Grade I ACJ injury

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A 24-year-old male professional player presented with an acute onset of left shoulder pain following a fall onto his left shoulder. He described jumping to challenge for a header, losing balance and landing on the point of his left shoulder. It was immediately painful, and he had to be substituted. He had localised tenderness over the left ACJ and a high pain arc. There was no gross deformity.

An x-ray of the left shoulder and ACJ is normal. There was no evidence of instability on either Zanca or stress views. The distal clavicle has mild subcortical oedema. There is an AC joint capsular stripping injury from the distal clavicle, with a thin cleft of separating fluid. Some anterior capsule fibres remain. The AC joint alignment appears maintained. The coracoclavicular ligaments are intact.

This player was managed with a short period of relative rest. Despite experiencing quite significant pain and disability immediately after the injury, his symptoms settled quickly. He was able to participate in a competitive game, with his shoulder strapped, three weeks post-injury.

Stability of the ACJ is maintained by the acromioclavicular (AC) ligaments, coracoclavicular (CC) ligaments and the deltopectoral fascia. The AC ligaments primarily act to limit anteroposterior movements while the CC ligaments prevent superior displacement of the distal clavicle. The Rockwood classification is widely used to classify ACJ injuries and provides some guidance for treatment decisions and prognostic information. This classification involves six types of injury and takes into account each of these stabilising structures. In most cases x-rays are the only imaging that is needed. Three standard views should be obtained: an AP view with the x-ray tube angled upwards 20 degrees, a stress view (where the patient holds a heavy object) and an axial shoulder view. Comparison views of the other side can be helpful when subtle joint widening or an increased coracoclavicular space is suspected.

Most ACJ injuries sustained in football are of grades I, II or III. Grade I injuries are a sprain of the AC ligaments and are not associated with any malalignment of the clavicle (relative to the acromion). Type II injuries involve rupture of the AC ligaments and a sprain of the CC ligaments. X-rays in these cases demonstrate elevation of the distal clavicle however it does not lie above the superior border of the acromion. Type III injuries involve an injury to both the AC and CC ligaments. X-rays in this setting show that the clavicle is elevated above the superior border of the acromion. This is associated with an increase in the coracoclavicular distance of less than twice normal (or <25mm). In most cases type I-III injuries can be managed without surgery. Types IV, V, and VI are variants of type III, but with increasing degrees or direction of displacement. Most of these injuries require surgical management.

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