Dr. Allan Horowitz, published newspaper article, Richmond Hill Liberal, Copyright February 28, 1990
Dear Dr. Horowitz:
I never thought I would be writing to you with a problem like this, but I hope you can give me some answers.
I am a 16-year-old Jr. B hockey player and I am interested in getting as far as I can in hockey. If not to the pros, then at least I will try for a US college scholarship. The reason I tell you that is so you will know how important this is to me.
I was checked into the boards last week and, despite the fact that I wear the best shoulder pads money can buy, the tip of my shoulder hit the boards. I had sudden pain and I couldn’t move my arm at all when I got up.
The trainer told me to ice it and after the game he took me to the local hospital where the doctor took x-rays and told me I had a shoulder separation. He gave me a sling and told me to keep icing the top of my shoulder.
I can’t lift my arm yet, and it really hurts me. In the meantime, I am missing my hockey season and maybe seeing my hopes of the scholarship go down the drain.
Is there anything else that I can do to get back into action faster? The way it’s going now, it seems that I will never get better. Please help.
Answer:
The only problem with this situation is that you described an injury which should be treated immediately and by the time you see this answer in the paper, it will be six weeks after the date on your letter.
I must remind readers I do welcome all questions and will do my best to answer all questions forwarded to me, but it is impossible to answer them quickly enough to be of any immediate benefit for problems such as this. My reason for answering this type of question is that there are likely many other people reading this answer who have similar conditions who will benefit from the answer. (It will also keep me off the streets, and out of trouble.)
What you have described to me sounds like an injury to the acromioclavicular joint. This is the joint where the acromion (the very top part of the shoulder blade which makes the point at the tip of the shoulder) meets the clavicle (the collar bone).
The coracoclavicular and acromioclavicular ligaments are the main stabilizers of this joint, and when they are torn or damaged in any way, the joint will not work properly.
POLO INJURIES
The most common mechanism of injury to this joint is a fall onto the point of the shoulder. Believe it or not, one book I consulted stated that the sport most commonly involved in this type of injury is polo. The horseman falls off the horse and lands on the point of his shoulder. (I checked to see where this book was published, thinking that it couldn’t be in North America, but it was written by a group of doctors at the University of Oklahoma medical school.) I must admit I have never seen a polo injury.
As with many of these “sprain” injuries, they can be discussed as first degree (mild), second degree, or third degree (severe) injuries to the joint.
A first-degree sprain is similar to a bruise of the top of the shoulder. It should be rested for a few days, treated with ice and maybe with a bit of padding over the shoulder to prevent further injuries.
A second-degree sprain must definitely be treated with ice, rest (strapping the arm to the side with the elbow flexed to 90 degrees) for at least four weeks and local ultrasound treatment to speed up the repair of the ligaments and reduce the possibility of future disability. Exercise to increase range of motion and gradually regain strength must then be done to prevent future injury as soon as active sporting activity is undertaken.
A third-degree injury usually involves a complete tear of one or more of the involved ligaments. An orthopedic surgeon must be consulted in this type of injury because very often surgical intervention is the only way to gain lasting results and future stability of the joint.
The surgeon may decide he doesn’t have to operate, but a surgeon who is well-versed on the newer surgical techniques used in the shoulder, and preferably one who understands “sports injuries” should be consulted if the ligament is completely torn.
The only way to determine the degree of injury is through x-Ray. Initially the x-Ray will show if there have been any broken bones.
After a week or two, another set of x-Rays should be taken. These x-Rays will determine how “loose” the acromioclavicular joint is. Weights are held in the hand while the x-Rays are taken. These weights will pull the shoulder down in the shoulder blade (and therefore the acromion) along with it.
If the ligaments have been damaged there will be greater separation between the acromion and the clavicle than there should be. The other shoulder is always taken for a comparison, to see what separation is normal for that patient.
Getting back to your problem… It sounds like you have a second or third-degree injury. You should have the weight x-Rays done if they haven’t been done already.
You should have local treatment immediately, namely ultrasound. This helps speed things up tremendously in these cases.
If this doesn’t work within a few weeks, then a surgeon should be consulted as quickly as possible. Remember to wear your arm sling as the doctor told you. Your hockey season may be a complete write-off for this year if surgery is required. But it is possible that you will only have to miss a few weeks of playing time if you are treated properly.
See your doctor and ask him/her to refer you to someone who can treat your shoulder immediately. This might be a physiotherapist, a chiropractor or an orthopedic surgeon.