Grade 3 plus 2008. Left as is. The only time I notice it is after masters when someone says "what the hell happened to you?" Otherwise total non issue for me

Bone cutting?????

I had a shoulder separation back in college when I got smashed in a rugby game. (Yes, I actually thought I could play with the big boys.)

The first orthopedic surgeon I went to was a waste of time. He said it would "heal on its own," but I did not know that meant it wasn't actually going to heal and go back to its original setting but was just going to stop hurting. So I dug up a second orthopedic surgeon through the college's athletics program. He said it was a fourth degree separation and most certainly could be operated on. (My understanding is that they do not go for the surgery unless it's fourth degree. You seem to have that option, so maybe they have changed their approach in the twenty-five years since I did this.)

Personally, I am glad I had the surgery. It really bothered me and looked quite funky. I also do not think I would have been able to do most of the athletic things I have done since then if I had not gotten the surgery. I believe it is still an outpatient surgery, so it's probably not that serious of an undertaking physically. At least it wasn't for me. I think I was pretty messed up for a week and then in a sling for a few weeks, but nothing as bad as some of my other visits to the operating table.

Now, it's barely noticeable to anyone who sees me without a shirt. And it feels pretty much normal.

I want to be very clear that what I am writing should not be taken as an encouragement to get the surgery. My experience was overall very positive with this surgery, but I've had another surgery where I was supposed to be out in three days, but ended up spending 10 days in ICU and then three more weeks in a hospital room trying to recover from staph and then get through some hellish physical therapy where I had to learn how to talk, walk and feed myself again. Stuff happens.

You are doing the right thing by getting input from other folks, but make sure you trust your doctor and understand your risks. Best of luck with this no matter what you decide.

I had a type 2 back in college. I was not into tris yet but was in the middle of my senior year soccer season and I also played handball. Being a goalkeeper, it hurt like hell EVERY DAY for a while. Used a heating pad and lots of stretching to loosen everything up before practice and iced afterwards. I was able to play through it with minimal pain after a couple weeks. Handball is where I took the biggest hit as it was my dominant shoulder. Never was really able to play as well as I wanted.

I still have a slightly raised bump on that shoulder. If I wasn't in the middle of my senior seasons (or if I was planning on grad school and could have taken a medical redshirt) I probably would have had surgery to fix it, especially since the school would have paid for it.

I had lingering effects for maybe a year with any type of lifting overhead. It took me 2-3 years to be able to lift weights (bench press, etc) without any pain/popping. 8 years out now and I couldn't tell you the last time I actually thought about it.


My opinion - if you are just wanting to get the bone shaved down, I don't think having surgery is worth it. As far as a recovery aspect, you will probably be better off having surgery to set everything in its correct place before trying to rehab.

I had chronic subluxations that lead to dislocations in high school. Had surg in 1989. Made it nice and tight and has not come out again. Maybe too tight. I have a chronic mid scapular pain since, feels like a constant pulled muscle back there. No amount of PT the last 20 years has fixed this...imbalance. Also, I am prone to upper bicep tendonitis. I f I ramp up my swimming too fast or too much...bammm. I can really only swim about 2x per week. So, some issues for me. Much better than it popping out al lthe time.

Fell off my Tri-bike July/2013 and now have a Grade 3 AC joint separation. 3 weeks later I was back in the pool swimming. (I shaved 11min off Ironman swim time) Only time it bothers me is when I do push-ups only time I remember is when someone questions the bump! It makes for an epic story and I change it every time someone asks. When I saw the Dr. he said not to worry about it and that I would get normal range of motion and if I wanted the bump gone he could operate to fix but if it doesn't bother me let it be. (The Orthopedic surgeon I saw was the San Diego padres ortho guy so I figured he knew what he was talking about)

There have been other threads about this in the past, e.g.
http://forum.slowtwitch.com/..._reply;so=ASC;mh=25;

I had an ACJ separation in the middle of this year. One thing to understand is that the diagnosis of grade isn't very exact.
http://www.internationalshoulderjournal.org/...e=104;aulast=Dearden
"Rolf et al. have noted in a series of patients treated surgically for ACJ dislocation; 55% of patients with radiographic diagnosis of grade III injuries were found to have grade IV or V injuries at time of surgery. [8]"

There seems to be very little agreement about whether a grade 3 should be operated on or not. I spoke to numerous surgeons before and after having surgery on mine, and some were of the opinion that surgery would generally improve the outcome for overhead movements such as swimming, while others thought that it wasn't worth it. However, there is more consensus about grade 4, which is why it is relevant that in patients treated surgically, 55% who were thought to be grade 3 turn out to be grade 4 or 5. This suggests that anyone who is diagnosed as grade 3 needs to consider the possibility their injury is in fact a grade 4 or 5, in which case there would be a much stronger case for surgery.

In my case, I could really feel the clavicle digging into my shoulder when I raised my arm overhead, and the shoulder surgeon I saw who went through the options didn't suggest this problem would ever go away. Excising the end of the clavicle can solve this and other problems and is a very straightforward arthroscopic surgery. But the crucial thing he explained to me is that fundamentally there are two ways you can go with surgery. You can do something soon after the accident, up to around 3 weeks, to hold the clavicle in place, and this will allow the ligaments to heal back together, putting your shoulder back to more or less how it was before the accident. Or later on you can perform a reconstruction. The main options for the immediate option are tightrope, clavicle hook plate or surgilig, all with their pros and cons. There are many studies you can read:
http://www.ncbi.nlm.nih.gov/...=clavicle+hook+plate
The surgeon I spoke to refused to consider the tightrope as he found the failure rate unacceptable. The benefit of tightrope is it can be done arthroscopically, so less cutting of flesh, and it generally allows more movement while healing is taking place. This is important, as any period of reduced movement of the shoulder causes problems and is not easy to reverse. The downside is it is more prone to breaking before the ligaments have healed enough to hold the clavicle in place. There are variants on the tightrope such as a twin tail, or putting two separate tightropes in to try to reduce the risk of failure. The preferred option for immediate fixation of the surgeon I saw was the clavicle hook plate, and that is what I had done. They put a plate in which is screwed to the clavicle, and it hooks under the bone next to it. It sounds like this is the surgery you have been offered. It requires a fairly large incision, mine is 7cm. The plate is left in for 3 months, then removed. It can be removed by cutting around the original wound, so you only have one wound at the end of it, but apparently different surgeons have their own preferred ways to do it. I suffered very badly with the plate in, I could basically do almost nothing in the time it was in, and got about 2 hours sleep per night due to the pain. I had very little movement with it in, so my shoulder seized up badly in that time. Apparently this is quite variable from person to person, and there is no way to predict how it will affect each person in advance, some people aren't bothered much by the plate at all. However, as soon as the plate was removed and the immediate effects of the surgery had healed and I was able to start using my arm again, the improvement was very rapid. I'm not back to full function yet, but I can train in the TT position, and I can swim with technique that is pretty close to pre-accident, this is 4-5 weeks after being allowed to start using my shoulder again after plate removal. The problem everyone has is they can never know how it would have progressed if they had gone down a different route. If I could go back in time and try another approach I'd be pretty keen on having two tightropes put in instead of the hook plate, given how badly the hook plate affected me. And not having a 7cm wound would be nice. It would of course be interesting to know what it would have been like without surgery, but there is only a window of a few weeks to make the choice, so you can't try that option then go back and have the surgery if you aren't happy with the end result.

Which brings me to the second fundamental surgical approach, which is reconstruction. So this is for people who are outside the window for the ligaments being able to heal. Surgilig was the preferred option of the surgeon I saw, and he was willing to let me choose to complete my cycling season, see how it all went, and if I still wanted surgery, put the surgilig in, which is a synthetic replacement for one of the ligaments that is then left in the body for ever to hold the clavicle down towards the scapula. I just couldn't escape the feeling that it would be much better to heal my own ligaments rather than have something alien in my body for ever more. There are numerous other possible approaches to reconstruction. The surgeon who ended up performing my operation and has handled all my post-operative care, when I mentioned that this option had been considered, basically thought you'd have to be mad to choose it over healing the ligaments in the initial window after the accident.

There's no doubt that the hook plate surgery can be a major undertaking for the patient. You may or may not go through hell in the time the plate is in there. The studies are very ambiguous on whether it is better than no surgery, but from my experience I would say that the way the outcomes are measured is stacked against the surgical option. For starters, they look at timescales that are quite short. There is no doubt at all that the surgery will set you back in the short term compared to no surgery. Comparing function at 3 months, for example, is a nonsense, of course you'll be worse off with surgery. And the way they assess it, with the Oxford Shoulder Score, is also a nonsense, in my opinion. I have filled in an Oxford Shoulder Score questionnaire, and it asks you whether you can do activities such as carrying a shopping bag, or hanging up clothes. What I wanted to know is which approach would get my swimming performance back closest to where it was pre-accident. There is no research that has studied function by that sort of measure.

x2

Montain biking in 2005. No issues. Makes interesting conversation topic when in my Speedo by the pool....

To add a little more.... my 2008 ortho said that there were several methods of repair, with varying degrees of success. It's at least an 8 week rehab if not more, and in his words I was "trading a bump for a scar, and the bump's a better story." He also said since I was a total tear, I could have it done at any time if it was a problem.

Mine was done mountain biking in 1992. At the time it was called a complete or total separation.

My orthopod advised strongly against repair. He told me (correctly) that I would have no sequelae from leaving it alone. He also told me that there was a 100% chance I would develop arthritis in the AC joint if it was repaired since the natural architecture of the joint was essentially destroyed.

It took about a year to get 100% function back. I have never regretted not having it operated on.

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Jason
None of the secrets of success will work unless you do.

I think what you must both be talking about when you say "repair" is a reconstruction. The procedure with a hook plate insertion cannot be done at any time, it must be done within ~3 weeks of the injury, otherwise the ligaments will have healed in a separated state and will not join back together. It is not the case that this procedure will destroy the natural architecture of the AC joint, quite the opposite, it will restore the natural architecture of the joint by putting the clavicle back where it should be and allowing the ligaments to heal to serve the same function that they did before the injury.

Received my grade 4 separation in a mt biking wreck, 10 years ago. Feels fine now and i don't look like quasi-moto anyomre.

Ortho gave me an option to let it heal on its own, or do surgery to fix it back in place. Based on the activities I wanted to do in life, i chose the surgery, seem to go ok, and besides the scar, seems ok to me.

.

I was hit by a car 2.5 years ago and got a grade 3 shoulder seperation and 2 broken cervical vertabra.
I had to wait 6 weeks for neck to stabilise then was was advised I was borderline for shoulder surgery and it would only be worth it it causd me problems in the longer term.
So I have not had surgery.
The shoulder was very clicky and felt weak for a long time. Much less so now but still not as strong in my left arm and shoulder as I used to be. Never got my swim speed back but on the other hand I don't swim as much as I used to. I haven't suffered any aches in the shoulder, it just feels week and my range of movement feels a bit restricted.
Still not sure if surgery would have been worth it.

Sorry to keep going on about this, but I think it's important for people reading all this to understand why people are getting apparently different advice to each other. So in your case, because you had to wait 6 weeks, you were outside the window of opportunity for having a hook plate or tightrope put in to allow the ligaments to heal, and your only option would have been reconstruction. Because the reconstruction can be done at any time, in this situation you may as well see how it goes and only have it done if you have problems. This is a different scenario to being able to choose immediate surgery, where you can't wait and see how it goes because you'll miss your one-time opportunity to have a hook plate or tightrope put in to heal the ligaments.

Just curious, when was the hook plate available? I had mine in '08 and there was no stated urgency for surgery. Of course, I told my doc I was training for IMAZ 8 weeks later, and was swimming 3,000 within the month and toe'd the starting line.

I was a decent swimmer before and never lost any speed, nor endurance, and have done 2 IMs and a 10K Swim since then and swim approx 350K yds per year

BTW I am a patient for another condition and I read all sorts of doc's opinions from all over the world, there is no consensus on this issue. I usually chalk differing opinions up to the patient's stated goals (i.e. IM), geographical location, the doc's bedside manner, etc. May or may not be true for a SS, but certainly is for this other condition.

ETA - was told that if it had been a G4 (with ... subluxion? or something), surgery would have been required

I don't know how long it has been in common use for, but there was this study in 2006:
http://www.ncbi.nlm.nih.gov/pubmed/16951527

It is amazing the difference in practices between different surgeons. E.g. reading this:
http://www.aaos.org/.../dec12/clinical3.asp
they left the plates in for 8 months on average, and didn't remove them at all in 8 patients. The plate manufacturers recommend 3 months, and my surgeon told me this is very conservative, and the ligaments are normally sufficiently healed at 6 weeks. My plate was removed at 9 weeks and the clavicle has remained perfectly in place. So leaving the plate in for 8 months seems pointless. They talk about the complication of acromial erosion, but this is a major reason why the plate should be removed after no more than 3 months! And the idea of leaving the plate in forever in some patients totally contradicts what every surgeon I've talked to has told me, which is that the plate MUST be removed as it will eventually wear through things in the joint, even if the patient has no obvious immediate problems from its presence.

Two things.

I am giving a 21 year testimonial that not repairing my Acromioclavicular ligament worked out just fine for me. I am planning on living another 50 years, so things may develop down the road, but so far, so good.

What you have had is an Acromioclavicular ligament reconstruction. Your anatomical orientation in the AC joint may be as it was before your injury, but I guarantee you that the joint is not the same internally as it was. It may be fine for the rest of your life or it may develop arthritis. This is kind of like the football player who gets their knee reconstructed. It may look and work the same but it has been subtly changed by the injury (cartilage tear, inflammation, etc) and by the surgeons presence in the knee. That often leads to joint issues later in life. By not repairing my AC rupture, I have no AC joint at all, therefore no chance to develop arthritis in that joint. The two bony surfaces are not in contact with each other.


I would love to hear from some of the forum's orthopedic surgeons to see what they have to say. As someone pointed out above, there does not seem to be a clear consensus.

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Jason
None of the secrets of success will work unless you do.

I've never heard it described as a reconstruction. The plate simply holds the clavicle in place relative to the acromion, there is no other intervention during the surgical procedure, or at least there wasn't in my case. For example, this study describes ligament reconstruction as something that can be done in addition to insertion of a hook plate:
http://www.ncbi.nlm.nih.gov/pubmed/23895758
Surgeons seem to take varied approaches, and mine said there is no need to do that, if you simply put the hook plate in to hold the clavicle in place, the ligaments will heal without any need to interfere with them.

I agree it isn't identical to before, it can't be, it is a healed injury. But my bony surfaces would definitely have contacted each other during overhead movements if I hadn't had surgery, the clavicle was pressing against the shoulder with my arm pointing upwards. The surgery has actually fixed this problem in that the clavicle now moves like it is supposed to, and moves out of the way when I move my arm overhead, avoiding the problem of the two bony surfaces contacting. The problem of the two bony surfaces contacting after the injury is why one surgical intervention is to remove some bone from the end of the clavicle to prevent this problem. It sounds like yours was perhaps dislocated so far that it actually moved out of the region where contact would be a problem.

Thank you guys for the all the "shared words & stories", as stated w/ the writer above to the folks that have no knowledge or idea what a shoulder seperation
this is a good read, as this shoulder separation & dislocation goes hand in hand w/ cycling injuries, wether it's a fall, car going head on or you going head on against a non mobile sturcture. It's good to know, when it does happen you know what your options are, unlike myself some windows have closed in my end.

In my end, I ended up going to a hospital that was government owned, w/ that being said, the info & care was very much lacking. Nobody informed me that i had a 2 week window to get my shoulder back to how it was, it's been 6 weeks & just finding this out. I thought like all other injuries things will heal and that was that, did not realized that part of our body was capable to taken out of it's position, label it ok & still be functional.

Here's the thing, currently my arm could move like how it was before, therefore telling me my injury is none concern for surgery. I finally had a chance to see the doctor, 1st follow up doctory was from the hospital about 3 weeks ago, guy just wave me off and did jack & a hack of a job. (Here in NYC, I can't believe the waiting time to be seen by a shoulder specialist, this is why i'm 6 weeks into this & ignorant) Yesterday finally seen the real deal, pressed, pulled & gave his 2 cents, and I felt short handed, because he said i was ok. Then I told him if that is ok, (as Steve has described above "the clavicle was pressing against the shoulder with my arm pointing upwards" ) why do I feel a part of my body is pressing upwards & my upper spine & lower spine is have a tingly feeling. My body right now feels like it's shifting towards my right (my injury is in my left shoulder) & legs feels figidity as if a part of my body wants to take up space that is already accupied by a body part, he then says in do time it will go away. He then thinks, then decided to do an x-ray, sat on his office looked at the x-ray
& gave me my options, shave the bone or apply the plate & have a scar. He then goes on saying, at the time after the operation the difference is very little in the sense of the physical aspect, that the bone will still be or slightly popping up and with out care or feel on his voice "lets see in a month, if you feel we should operate then will operate"

The stories you guys presented, as well what i have read, is like it's a 50/50 scenario, it's as if the doctors don't have a real grasp of the injury & uncertain which way to proceed.

Schduled to see another doctor, and yes waiting period is long, in a month!

x3

Christmas party last year got a bit out of hand. Docs at work say it is one of the worst looking Grade 3's they've seen but it works for me. Now I notice no issues with it including doing heavy overhead lifting and tons of body weight movement plus swimming. I was very limited for a month, took about 4 months to be mostly back to normal, maybe after 8 months had full strength and ROM.

   




I understand that doing no operation will still heal and get all motions back in place, but when you say worst Grade 3, how far up was your bone sticking up and i guess it does not bother you, appearance wise. Any physical feeling out of the ordinary at this point?

What I mean is that the visible appearance of the bump on my shoulder is very noticeable in comparison to other shoulder bumps people get when they have a grade 3 separation. I have physicians in the office that made the comments about it which gives a little more credibility to my assessment of the large bump. I think that I was anatomically predisposed to this though as prior to the injury I already had collar bones which are naturally pointy on the top as compared to a normal person. All this being said a year out from the injury other than my fiance teasing me about it quite often I don't even notice it is there. I'm active in a lot of things outside of triathlon like lifting, hockey, skiing, softball, and climbing and I would say that there is no lasting issues with any of these activities. The one thing I have noticed in the past month is that when I'm flopping around on a foam roller with all sorts of weird, changing angles of force on it I can slightly feel it knocking around in there a bit. It's also worth mentioning that it's on my non-dominant arm. Talking it over with my docs and my ortho this actually matters a lot. For people who do things like pitching, golf, or, other sports requiring precise strength and fine motor skills of their dominant arms, there is more of a chance the surgery will actually provide a benefit to them. If this had happened to the other arm I may have gone that route as I'd like to be able to still out heave everyone at a tailgate with a football. I can live with the bump, I kind of like it now. I've never heard of 'bone shaving', since my bump is so big they'd likely need an angle grinder on that to take off 3/4" of collar bone.

I had a level 2 AC separation due to a bike crash in 2010, had an ortho consultation who recommended leaving as is. I chose to leave it. Arm was in a sling for ~ 6 weeks, I just started swimming and running this year, so it didn't affect any racing plans. I've had Bikram instructors comment on it in Tree Pose. My swim coach comments that it looks like my shoulder hurts - that's the only time it comes up, and that may be more due to my form (which continues to be a work in progress).

If I take a week or two off swimming, and am hunched over a desk - I get some tightness, though I suspect that is more due to poor posture/ergonomics than this old injury.

Can you clarify what "Grade 4" means to you? I always thought there were only 3 levels of classification, with grade 3 being complete tear of all the ligaments, but it someone above says they had a Grade 4 (??)

I had a grade 1 separation which was immobile for almost two weeks, then on week 3 i did a 100-mile mtb race.

I crashed hard this past May and suffered a grade 3, tearing three out of the four ligaments that hold the shoulder together. I saw two good sports surgeons, both convinced me to avoid surgery. They went over the hook deal and the total reconstruction. Both involved extended time off the bike with not so great odds of success. I chose to do the PT and rehab. Three months after injury I won the gold and bronze at the NSG although I was nowhere near peak condition. Seven months later I have full range of motion and very little pain, although my upper body strength has been significantly reduced. I struggle to lift half the weight and sometimes that arm feels like it's going to rip off. I just keep on lifting and strengthening trying to get as much back as I can. It will never be the same, though.