Ac separation shoulder: to operate or not?

[andreaswp]

4 days ago I suffered a class 3 ac separation after falling on my shoulder skiing. The doctor asked me my occupation and when I replied software engineer she recommended not doing surgery.
From what I can read not doing surgery is recommended in most cases. However it bothers me this question about my occupation. To me that seems to indicate that I will be weaker without the surgery. Also I do not know how much weaker since the strength requirements for software engineering are extremely low. It would be more assuring if I was a firefighter and she said sure no problem you will be able to carry people without an operation.

I am not particular strong at the moment and I do not have any desire to be much above average strong either. What is important to me is to train my fast muscle fibers since I am loosing them with age. I need these to react and catch my fall. To do this I have to lift heavy. That is heavy for me. Probably not heavy for many of you guys:-). Also not heavy compared to my potential. As an example I weigh 100 kg and estimate that I need to be able to bench 75 kg to catch a forward fall.
My potential was perhaps 150 kg (not much but I have long arms and mostly slow muscle fibers).
If my new potential without the operation is 120 kg (20% reduction) that is not a big problem to me. Sure it will be harder to achieve 62.5 % of my potential than 50% but that should be doable?
On the other hand I dont understand why this would not apply to almost all occupations. Who except from professional athletes have a job where the required strength is close to their potential? On the other hand it might be that without operation I will suffer some pain when doing overhead work. This might be a problem in some jobs.

Will I have problems training the basic powerlifts if I choose not to operate? In particular I worry about the overhead press and the bench. I understand there will be a long adoption period where I will be super weak and overhead press and bench is painful, but will I be able to push trough this period with determination and many light reps?

[pogioli4]

I've separated the same shoulder twice. second time was a grade 3 if I remember correctly.
I opted not to get surgery. I put my shoulder in a brace for awhile, but I just kept lifting. did a crazy amount of band work and overall shoulder resistance training. It definitely hurt for a long while, but strengthening up those muscles allowed me to get back and compensate for the injury a bit. unfortunately shoulder surgeries tend not to keep very well.
That being said, I've watched a lot of surgeries performed on the AC joint and a few docs present about their new methods for doing so and some of them look quite promising. if you take that chance though you won't be using that arm for awhile. so keep that in mind.

Edit: so I guess to answer your question, I'm not suggesting to go one route or the other and I don't want to try to guess which is the better option for you, but you should eventually be able to OHP and bench again even if ya don't get the surgery

[andreaswp]

Thanks for your reply pogioli4! There are a lot of cyclists on other forums with this accident but I would think they are not that worried about upper body strength. It is therefore great for me to hear from someone who has had this accident but still are weight training the upper body.

[blackjack2006]

Thanks for your reply pogioli4! There are a lot of cyclists on other forums with this accident but I would think they are not that worried about upper body strength. It is therefore great for me to hear from someone who has had this accident but still are weight training the upper body.

Hey andreaswp. I'm in the same boat. Fell down on my right shoulder while skiing 3 weeks ago as my hands were strapped to ski poles (usually i land on the outer side of my hand in a breakfall, and this is usually enough to absorb the energy of the fall).

Was prepping for an early surgery (2 weeks), but the orthopod said no op is needed, and eventually I can get back to sports (including weight lifting and contact sports). I told the doc that I'm left handed and have a sedentary life style, although his suggestion (no-op route) was made right after examining my shoulder, before inquiring as to my profession. I could fly to another country and do the surgery there (hookplate + absorbable sutures), but reasoned that there are more downsides than upsides in such a move.

After reading information available on the internet, I figured out that these injuries seem to be very individualized, especially in ACJ Separation Level III. A lot of folks were happy that they went with surgery route, but I have also read stories about complications, the need for re-ops in certain cases, and long-term loss of ROM + disabling arthritis. Many people opted for non-surgery route. Some of them claimed that their injured shoulder is now better than before, some complained that the original strength never returned. There also seems to be some controversy between X-ray images (the distance between CC/AC joints showing how badly are ligaments torn or ruptured) and clinical symptoms (ROM, clacivle movements and positioning, etc.). There is also information that torn ligaments are never the same after they heal, that transplants may get rejected, and that sutures or artificial ligaments are not as strong as native original ligaments....

I'm meeting with a sports medicine doc specializing in shoulder injuries and will see what he says. In any case, since I ended up in a no-op route for my acute ACJ injury, I will have to work on managing and reducing the instability caused by the displaced clavicle, which means I'm focusing on reducing shoulder instability by building compensatory muscles (trapezius, scapular, etc...have to figure this out). Once these muscles are built and are in place, I hope, it would be easier to train the rest of the upper body + heavier weights. I'm also considering doing a PRP (plasma-rich platelet) therapy which can help to improve the degree and rate of healing of tissues/ligaments. If all this fails, a surgery will be considered again.

After reading all the stuff on the internet, I felt a bit upset about the injury, but now I think it's manageable long-term with pretty good outcomes. Wish you good luck. Feel free to PM me if you have any questions.

[andreaswp]

Hello blackjack2006 and thank you for your reply! This info was really useful to me.

Today I visited another orthopedist at a clinic that deals more with athletes. He asked about my hobbies: kayaking, skiing and weightlifting and said he thinks I should be fine, and if not I can always take the operation later. The way the operation is done at this clinic is that they take a bit of ligament from your hamstring and use this to reconstruct the one of these two (the A and the C) that pulls the clavicle down. Think this is called coracoclavicular reconstruction (so it was the C).

Also I have read several places that 9 out of 10 who do not operate have normal function after one year.

From what I understand there has been a trend with less operations now than before. Like you mentioned the result is not always perfect if you operate either and it involves some risk.

So like you I am opting to not take the surgery now, wait for a year and decide then. And like you I am optimistic about the outlook of this :-).

BTW I found this interesting article that states that NFL players seldom operate:
www . drdavidgeier.com/ac-joint-shoulder-injuries-nfl-football/
The average recovery time was awful short though (10 days).
I have read similar things about NHL players.
So I guess this means that it is not dangerous to hit the same shoulder twice. This agrees with advice I have read cyclists have gotten from their doctors.

There was however a norwegian cross country skier who operated last year. Nowadays cross country skiing relies heavily on using the arms and pushing behind you which probably is an anatomically difficult position.
Anyways I am not a world class athlete and think I should be fine.

Luckily I also hit my non dominant shoulder. I think the body by instinct always try to impact with the non dominant side of the body.

Reagrding rehabilitation I found a really useful thread from this NFL sports medic who himself separated the shoulder 20 years ago: www mikeryansportsmedicine.com/how-to-treat-shoulder-pain-caused-by-ac-joint-separation/

Good luck to you as well!

[blackjack2006]

Hey andreaswp,

Talked to a sports medicine doc yesterday. He's been a physician doc for hockey and rugby teams. Having seen my X-rays, his opinion was that it's 50/50 in my case, which as I understand means, I could either take non-op or op route (and the time still allows for that <6-8 weeks), with a hook plate reconstruction. He mentioned that if there was a collar bone fracture, there would have been a clear case for surgery, but since there is no fracture, it could go either way. There's general consensus among docs in Ontario / Canada, that for grade III AC separations, conservative treatment should be considered first. In the case of hook plate reconstruction, there are potential risks of skin and bone irritation from a foreign body. Plus, there are important nerves and blood vessels under clavicle and if they are improperly touched upon during surgery, there might be far bigger complications. I asked him if he's seen any surgeries done for ACJ grade III separations for the reasons other than cosmetic, and he said no.

I decided to stick to the non-op route. He mentioned that I'll need to do taping with the strong (brown) tape and continue doing rehab excersises. At the third week, I have full ROM with lost strength on my right side and cleared for lightweight cable rows, biceps curls with tape on. My PT also hooked me up with a pilates instructor who will focus on strengthening apular muscules and the other muscles needed to reinforce the ACJ stability. Will also take PRP injections.

In the back of my mind, I still had questions if I'm doing the right thing, but having reviewed the information and talked to people, I think whatever you choose is a roll of dice. Maybe if I could take 6-8 weeks off, I would have thought harder about taking the op route, but given my circumstances, I decided to try my luck with rehab first.

fyi, there is the stamdard pf care for conservative treatment of AC Joint separations from Brigham and Women's Hospital, which I found useful and informative: ht tps: // brighamandwomens.org/assets/BWH/patients-and-families/pdfs/shoulder-acromioclavicular-separation.pdf


Good luck!