Fear of separation

Tuesday, September 8, 2009

It took the blink of an eye to dash the hopes the Sooner nation for a football championship. In that split second, the weight of a tackler landed just at the right angle on the shoulder of Oklahoma quarterback Sam Bradford and caused damage to the AC joint. X-rays were negative and optimism reigned since in most people’s minds, no broken bone equals no serious injury; but that is far from the truth. For most of the world, acromio-clavicular injuries are not a big deal, but for a person making their living throwing a football, it can be a disaster.

The AC joint brings together two bones: the acromium is the part of the shoulder blade that swoops forwards and forms the top bony prominence of the shoulder and the clavicle or collarbone. Coming together, the joint allows the arm to be raised above shoulder height and to pivot the scapula or shoulder blade to allow rotation. The joint needs to work properly to and the two motions are required for any throwing motion and especially throwing a tight spiral with velocity.

Landing directly on the outside of the shoulder transmits all the force through the AC joint and can tear the surrounding ligaments that hold the joint together. While it is proper to use the term sprain to describe torn ligaments, the AC joint injuries are also called AC separations or shoulder separations.

AC separations are graded 1 through 6 depending upon the distance that the joint is displaced, meaning how far apart the end of the clavicle and the acromium of shoulder blade are separated. Grade 1 and 2 separations are usually treated with rest, keeping the arm supported in a sling and physical therapy. Rehab can potentially last 6-12 weeks. Because it takes time for ligaments to heal, returning too early to activity may lead to a worsening separation that might require a surgical repair.

The treatment of grade 3 AC injuries (the injury reportedly suffered by Bradford) is controversial. Some orthopedic surgeons suggest watchful waiting and a non-operative approach, while others recommend early operation to repair the damage. After surgery, the recovery time can be as long as 12 weeks. Either approach seems to take longer than the quoted 2-4 weeks that might keep Oklahoma’s fans cheering for an early return of their star player.

For most of the world, 2-3 months of healing time is an inconvenience but for an elite athlete, it might be a whole season of competition. For a quarterback whose raison d’être depends upon the throwing motion, the injury can be a disaster when it comes to career planning. Come back too soon, performance suffers and the risk of re-injury is high. Wait too long and a season is lost and along with it, the opportunity to move to a higher level of competition in the NFL.

Aside from recurrent pain and weakness, the longer term complications of an AC separation are similar to any other joint that has been damaged. The risk of arthritis increases with the severity of injury and the amount of damage sustained, regardless of whether the treatment was surgical or conservative (non-surgical). Eventually, the long term pain and decreased range of motion caused by the arthritis and degeneration of the joint may lead to surgery to reconstruct the joint.

The injury to this small joint, whether it is called a sprain or a separation, should be a reminder that not broken does not equal not damaged. Sprains may be as painful and as difficult to repair and rehabilitate as a fracture, but they are the Rodney Dangerfield of the injury world. They get little respect.

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