I knew it was bad when I heard a “pop”.
I’ve given and taken several hits playing hockey over the years, but this one was different.
I got flipped over and landed directly on my shoulder and heard that “pop” on my right side.
I was slow getting up and immediately felt pain in that shoulder.
At first it didn’t seem that bad, the pain was manageable.
Skating back to the bench it started getting worse. Moving the shoulder got more difficult.
Once in the dressing room it became more painful to move. I slowly got my gear off and cracked a beer. I got up and looked in the mirror, it looked gross.
Having a shower was difficult, it got to the point I could barely move the arm and cradling it was the only way it felt comfortable. I packed up my equipment, slowly got dressed with one arm and made my way to the emergency room.
They sent me in for x-rays immediately.
I could see the guys taking the x-ray and the look on their face was terrible. I actually heard them say “oh man, that’s bad”, umm I’m right here.
Recognizing The Degree Of Shoulder Injuries
After the x-ray I sat and waited impatiently for the on-call doctor to come in and give me the bad news.
“You’ve got a third degree separation of your A/C joint”.
He called the local Orthopedic shoulder specialist, who got mad at the doc for waking him up and was informed they don’t do surgery, just put the shoulder in a sling.
With an Acromioclavicular separation they are classed from Type I – III with more severe cases being Types IV – VI.
According to the Foundations of Athletic Training, a Type I separation the ligaments are still intact and there is minimal deformity. Type II starts to show some deformity, the A/C ligaments are damaged but the coracoclavicular one is still fine. Type III shows obvious deformity and all the ligaments are damaged.
There is also more pain and restricted range of motion with a Type III compared to Type I or II.
When it comes to a Type IV – VI there is total disruption of the supporting ligaments and where surgery is necessary.
If you’ve never seen a separated shoulder injury when it happens, it can be difficult to figure out if it’s a separation or a dislocation. Magee gives some good information on how to tell the difference. There’s a few indicators that would point to a dislocation:
- Flattening of the deltoid indicates an anterior shoulder dislocation.
- The person’s arm will be held Abducted.
- If you palpate into the armpit, you would feel the head of the humerus.
While it’s important to know the difference between the two, it’s not going to change how you deal with it.
First Aid For A Separated Shoulder
Whether it’s a dislocation or separation, we just want to stabilize the shoulder until we can get more advanced medical attention.
Chances are the person will be holding their arm/shoulder in the position that is most comfortable for them, you just need to work around it.
As it is with a fracture, dislocation or separation there are a few principles to keep in mind.
- Immobilize in the position found.
- Always check distal to the injured area for circulation.
- Put ice on the injury to help with pain and inflammation.
- Stabilize the injured joint or area as much as possible.
- Keep the injured area above the heart as much as possible (but only if it can be done pain free)
The easiest way to remember is with the mnemonic RICE
R – Rest, stop whatever activity the person was doing.
I – Immobilize
C – Cold, cool the area for 20 minutes
E – Elevate
When it comes to applying a sling to immobilize and stabilize a shoulder, the most common thing used is a triangular bandage. Some people hate these things, but I think they’re great because they may be the most versatile tool in a First Responder kit.
Not only can you make a sling, you can turn them into broad bandages, donut rings, stabilizing ties and various other things. One of the other reason they’re in most First Responder kits is because they’re cheap.
You can buy premade shoulder slings and braces but they cost ten to thirty dollars and when you send someone to the hospital with one, its doubtful you’re getting it back. A triangular costs anywhere from twenty five cents to a dollar.
No big deal if you never get it back.
If you ever have to deal with it, here’s some instructions on how to put the shoulder in a sling:
An article published in 2012 used 24 articles to draw information from on the best practice for treating A/C separations.
For a Grade I – III range of motion and strengthening exercises within pain tolerances were recommended. Exercises were mainly to provide stability to the shoulder blade and rotator cuff. Grade IV – VI are typically dealt with by surgery.
There wasn’t much information as far as any treatment protocols. The advice was to use your knowledge of anatomy, movement and healing process to develop the best plan for you patient.
What I can tell you from personal experience is that for that first week, having one of my buddies that is an Athletic Therapist tape the joint helped with pain management and providing stability.
Getting regular Massage Therapy to treat the muscles connected around the AC joint also helped with pain management and function. Even a year and a half later it feels like there is constant tension from the joint all the way through the shoulder.
If ever dealing with something like this, it’s important to remember that patient comfort is key. Applying a sling, icing the injured area and stabilizing the joint not only provides more comfort but also prevents further injury. Your anatomy and movement knowledge is critical not only in the acute treatment but also in the rehab of this injury. If the separation is severe enough, the person will be left with a step deformity at the joint. But because you helped take care of them properly when it happened, they should be able to get full function back. If nothing else came from this, at least I get to show students what a step deformity looks like.