-Cyprus Orthopaedics

Acromioclavicular Instability

Shoulder Instability is a condition that results in symptoms of popping, “slipping” or the shoulder coming out of joint. It commonly occurs in young active individuals who have suffered a dislocation of the shoulder but may occasionally occur in older individuals. It usually occurs after an injury to the shoulder (“traumatic instability”) but may sometimes occur in the absence of an injury (“atraumatic instability”). It is also known as “Recurrent dislocation” of the shoulder.
Shoulder Conditions-Cyprus Orthopaedics

Acromioclavicular Instability

Acromioclavicular instability is a condition that affects the joint between the acromion (a bony projection on the scapula) and the clavicle (collarbone). This joint is essential for the proper functioning of the shoulder, as it allows for a wide range of motion. However, when the ligaments that support this joint become stretched or torn, it can lead to instability and pain.

Acromioclavicular instability can occur due to various reasons, such as trauma, repetitive overhead activities, or degenerative changes in the joint. Traumatic injuries, such as falls or direct blows to the shoulder, are the most common causes of acromioclavicular instability. These injuries can result in a sprain or tear of the ligaments, leading to instability and shoulder pain.

Causes of Acromioclavicular Instability

There are several factors that can contribute to the development of acromioclavicular instability. One of the primary causes is trauma to the shoulder, such as a fall or a direct blow. These injuries can cause the ligaments that support the acromioclavicular joint to stretch or tear, resulting in instability.

Repetitive overhead activities, such as throwing or weightlifting, can also contribute to the development of acromioclavicular instability. These activities place significant stress on the shoulder joint, leading to wear and tear of the ligaments over time.

Additionally, degenerative changes in the joint can also cause acromioclavicular instability. As we age, the cartilage in our joints naturally wears down, making them more susceptible to injury and instability.

Symptoms of Acromioclavicular Instability

The symptoms of acromioclavicular instability can vary depending on the severity of the condition. Common symptoms include:

  • Shoulder pain: Pain in the shoulder joint is one of the primary symptoms of acromioclavicular instability. The pain may be mild to severe and can worsen with certain movements or activities.
  • Shoulder weakness: Instability in the acromioclavicular joint can result in shoulder weakness. You may notice a decrease in your ability to lift or carry objects, as well as difficulty performing overhead activities.
  • Swelling and tenderness: Inflammation and swelling around the acromioclavicular joint are common symptoms of instability. The area may be tender to the touch and appear swollen or bruised.
  • Clicking or popping sensation: Some individuals may experience a clicking or popping sensation in the shoulder joint when moving their arm. This can be a sign of joint instability.

Treatment Options for Acromioclavicular Instability

The treatment options for acromioclavicular instability will depend on the severity of the condition and the individual’s specific needs. In mild cases, non-surgical treatments may be sufficient, while more severe cases may require surgical intervention.

Non-surgical treatments for Acromioclavicular Instability

Non-surgical treatment options for acromioclavicular instability include:

  • Rest and immobilization: Giving the joint time to heal and avoiding activities that exacerbate the symptoms can help reduce pain and promote healing. Immobilization, such as wearing a sling, may be recommended to support the joint during the recovery process.
  • Physical therapy: A physical therapist can guide you through exercises and stretches to improve the strength and stability of the shoulder joint. They may also use techniques such as ultrasound or electrical stimulation to reduce pain and inflammation.

Surgical options for Acromioclavicular Instability

Surgical intervention may be necessary for individuals with severe acromioclavicular instability or those who do not respond to non-surgical treatments. The specific surgical procedure will depend on the extent of the instability and any associated injuries.

Common surgical options include:

During a reconstruction surgery, the damaged ligaments are repaired or replaced with grafts to restore stability to the joint. This procedure is typically performed arthroscopically, using small incisions and a camera-guided instrument.

In some cases, the acromioclavicular joint may need to be stabilized using screws, plates, or other hardware. This is often done in conjunction with ligament reconstruction to provide additional support.

Rehabilitation and Recovery after Acromioclavicular Instability Surgery

Following surgery for acromioclavicular instability, a rehabilitation program will be essential to regain strength and restore full function to the shoulder joint. The rehabilitation process typically involves a combination of exercises, manual therapy, and progressive strengthening.

During the initial stages of rehabilitation, the focus will be on reducing pain and inflammation, improving range of motion, and gradually reintroducing functional movements. As the healing progresses, exercises to strengthen the muscles around the shoulder joint will be incorporated.

Physical therapy sessions may be scheduled several times a week initially, and then gradually reduced as the individual gains strength and stability. It is important to follow the prescribed rehabilitation program and attend all scheduled therapy sessions to optimize recovery.

Preventing Acromioclavicular Instability

While some cases of acromioclavicular instability are the result of traumatic injuries that may be difficult to prevent, there are steps you can take to reduce your risk:

Strengthening exercises: Regularly performing exercises that target the muscles around the shoulder joint can help improve stability and reduce the risk of injury.

-Proper technique: When engaging in activities that involve overhead movements, such as throwing or weightlifting, it is important to use proper technique and avoid placing excessive stress on the shoulder joint.

Gradual progression: When starting a new exercise or activity, gradually increase the intensity and duration to allow your body to adapt and minimize the risk of overuse injuries.

Protective gear: If you participate in contact sports or activities with a high risk of shoulder injury, consider wearing appropriate protective gear, such as shoulder pads or braces.

A dislocation of the shoulder usually results in damage to the ligaments of the shoulder, the labrum (the “bumper”) or to the bony rim of the socket of the shoulder. The most common injury is a detachment of the anterior labrum (referred to as a “Bankart lesion”). It may also result in indentation of the ball of the shoulder (a “Hill-Sachs” lesion). Some individuals with “loose” joints may suffer recurrent instability due to their muscles working in abnormal fashion (referred to as instability due to abnormal “muscle patterning”).

A diagnosis of Shoulder instability is made based on the history of repeated episodes of the shoulder coming out of joint. Occasionally patients may experience symptoms of a “dead arm” with sporting or other activities in the absence of dislocation. Examination may show signs of laxity or “looseness” in multiple joints, pain with certain movements of the shoulder and signs of apprehension or a feeling that the shoulder may come out when placed in certain positions. X-rays are essential to look for damage to the bony rim of the socket or indentation of the ball of the joint. Special imaging with an MRI scan may be requested to obtain further information about the state of the labrum and the ligaments. In some instances an MR arthrogram (MRI scan after injection of contrast fluid in the joint) may be requested. A CT scan may be arranged to assess the damage to the bony rim of the socket (glenoid) or the ball of the joint (humeral head).

The risk of recurrence of traumatic instability depends on gender and the age at which the first episode occurred. The risk of recurrence is lower in women and is greatest in young men below 25 years of age and diminishes with age.

In the early phase, symptoms may be controlled with activity modification.

Supervised physiotherapy: You may be advised to see a physiotherapist to start a regime of specific exercises to improve scapular positioning and strengthen the rotator cuff.

The British Elbow and Shoulder Society (BESS) video on shoulder instability has useful guidance and exercises for patients with shoulder instability.

Physiotherapy is often the main treatment for patients who have developed symptoms of instability in the absence of an injury.

Braces: A specific brace for the shoulder may be used for short periods of time to protect the shoulder and get sporting individuals through to the end of a season.

Surgery: Surgery may be appropriate following a single dislocation in individuals who are at a high risk of recurrence or where an individual has suffered more than one episode of instability following an initial injury. This is a highly individualised decision and should be made after detailed discussion with a specialist surgeon. The operation performed will depend on the pathology identified on clinical and radiological assessment. It may consist of an Arthroscopic repair where the tears in the labrum and ligaments are repaired with “keyhole” surgery. In cases where there is significant bone damage to the rim of the socket or the ball of the joint, additional procedures such as a “remplissage” or bony reconstruction of the rim of the socket may be necessary.

For further information on surgical treatment, please refer to the procedures section.

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