues to advance, perhaps with things like 00:32:03.930 --> 00:32:07.490 better biological augmentation or even more refined, 00:32:07.710 --> 00:32:10.269 minimally invasive techniques, how do you see 00:32:10.269 --> 00:32:12.910 the approach to AC joint stability and recovery 00:32:12.910 --> 00:32:15.390 evolving further in the future? That's the exciting 00:32:15.390 --> 00:32:17.950 part, isn't it? Always looking ahead. Indeed. 00:32:18.289 --> 00:32:20.309 If this deep dive has sharpened your perspective 00:32:20.309 --> 00:32:22.829 on AC joint injuries, please do consider rating 00:32:22.829 --> 00:32:24.450 and sharing it with your colleagues. Thank you 00:32:24.450 --> 00:32:25.609 for joining us. Thank you.