Depending on your patient population, you may treat acromioclavicular joint (ACJ) injuries on a daily basis or only on a rare occasion. While the ACJ is often involved in shoulder dysfunction, it may or may not be directly injured. A specific ACJ injury occurs with either a fall (or similar trauma) to the lateral shoulder with the arm adducted or with a FOOSH (fall on outstretched hand) injury. Pain is anatomically localized with this joint as it is primarily located directly over the ACJ.
To test for ACJ injury, first start with observation. ACJ injuries are sometimes palpable/visible with a step-off. The amount of step-off will depend on the severity of injury. As far as our clinical tests go, the Horizontal Adduction Test (the shoulder is adducted and may be elevated simultaneously as well) is preferred as it stresses the ACJ directly. Additionally, an x-ray series of the shoulder is often ordered to assess alignment and rule-out clavicular fractures.
How Do We Classify the Severity of Injury?
If there is no visual deformity (meaning if it is Type I or II), it will most likely be managed conservatively. This incorporates a period of rest and relative immobilization for up to a week before transitioning to protective ROM and isometric exercises. During the initial stages, we will limit end-range elevation with strength training as this position strains the ACJ. After the acute phase, isotonics, closed kinetic chain, end range of motion exercises, and higher level strengthening can be initiated. Below are several higher level exercises that the patient can progress to during later stage therapy.
Type IV-VI ACJ injuries will almost always be managed surgically, so these patients are rarely seen in the PT clinic prior to surgery. The type of injury and procedure will dictate the rehab. As always, use the physician's protocol and EBP to guide the program. As you may have noticed, we have not talked about type III ACJ injuries. These are the most difficult type manage as they can be treated either surgically or conservatively. The decision is based off the patient's occupation, hand dominance and activities he/she likes to perform. Typically, conservative management is tried first for a few months. Should the patient have a difficult time getting back to their desired level of function, surgery may be performed, however, this delay may impact the prognosis.
As we have highlighted, the staging of the injury is essential to dictating how to proceed with rehab. At times, surgical consultation is recommended and/or necessary for proper recovery. My recommendation is to start with conservative management if no step-off deformity is present; however, be ready to reach out for a second opinion as needed.
When evaluating a patient with shoulder or neck pain, it is important to consider all of the structures that may contribute to their current symptoms. These structures include local muscles, peripheral or central nervous system dysfunction, soft tissue stabilizing structures, among others. Next, use this information in combination with other portions of the subjective history (mechanism of injury, description of symptoms, and pattern of symptoms) to identify the one or two primary causes of the problem.
No recent injury, shoulder or neck pain, but still muscle atrophy...
Look Beyond the Local Muscle Atrophy
Since muscle atrophy was present (without signs of a single muscle trauma or strain), it is important to investigate other muscles with the same segmental and peripheral nerve contributions. This will determine if the weakness is localized or present in multiple muscle groups. Below I review the pectoralis muscle with a special emphasis on the sternocostal fibers.
Later in the evaluation, the patient remembered that his biceps brachii and pectoral muscle strength had gradually decreased on his right (involved side) versus his left over the past few months while strength training.
This statement is very important because it most likely ruled out a muscle strain, and ruled in nervous system dysfunction. Further physical examination helped rule out red flags for cervical myelopathy. Additionally, muscle strength testing found weakness in other C5, C6, and C7 muscles. At this point, I concluded that he was safe for treatment, but needed regular reassessment to ensure no further progression of neurological symptoms.
To learn more about the outcome of this patient, watch the video below!
No matter where you do your rotations or practice physical therapy, you are bound to work with both people who target the VMO with their interventions and people who think it's impossible to do so. Following trauma, knee surgery, or patellofemoral pain syndrome, many practitioners claim selective atrophy and weakness of the VMO relative to the rest of the quadriceps.
Rectus Femoris Origin:
-Anteroinferior iliac spine (straight head), groove above rim of acetabulum (reflected head)
Vastus Lateralis Origin:
-Proximal part of intertrochanteric line, anterior and inferior to borders of greater trochanter, lateral lip of the gluteal tuberosity, proximal 1/2 of lateral lip of linea aspera and lateral intermuscular septum
Vastus Intermedius Origin:
-Anterior and lateral surfaces of proximal 2/3 of the body of femur, distal 1/2 of linea aspera, and lateral intermuscular septum
Vastus Medialis Origin:
-Distal 1/2 of intertrochanteric line, medial lip of linea aspera, proximal part of medial supracondylar line, tendons of the adductor longus and adductor magnus and medial intermuscular septum
| || |
See how Dr. Chris Fox PT, DPT, OCS treats Cervical Radiculopathy