A 32-year-old laborer presents with reports of immediate pain and a bump over the left distal end of the clavicle following an accident at work when he fell on his left shoulder. The patient reports that the area over the left acromioclavicular (A-C) joint is very tender to touch and that attempts to elevate his shoulder are very painful. The patient's past medical and surgical history is unremarkable and an x-ray taken the previous day ruled out the possibility of a fracture of the clavicle.
What is your best working hypothesis at this stage?
The best working hypothesis at this stage would be a shoulder separation involving the acromioclavicular joint.
What are the pathomechanics of this type of injury?
This injury is common in contact sports resulting from a hard fall on to the point of the shoulder.
Describe the three major supporting ligaments of the AC joint.
The acromioclavicular joint capsule and ligament complex, the conoid ligament, and the trapezoid ligament (the latter two are collectively known as the coracoclavicular ligament).
The physical examination revealed the following:
- Pain and tenderness with palpation over the left AC joint, with a protruding bump felt over the left distal end of the clavicle.
- Pain reported at the extremes of all motions of the glenohumeral joint.
- Active range of motion was full and painful, but both left shoulder abduction to 90° and horizontal adduction elicited increased pain.
- Left shoulder flexion and abduction to 90° were graded at good minus.
- Positive crossover and O’Brien test
Using the findings from the physical examination, what grade of A-C joint disruption appears to have occurred with this patient?
It is highly likely that this patient suffered a left Type II A-C joint separation.
Having made a provisional diagnosis, describe the various stages of your intervention?
How would you describe the pathological process behind this condition to the patient?
How would you explain the rationale behind your planned intervention to the patient?
What activities and positions would you advise the patient to avoid? Why?
Estimate this patient’s prognosis in terms of number of visits required.
What electrotherapeutic modalities could you use in the intervention of this patient? Why?
Which manual techniques might be appropriate for this patient, and what is your rationale for each?
What upper kinetic chain exercises would you prescribe? Why?