Physical therapist examination, evaluation, and intervention following the surgical reconstruction of a grade III acromioclavicular joint separation: rehabilitation of acromioclavicular joint separations is common in contact sports.

Acromioclavicular (AC) joint injuries commonly occur as a result of a traumatic lateral blow or a fall on the shoulder with the arm in some degree of adduction. The incidence of AC injuries is highest in activities such as ice hockey, skiing, snowboarding, football, rugby, and bicycling (1-3) in which collisions are common and following motor vehicle accidents. (1,2,4) The AC ligament and the coracoclavicular ligaments provide most of the AC joint's restraint. (5)

Allman (6) subdivided AC injuries into 3 grades. Grade I injuries occur with a lateral force and involve an isolated sprain of the AC ligament. Grade II and III injuries are the result of a superolateral force, (7,8) with the grade II injuries involving a tear of the AC ligament and a sprain of the coracoclavicular ligaments. In grade III injuries, both the AC ligament and the coracoclavicular ligaments are completely ruptured, often leaving the patient with a complete superior dislocation of the clavicle (9) and a visible "step" deformity between the clavicle and the acromion. Grade I and II injuries are typically managed conservatively with immobilization, cryotherapy, range of motion (ROM), and the use of nonsteroidal anti-inflammatory drugs and analgesic medications. (9-11) Considerable debate remains regarding the appropriate management of grade III injuries. (12)

Proponents of conservative management cite reports of "good" or "satisfactory" outcomes in terms of strength (force-generating capacity of muscle), ROM, and a return to close to preinjury levels of function in 80% to 96% of cases. (10,12,13) Despite widespread reports of satisfactory outcomes, many participants in previous studies who were physically active or manual laborers reported outcomes to be favorable, yet never became completely free of pain and dysfunction. (13,14) Urist (15) reported rates of unsatisfactory results from 10% to 50% that in some cases resulted in a change of jobs or recreational activities or subsequent surgery. Thus, although conservative management may be adequate to facilitate an acceptable outcome in many patients, it may not offer the best course for those who aspire to return to heavy lifting or manual labor.

Surgical fixation of the AC joint has been used to improve cosmetic appearance, lateral clavicular pain, and compromised lifting or bench press strength. (12,16,17) Many surgical fixation techniques have historically been marred by technical shortcomings such as fixation failure, pin migration, risk of nonunion fracture, musculocutaneous nerve injury, and in many cases the need for a second surgery to remove fixating hardware. (7,9,16,18) As a result, conservative management is often chosen to avoid the technical complications of surgery and post-surgical rehabilitation as much as to achieve patient satisfaction in functional outcomes. (12-14,16)

The Weaver-Dunn procedure addresses some of the potential complications of other surgical techniques by resecting the distal end of the clavicle and transferring the coracoacromial (CA) ligament from the acromion to the shaft of the distal clavicle. (3,4,7,8,19) Resecting the distal end of the clavicle reduces the risk for degenerative arthritis of the AC joint and provides a better bony surface to support the new attachment of the CA ligament. Subsequent modifications of this technique include stabilizing the clavicle to the coracoid process with absorbable sutures or fiber wire instead of pins or screws to eliminate the risk of hardware migration and the need for later surgical removal. (3,4,7,8,19-23)

Weinstein et al (3) and Dumontier et al (20) reported no differences in the long-term postsurgical outcome of patients who underwent the Weaver-Dunn repair either less than 3 weeks after injury or more than 3 weeks after injury. However, patient satisfaction decreased significantly when the surgery took place more than 3 months after the initial trauma. (3) Because satisfactory outcomes can be achieved with both conservative and surgical interventions, many authors (8,17,20,21) have recommended an initial period of conservative management of up to 3 months followed by surgical reconstruction in those patients who experience unsatisfactory outcomes or are young, active, or involved in manual labor.

We have found no reports in the literature of a detailed postsurgical rehabilitation protocol with measurements of strength and ROM and using validated functional instruments. As a result, the purpose of this case report is to present a detailed description of the rehabilitation and the outcomes of an active 34-year-old man following a modified Weaver-Dunn surgical fixation for a grade III AC joint separation.

Case Description

Patient Description

The patient was a 34-year-old college professor and physical therapist with sports clinical specialist certification and 13 years of experience treating sports-related injuries. He also is an author of this case report (WR). The injury was a result of landing on the lateral end of his left (nondominant) shoulder while catching a football in a recreational league game. The patient recalled several mild "shoulder separations when playing ice hockey" as a teenager but reported no other traumatic shoulder injuries. Immediately following the injury, the patient was examined in a local emergency department, and radiographs were taken (Fig. 1). Upon examination by the emergency department physicians, the patient reported acute pain of 6/10 at rest and 10/10 with left upper-extremity movement. He had tenderness to palpation of the AC joint and muscular spasm in the left upper trapezius muscle, and his left clavicle was visibly elevated over the acromion and was hypermobile. The patient was diagnosed with a "dislocated AC joint" and was prescribed a sling and hydrocodone for pain. A follow-up visit with an orthopedic surgeon was scheduled for 2 days later.

[FIGURE 1 OMITTED]

At his follow-up visit with the physician, the patient was comfortable without his sling as long as horizontal adduction and overhead motions were avoided. Without medication, the patient rated his pain as 2/10 at rest and 4/10 with movement. His discomfort limited left shoulder flexion and abduction strength to 4/5 and active range of motion (AROM) to 0 to 150 degrees of abduction. The patient had normal strength in external and internal rotation and elbow flexion and continued to take hydrocodone at night to assist with sleep for 7 days. At this point, the patient had learned to modify lifting, grooming, and donning a pullover shirt to minimize discomfort. The step deformity was still present and became more pronounced with active or passive horizontal adduction (Fig. 2). The surgeon confirmed the previous diagnosis of a grade III AC joint separation. (6)

[FIGURE 2 OMITTED]

Based on the research presented earlier in this report, the physician and patient decided on a conservative approach to management for 2 1/2 months. At that time, if the patient did not have a satisfactory outcome, a surgical option was to be considered. This would still be within the 3-month time frame supported by Weinstein et al. (3)

The patient independently determined and executed the rehabilitation program based on the physician's findings and his own assessment of functional limitations. The patient limited his lifting and physical activity for 3 weeks. After 3 weeks, he could complete all of his own shopping and housework and resumed running 4.8 to 6.4 km (3-4 miles) 3 times per week. He also began lifting weights on his own in an attempt to strengthen his shoulder and improve his ability to push open doors or complete a push-up. Eleven weeks after the initial injury, the patient was experiencing no pain, and he could perform activities of daily living and lift heavy objects from the floor and overhead with minimal difficulty. Despite a palpable click underneath the left scapula with overhead motions and horizontal adduction of the shoulder, the patient was able to run at his preinjury level and play golf.

The patient's primary complaint continued to be left upper-extremity weakness and a feeling of scapular instability with pushing open a heavy door or completing a push-up. This instability was probably not just due to postinjury muscular weakness, but instead to the mechanical disruption of the scapula's normal articulation to the thorax at the AC joint. The result was an unstable scapula instead of a stable foundation required for movement by the articulation between the acromion and the clavicle. This functional deficit remained despite activity-specific attempts to strengthen that motion with scapular stabilization and chest-press weight training over a period of 2 months and was unlikely to change without surgical fixation. Similarly, no change in the step deformity was apparent upon visual inspection.

Preoperative Physical Therapist Examination

Eleven weeks after injury, the patient was seen for a preoperative examination to assess his baseline ROM and strength. Range of motion as reported in Table 1 was performed as described by Norkin and White (24) The exceptions to this were the combined movements of overhead reach and behind-the-back reach as described by Magee. (25) Strength was measured in positions consistent with Kendall and colleagues' description of muscle testing. (26)

Several reports (27-29) have shown that goniometric measurements of shoulder ROM are reliable, especially when the measurements are taken by a single experienced clinician. In addition, manual muscle test scores for the internal and external rotators and middle trapezius muscle are known to have good intratester reliability. (30-32) All ROM and strength measurements were made according to published norms by the treating physical therapist, who had 15 years of clinical experience using these techniques. As a result, we believe that the ROM and strength measurements used in this case report were reliable.

The patient completed the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire and Sports/ Music or Work Module as a self-report measure of function. The DASH has been validated against the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) (-.36 to -.62) (33) and other joint-specific measures, including the Brigham (carpal tunnel) questionnaire and the Shoulder Pain and Disability Index (SPADI) (r>.69). (34) In addition, it has shown good test-retest reliability (intraclass correlation coefficient=.96) and better responsiveness than joint-specific instruments in convenience samples of patients with upper-extremity injuries. (33,34) A score of 1 on either the general form of the DASH or the Sport/Music or Work Module indicates no limit in function, and a score of 100 indicates the inability to perform activities of daily living with the upper extremities. The Sport/Music or Work Module is an optional 4-item instrument intended for groups whose activities require high levels of physical performance that may be beyond the scope of the DASH.

Beaton et al (34) reported a change of 5 to be the standard error of measurement for the DASH and thus the threshold for a minimal clinical difference. Other authors have suggested that cutoffs of 7% (35) or 15% (36) be used to indicate significant clinical changes. On the general DASH form, the patient scored 9.17/100; larger deficits were noted in the Sport/Music or Work Module with a score of 81.25/100. Measurements for strength and ROM are described in Table 1. We did not assess the reliability of our own measurements. As a result of the functional deficit that remained after 12 weeks of conservative treatment, the patient consented to undergo a modified Weaver-Dunn CA ligament transfer to surgically reconstruct his AC joint.

Surgical Procedure and Postsurgical Management

A modified Weaver-Dunn CA ligament transfer was completed as previously described. (3,4,7,8,19) Briefly, the clavicle was returned to its normal position by resecting the distal 1 cm and securing it to the coracoid process with Arthrex fiber wire. * The CA ligament was detached from the acromion and sutured to the distal clavicle. Upon completion of the surgery, the clavicle was stable in the anteroposterior direction with gentle manual manipulation. No evidence of abutment between the clavicle and acromion was present with horizontal adduction or rotation. An Iceman ([dagger]) wrap and sling with swath were placed about the arm.

Following surgery, the patient was required to use a canvas shoulder sling with an immobilizing swath on a full-time basis for 6 weeks and was restricted from all lifting other than manipulating small objects such as utensils in his hand. This length of immobilization was longer than the "few days" (7,37) to 4 weeks (4,38) described previously and was based on the surgeon's experience with more poor outcomes secondary to a failure of the surgical fixation in patients who began lifting too aggressively in the first 6 to 8 weeks after surgery.

After 3 weeks, follow-up radiographic images indicated that the space between the clavicle and acromion was in its surgically fixed position of approximately 3 mm. Strengthening was permitted for the wrist flexors and extensors, and the patient was encouraged to passively flex and extend his elbow with the arm supported on a table or countertop. Ten repetitions of passive range of motion (PROM) were completed independently for 2 to 3 sessions per day. Wrist flexion, extension, pronation, and supination were completed with red (weeks 1-3) and then green Thera-Band ([double dagger]) in a sitting position with the left elbow rested on left knee. Because the patient's job required considerable typing, he also was allowed to type with his left upper extremity supported. To maintain cardiovascular fitness, the patient rode a stationary bicycle sitting upright without use of the handlebars.

Postsurgical Physical Therapist Examination

Physical therapy began after 6 weeks of shoulder immobilization and a second postsurgical follow-up visit with the surgeon. Physician orders were for discontinuation of the sling and "passive ROM to 90 degrees of glenohumeral shoulder flexion and abduction and active-assistive ROM in supine." The physician verbally clarified these orders by emphasizing that the patient was encouraged to reach full PROM and active-assistive range of motion (AAROM) in a supine position. In a supine position, the weight of the scapula would be supported by the treatment table and would not pull on the surgical graft as would happen in gravity-dependent positions such as sitting or standing. The patient was allowed to complete isometrics for the shoulder and elbow and was encouraged to reach full glenohumeral PROM in external rotation.

After a prolonged period of immobilization, a review of the musculoskeletal, cardiopulmonary, neuromuscular, and integumentary systems was performed. The patient was found to have restrictions in glenohumeral and elbow ROM, poor active scapular control, and atrophy of the left deltoid and upper arm musculature. He also had restriction and decreased mobility near the surgical incision due to the adherence of the skin to the underlying tissue. Blood pressure was 110/70, and resting pulse was 64 beats per minute.

Range of motion and manual muscle test results for the shoulder and elbow are listed in Table 1. Left shoulder flexion, abduction, and external rotation and elbow extension AAROM were decreased compared with the preoperative examination. Although the measured ROM for left glenohumeral internal rotation was higher than during the preoperative examination, the ROM was still less than the documented norms for that motion. (24) Combined movements and strength of the shoulder and scapular muscles were not examined due to the risk of negatively affecting the healing tissues. The patient's left upper extremity was neurologically intact to light touch in dermatomes C4 to T1 except for an area of approximately 1 cm around the surgical incision where sensation was reduced. Gross restrictions in posterior and anterior glenohumeral accessory joint mobility were noted with the patient positioned supine and the shoulder in the open packed position (approximately 55[degrees] of glenohumeral abduction and 30[degrees] of horizontal adduction). (25) Because the patient had been immobilized for 6 weeks with his arm at his side, it is possible that his restricted accessory motion was due to apprehension, and thus muscle guarding, when placed in the open packed position. However, he did demonstrate restricted external rotation and internal rotation that are commonly associated with anterior and posterior glenohumeral capsular restrictions. (39)

The DASH questionnaire was again completed, and the scores were 45.75/100 on the general form and 100 on the Sport/Music or Work Module. As expected, both of these scores changed more than the 5 to 15 points, which is reported to indicate clinically significant changes in upper-extremity function. (35,36,40)

Diagnosis. The findings upon initial examination were consistent with musculoskeletal practice pattern I ("Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion Associated With Bony or Soft Tissue Surgery") of the Guide to Physical Therapist Practice. (41) The patient had impairments and functional limitations of ROM, strength, and endurance due to inactivity; impaired joint mobility; limited independence in activities of daily living; pain; and swelling. (41)

Prognosis. Restricted ROM, loss of strength, and impaired motor performance are common after surgical reconstructions of the AC joint. (14,42) It is likely that the patient in the present case had greater deficits secondary to a longer period of immobilization than patients in these previous reports. Given the patient's age, presurgical health, motivation, and the fact that there were no surgical complications, the physician and the physical therapist felt that there was a good prognosis for a full functional recovery. A short-term goal of increasing left shoulder AAROM to 90 degrees of external rotation, 150 degrees of flexion, and 145 degrees of abduction was established to be achieved in 2 weeks. Long-term, the patient wanted to resume his previous level of sports, including golf, bicycling, running, and recreational softball. In addition, he felt that completing 10 push-ups without difficulty would indicate a satisfactory resolution of his principal presurgical complaint of scapular instability with push-ups and opening heavy doors. Moreover, it would confirm a resolution of the mechanical instability corrected by the surgery. Given these goals, the patient would exceed the "good" outcome attributed to patients following conservative management of the grade 3 injuries in the series previously mentioned. (10,12,14)

Intervention

Postoperative weeks 7-8. Initial treatment consisted of moist heat for 15 minutes and available AAROM with a straight cane guided by the uninvolved upper extremity or physical therapist assistance into shoulder flexion, abduction, and external rotation (patient positioned supine). At his second treatment session, continuous ultrasound over the anteroinferior glenohumeral joint capsule (2.0 W/[cm.sup.2] x 9 minutes) and Maitland grade III anterior, posterior, and inferior glenohumeral joint mobilizations with the shoulder in the open packed position were initiated for 3 bouts of 30 seconds each. Active range of motion and manual resistance were applied to the scapula in superior, medial, lateral, and inferior directions (scapular clock), and ice was applied to the left shoulder for 15 minutes following treatment. The patient was seen in the physical therapy clinic 3 times per week and assigned a daily home exercise program that emphasized isometric shoulder strength and glenohumeral and scapular ROM within the postsurgical restrictions (Tab. 2). A daily log of home exercises was maintained throughout the duration of physical therapy intervention.

During week 8, the patient began to complain of pain and "pinching" in the posterior left shoulder with end-range glenohumeral PROM in external rotation. Because a gross restriction in posterior glenohumeral accessory motion was noted during the initial physical therapist examination, the physical therapist hypothesized that these symptoms may be secondary to a restricted posterior glenohumeral joint capsule or the early stages of an internal impingement of the supraspinatus muscle by the posterior glenoid rim. (43,44) As a result, 2 methods of posterior capsular stretching were initiated. The first method was performed by the physical therapist with the patient in a supine position and the shoulder in the open packed position. The second method was completed by the patient in a left side-lying position with his shoulder in 70 degrees of flexion. In both cases, the physical therapist or the patient passively moved the shoulder into internal rotation to the point of gentle stretch held 30 seconds for 5 repetitions. In addition, the grade III posterior glenohumeral joint mobilizations initiated during the second treatment session were emphasized by increasing the number of bouts to 7.

By week 9, left elbow PROM was within 3 degrees of the PROM of the uninvolved side. Elbow ROM activities continued, and the patient had no complaints of pain or loss of function other than transient stiffness attributed to the 6 weeks of immobilization.

Postoperative weeks 9-13. At week 10, the patient was allowed to perform shoulder AAROM and AROM in all planes without the scapular support of the treatment table in a supine position. Left shoulder AROM measurements at the beginning of week 10 are listed in Table 1. All of the patient's 2-week goals for ROM were achieved. However, left scapular winging and anterior tipping were noted during open-chain motions such as shoulder elevation and prone horizontal abduction and flexion.

Further assessment revealed that the manual muscle test strength for the rhomboid muscles was 4/5. The middle and lower trapezius muscles (26) were not able to overcome the resistance of gravity or potential tightness of the muscles attaching to the coracoid process to stabilize the scapula against the thorax, indicating a muscle testing grade of less than 3/5. (26) The tightness of the muscles attaching to the left coracoid process also was tested using the technique described by Kendall et al. (26) With the patient positioned supine, slight posterior pressure to the anterior left shoulder was required to resolve the anterior tilt of the scapula. This finding suggested that the inferior migration of the coracoid process and anterior tilt of the scapula were likely caused by either slight muscular tightness or weakness of the lower trapezius muscle. (26)

The strength of the serratus anterior muscle was found to be at normal (5/5) strength in the supine testing position. However, when the serratus anterior muscle was tested in the preferred, sitting (open-chain) position without support of the scapula by the treatment table, the muscle was not able to maintain the position of the scapula on the thorax when challenged with resistance by the examiner. (26)

In addition to tightness in the muscles attaching to the coracoid process or weakness of the serratus anterior and lower and middle trapezius muscles, impaired neuromuscular control of these muscles following 6 weeks of immobilization and 4 additional weeks of limited shoulder movement also may have played a role in the winging and anterior tilt of the scapula. (45) As a result, new short-term goals addressing the impairments believed to contribute to the scapular winging and anterior tilt became a priority over the next several weeks of treatment. These goals included: (1) increasing rhomboid muscle strength to 5/5 and testing serratus anterior and middle and lower trapezius muscle strength at a grade of 3/5 without scapular winging or anterior tilt and (2) improving neuromuscular control of these muscles both statically and dynamically.

In order to strengthen the scapular stabilizing muscles, closed-chain exercises and assisted exercises for the lower trapezius and serratus anterior muscles were initiated. With the patient in the prone manual muscle testing position for the lower trapezius muscle, (26) the physical therapist elevated the patient's arm and assisted him in holding that position for 5 seconds or as long as he could maintain the scapula in the correct position on the thorax. The patient also worked on strengthening at home by placing his arm at about 130 degrees of abduction with the shoulder externally rotated and contracting the lower trapezius muscle to facilitate scapula depression and prevent anterior tilting. Additional strengthening techniques during this period included manual resistance to the scapula to improve the patient's control of adduction and depression. Closed-chain scapular exercises including the push-up "plus" from a wall or floor (Fig. 3), shoulder extension in standing with (minimal) resistance supplied via a Pro Fitter Trainer ([section]),(1) (Fig. 4), partial weight bearing through the left upper extremity onto a Swiss ball with the patient bent over at the waist (Fig. 5), and weight bearing through the upper extremity to maintain a Swiss ball on the wall at shoulder height (Fig. 5). (46,47)

[FIGURES 3-5 OMITTED]

To address the deficit in glenohumeral ROM, joint mobilizations were continued with passive stretching. Glenohumeral joint distraction and mobilizations of the humeral head in the posterior, inferior, and anterior directions were performed with the humerus in the open packed position with neutral rotation or toward the end-range of external rotation. With the patient in this position, Maitland grade III oscillations were performed for 30 seconds, 5 repetitions in each direction, to facilitate humeral accessory motion. Rotator cuff strengthening exercises were progressed to emphasize strengthening through the full ROM with both concentric and eccentric contractions as detailed in Table 2.

The external rotators and posterior capsule were stretched for 3 bouts of 30 seconds each. With the patient in the prone position and the shoulder abducted to about 70 degrees, the physical therapist stabilized the scapula and gradually applied a stretch toward internal rotation. In his home exercise program, the patient continued to stretch the external rotators by stabilizing his scapula against the table in the left side-lying position with the shoulder in 70 degrees of flexion and using his opposite hand to internally rotate the shoulder.

Postoperative weeks 14-17. During postoperative week 14, clinic visits were decreased to 2 visits per week. The patient had no complaints of pain and noted that he was able to attain close to full active external rotation in the left shoulder in a supine position without assistance. He also demonstrated improved motor control of his shoulder girdle by being able to prevent scapular winging during prone shoulder flexion and horizontal abduction. From the manual muscle testing position for the lower and middle trapezius muscles, he also could maintain his scapula against the thorax while moving his humerus into further flexion and horizontal abduction. His ability to control the scapula during shoulder motion may have been due to improvements in lower trapezius and serratus anterior muscle strength, improved glenohumeral ROM, and a tactile cue to press the lower anterior surface of his shoulder forward into the table while tipping the coracoid process and AC joint posteriorly.

This tactile cue may have helped to accomplish 2 things essential to normal glenohumeral and scapular function. First, the feeling of posteriorly tipping the coracoid process and acromion may have helped him to become more aware of contracting the lower trapezius muscle to counter the anterior tip of the scapula and maintain the scapula flat on the thorax. Once the scapula was stable, the patient was able to concentrate on externally rotating the humeral head instead of moving the entire shoulder and scapula posteriorly to achieve a compensated relative external rotation of the upper extremity.

Because the patient used the tactile cue of his anterior lower shoulder contacting the treatment table or floor, it was not until week 16 that he could maintain this stabilization in an "all fours" position without the tactile feedback of the table (Fig. 6). Emphasis on exercises for scapular control, glenohumeral external rotation ROM and strength, and endurance to achieve the patient's long-term functional goals continued from week 17 until the end of physical therapy intervention. During week 16, the patient was allowed to hit golf balls at a driving range with a full swing using all clubs. He also was able to complete 10 full push-ups without instability or complaint other than fatigue.

[FIGURE 6 OMITTED]

Postoperative weeks 18-21. Beginning at week 18, the patient continued to complete home exercises and began an independent strengthening routine at his gym. This program is described in Table 3 and was self-guided and progressed by the patient with regular consultations with the treating physical therapist until he was discharged from formal physical therapy intervention.

Outcomes

At postoperative week 20, DASH scores were 3.33 on the general form and 0 on the optional Sport/Music or Work Module. Based on the findings (Tab. 1) and the patient's low score on the DASH, the surgeon released the patient to full activity by including golf, organized softball, bicycling, and running 5 months after surgery. At 15 months, the patient had completed a self-directed, 8-week, upper- and lower-extremity strengthening program using machine and free weights without restriction or weight limitations. Two years postoperatively the patient still participated in all desired recreational activities and reported no discomfort, loss of function, or restriction in function. His scores on the DASH were 0.83 on the general form and 0 on the Sport/Music or Work Module. He was satisfied with his outcomes, and all long-term functional goals were achieved.

Discussion

Grade III AC joint separations are common injuries in contact sports but the appropriate course of management is not well defined. We selected a course for the patient described in this case report that allowed him to undergo a period of conservative intervention for up to 3 months. Due to an outcome that did not meet the demands of his active lifestyle and recreational activities, the patient chose to have reconstructive surgical fixation of his clavicle. (3,8,17,20,21)

Despite the limited detail and outcome data available in the literature, there are some comparisons that can be made between the patient in the present case and those presented in previous reports. After 3 months of conservative rehabilitation, this patient continued to have complaints similar to those previously reported. Complaints included clavicle subluxation, crepitus, and an inability to use the involved upper extremity to push open a door or to complete a push-up or bench press lift. (12,16,17) The patient was able to return to work 3 days following the initial injury, but his job as a university professor was easily modified to include computer-based activities and lecturing. A better indication of his return to modest levels of function may have been the 3 weeks it took him to return to activities such as housework, lifting, and athletic activities such as weight lifting and running. This time frame for return to activity was consistent with the 2 to 4 weeks reported for other nonsurgically treated people to return to work and activity. (14,21,23)

Our surgeon and physical therapists recognized before surgery that if 6 weeks of immobilization was necessary to ensure the long-term integrity of the transected ligament, there would likely be short-term ROM and strength losses in the elbow and shoulder. After 6 weeks of immobilization, it was no surprise that there was significant impairment of ROM in glenohumeral abduction, flexion, and rotation and strength loss (10 weeks) in the muscles of the glenohumeral joint and scapula. We found no studies that specifically reported the ROM and strength deficits that our patient experienced immediately following surgery or in the early stages of physical therapy intervention. However, the decreased ROM and weakness that were found in external rotation, abduction, and flexion have been found in subjects in other studies. (16,21,22,42)

A major emphasis of our intervention addressed the winging, anterior tilt, and lack of scapular control that persisted until week 16. Despite the emphasis on scapular strength and neuromuscular control early in the physical therapy intervention, left scapular winging and anterior tilt were still noted in the 10th postoperative week. Unfortunately, we have found no previous studies that have detailed the strength, motor control, and return to normal biomechanics of the glenohumeral joint and scapula in similar patients. We believe that this case report makes a contribution to the literature by addressing this point in detail.

The physical therapy intervention described in this report lasted 11 weeks (29 sessions), with the discharge examination occurring during week 20. It is important to note that although this postsurgical intervention was extensive, all visits were covered by the patient's insurance, which was a standard point-of-service plan for State of Maryland employees. It is unclear what limitations, if any, that fewer approved patient visits allowed under other insurance plans would have on a patient's functional outcome following similar surgical procedures.

The patient was very active in recreational sports. As such, his expectations for function following conservative rehabilitation may have been higher than those of someone who is more sedentary or participates in fewer activities that require overhead motion or heavy lifting. He participated in noncontact athletic activities, including golf, bicycling, and running, at week 17 and was released for unrestricted activity, including organized recreational softball and football, at week 22. Previous authors (7,10) have documented full return to activity in as little as 4 to 6 weeks. Other authors (18,21,23,37) have reported on active patients who participated in manual labor or contact sports and have advocated a return to full participation in 4 to 6 months. Despite the extensive intervention required to return his full ROM, strength, and scapular control, the intervention used for the patient in the present case was consistent with the 4- to 6-month time frame reported previously.

Comparing the outcomes following the surgical or conservative interventions reported in the literature is challenging. Several studies (7,13,16) used retrospective designs that lacked random assignments of subjects or neglected to account for subject age, occupation, or preinjury activity level. Many of the reported outcomes on strength, pain, ROM, and function were based on interviews and patient-report questionnaires developed exclusively for the study in question (3,7,22,42) instead of instruments validated against established quality-of-life or functional assessment tools. (3,4,10,16,18,22,37) Moreover, much of the focus in the previous investigations was on the technical aspects of the surgical procedure, with less attention given to the details of the conservative or postsurgical rehabilitation protocols. (4,7,12,16,18,20,22) In the present case report, we detailed the presurgical and postsurgical rehabilitation of a patient following a modified Weaver-Dunn reconstruction of the AC joint. We used measures of ROM and strength and believe that this is the first report that utilized serially completed and valid outcome measures of upper-extremity function and disability (eg, DASH questionnaire).

Although we have found no reports of studies that used the DASH questionnaire to assess the outcomes following grade III AC joint separations, some studies have used this instrument to assess function after trauma to the clavicle and scapula. A series of 15 patients who required surgery to repair a malunited clavicle fracture had an average DASH questionnaire score of 32. (48) After a rehabilitation intervention that included PROM and AAROM at 2 weeks after surgery and resisted strength activities at 6 to 8 weeks after surgery, the patients had an average DASH questionnaire score of 12 at 20 months after surgery. Although the pathology and repair of a malunited clavicle fracture are different from those of an AC dislocation, the mechanism of injury and rehabilitation precautions and progression presented were similar and may serve as a reasonable basis for comparison. The patient described in our case report recorded a DASH questionnaire score of 3.33 following surgery and 11 weeks of physical therapy. Twenty-four months after surgery, the patient had a DASH score of 0.83 that was near the average 24-month postsurgery score and within the range of scores reported by McKee et al. (48) These findings suggest that the DASH questionnaire outcome scores reported by the patient in the current case are consistent with those previously reported for people with traumatic disruption of the AC complex.

This article was received September 21, 2005, and was accepted January 22, 2006.

References

(1) Stuart MJ, Smith A. Injuries in junior A ice hockey: a three-year prospective study. Am J Sports Med. 1995;23:458-461.

(2) Kocher MS, Dupre MM, Feagin JA Jr. Shoulder injuries from alpine skiing and snowboarding: aetiology, treatment and prevention. Sports Med. 1998;25:201-211.

(3) Weinstein DM, McCann PD, McIlveen SJ, et al. Surgical treatment of complete acromioclavicular dislocations. Am J Sports Med. 1995;23: 324-331.

(4) Karlsson J, Arnarson H, Sigurjonsson K. Acromioclavicular dislocations treated by coracoacromial ligament transfer. Arch Orthop Trauma Surg. 1986;106:8-11.

(5) Debski RE, Parsons IM III, Fenwick J, Vangura A. Ligament mechanics during three degree-of-freedom motion at the acromioclavicular joint. Ann Biomed Eng. 2000;28:612-618.

(6) Allman FL Jr. Fractures and ligamentous injuries of the clavicle and its articulation. J Bone Joint Surg Am. 1967;49:774-784.

(7) Weaver JK, Dunn HK. Treatment of acromioclavicular injuries, especially complete acromioclavicular separation. J Bone Joint Surg Am. 1972;54:1187-1194.

(8) Rockwood C, Williams G, Yound D. Acromioclavicular injuries. In: Rockwood C, Green D, Bucholz R, Heckman J, eds. Fractures in Adults. Vol 2. 4th ed. Philadelphia, Pa: Lippincott-Raven Press; 1996: 1341-1413.

(9) Nuber G, Bowen M. Arthroscopic treatment of acromioclavicular joint injuries and results. Journal of the American Academy of Orthopedic Surgeons. 2003;5:11-18.

(10) Bjerneld H, Hovelius L, Thorling J. Acromio-clavicular separations treated conservatively; a 5-year follow-up study. Acta Orthop Scand. 1983;54:743-745.

(11) Turnbull JR. Acromioclavicular joint disorders. Med Sci Sports Exerc. 1998;30(4 suppl):S26-S32.

(12) Schlegel TF, Burks RT, Marcus RL, Dunn HK. A prospective evaluation of untreated acute grade III acromioclavicular separations. Am J Sports Med. 2001;29:699-703.

(13) Rawes ML, Dias JJ. Long-term results of conservative treatment for acromioclavicular dislocation. J Bone Joint Surg Br. 1996;78:410-412.

(14) Galpin RD, Hawkins RJ, Grainger RW. A comparative analysis of operative versus nonoperative treatment of grade III acromioclavicular separations. Clin Orthop Relat Res. 1985;193:150-155.

(15) Urist MR. Complete dislocation of the acromioclavicular joint. J Bone Joint Surg Am. 1963;45:1750-1753.

(16) Larsen E, Bjerg-Nielsen A, Christensen P. Conservative or surgical treatment of acromioclavicular dislocation: a prospective, controlled, randomized study. J Bone Joint Surg Am. 1986;68:552-555.

(17) Bradley JP, Elkousy H. Decision making: operative versus nonoperative treatment of acromioclavicular joint injuries. Clin Sports Med. 2003;22:277-290.

(18) Adam FF, Farouk O. Surgical treatment of chronic complete acromioclavicular dislocation. Int Orthop. 2004;28:119-122.

(19) Guy DK, Wirth MA, Griffin JL, Rockwood CA Jr. Reconstruction of chronic and complete dislocations of the acromioclavicular joint. Clin Orthop Relat Res. 1998;347:138-149.

(20) Dumontier C, Sautet A, Man M, Apoil A. Acromioclavicular dislocations: treatment by coracoacromial ligamentoplasty. J Shoulder Elbow Surg. 1995;4:130-134.

(21) Press J, Zuckerman JD, Gallagher M, Cuomo F. Treatment of grade III acromioclavicular separations: operative versus nonoperative management. Bull Hosp Jt Dis. 1997;56:77-83.

(22) Pavlik A, Csepai D, Hidas P. Surgical treatment of chronic acromioclavicular joint dislocation by modified Weaver-Dunn procedure. Knee Surg Sports Traumatol Arthrosc. 2001;9:307-312.

(23) Cardone D, Brown JN, Roberts SN, et al. Grade III acromioclavicular joint injury in Australian rules football. J Sci Med Sport. 2002;5: 143-148.

(24) Norkin C, White D. Measurement of Joint Motion. 2nd ed. Philadelphia, Pa: FA Davis Co; 2003.

(25) Magee D. Orthopedic Physical Assessment. 4th ed. Philadelphia, Pa: WB Saunders Co; 2002.

(26) Kendall F, McCreary E, Provance P, et al. Muscles: Testing and Function, With Posture and Pain. 5th ed. Baltimore, Md: Lippincott Williams & Wilkins; 2005.

(27) Bovens AM, van Baak MA, Vrencken JG, et al. Variability and reliability of joint measurements. Am J Sports Med. 1990;18:58-63.

(28) Sabari JS, Maltzev I, Lubarsky D, et al. Goniometric assessment of shoulder range of motion: comparison of testing in supine and sitting positions. Arch Phys Med Rehabil. 1998;79:647-651.

(29) Riddle DL, Rothstein JM, Lamb RL. Goniometric reliability in a clinical setting, shoulder measurements. Phys Ther. 1987;67:668-673.

(30) Frese E, Brown M, Norton B. Clinical reliability of manual muscle testing: middle trapezius and gluteus medius muscles. Phys Ther. 1987;67:1072-1076.

(31) Hayes K, Walton JR, Szomor ZL, Murrell GA. Reliability of 3 methods for assessing shoulder strength. J Shoulder Elbow Surg. 2002; 11:33-39.

(32) Leggin BG, Neuman RM, Iannotti JP, et al. Intrarater and interrater

reliability of three isometric dynamometers in assessing shoulder strength. J Shoulder Elbow Surg. 1996;5:18-24.

(33) SooHoo NF, McDonald AP, Seiler JG III, McGillivary GR. Evaluation of the construct validity of the DASH questionnaire by correlation to the SF-36. J Hand Surg [Am]. 2002;27:537-541.

(34) Beaton DE, Katz JN, Fossel AH, et al. Measuring the whole or the parts? Validity, reliability, and responsiveness of the Disabilities of the Arm, Shoulder and Hand outcome measure in different regions of the upper extremity. J Hand Ther. 2001;14:128-146.

(35) Redelmeier DA, Lorig K. Assessing the clinical importance of symptomatic improvements: an illustration in rheumatology. Arch Intern Med. 1993;153:1337-1342.

(36) Redelmeier DA, Guyatt GH, Goldstein RS. Assessing the minimal important difference in symptoms: a comparison of two techniques. J Clin Epidemiol. 1996;49:1215-1219.

(37) Kumar S, Sethi A, Jain AK. Surgical treatment of complete acromioclavicular dislocation using the coracoacromial ligament and coracoclavicular fixation: report of a technique in 14 patients. J Orthop Trauma. 1995;9:507-510.

(38) Larsen E, Petersen V. Operative treatment of chronic acromioclavicular dislocation. Injury. 1987;18:55-56.

(39) Terry GC, Hammon D, France P, Norwood LA. The stabilizing function of passive shoulder restraints. Am J Sports Med. 1991;19:26-34.

(40) Wyrwich KW, Nienaber NA, Tierney WM, Wolinsky FD. Linking clinical relevance and statistical significance in evaluating intra-individual changes in health-related quality of life. Med Care. 1999;37: 469-478.

(41) Guide to Physical Therapist Practice. 2nd ed. Phys Ther. 2001;81: 9-746.

(42) MacDonald PB, Alexander MJ, Frejuk J, Johnson GE. Comprehensive functional analysis of shoulders following complete acromioclavicular separation. Am J Sports Med. 1988;16:475-480.

(43) McFarland EG, Hsu CY, Neira C, O'Neil O. Internal impingement of the shoulder: a clinical and arthroscopic analysis. J Shoulder Elbow Surg. 1999;8:458-460.

(44) Walch G, Liotard JP, Boileau P, Noel E. Postero-superior glenoid impingement: another shoulder impingement. Rev Chir Orthop Reparatrice Appar Mot. 1991;77:571-574.

(45) Sahrmann S. Diagnosis and Treatment of Movement Impairment Syndromes. Vol 1. St Louis, Mo: Mosby; 2002.

(46) Uhl TL, Carver TJ, Mattacola CG, et al. Shoulder musculature activation during upper extremity weight-bearing exercise. J Orthop Sports Phys Ther. 2003;33:109-117.

(47) Wise MB, Uhl TL, Mattacola CG, et al. The effect of limb support on muscle activation during shoulder exercises. J Shoulder Elbow Surg. 2004;13:614-620.

(48) McKee MD, Wild LM, Schemitsch EH. Midshaft malunions of the clavicle. J Bone Joint Surg Am. 2003;85:790-797.

* Arthrex Inc, 1370 Creekside Blvd, Naples, FL 34108-1945.

([dagger]) dj Orthopedics Inc, 2985 Scott St, Vista, CA 92081.

([double dagger]) The Hygenic Corp, 1245 Home Ave, Akron, OH 44310-2575.

([section]) Fitter International Inc 3050, 2600 Portland St SE, Calgary, Alberta, Canada T2G 4M6.

LB Culp, PT, MBA, is Manager, Outpatient Rehabilitation Facility, Department of Physical Medicine and Rehabilitation, Johns Hopkins Hospital, Baltimore, Md.

WA Romani, PT, PhD, SCS, is Assistant Professor, Department of Physical Therapy and Rehabilitation Science, Johns Hopkins Hospital, Baltimore, MD 21205 (USA) ([e-mail]). Address all correspondence to Dr Romani.

Both authors provided concept/idea/project design, writing, data analysis, and consultation (including review of manuscript before submission). Ms Culp provided data collection and facilities/equipment. Dr Romani provided project management and institutional liaisons. The authors acknowledge Rebecca Sauder for her help in preparing the manuscript for publication and Dr Tim Uhl and Dr Leigh Ann Curl for their assistance with the management of this case.

Table 1.
Strength and Range of Motion (ROM) Findings for the Left Upper
Extremity Throughout the Course of Treatment (a)

ROM and                       Pre-op           Post-op   Post-op
Strength                      Examination      Week 6    Week 10

Range of motion ([degrees])

  Glenohumeral joint          Active/Passive   Active    Active
    Flexion                   168/170          135       166
    Abduction                 150/155           90       150
    ER (90[degrees] ABD)       95/126           60       90
    ER (0[degrees] ABD)        85/90            45       N/A
    IR (90[degrees] ABD)       40/38            55

  Overhead reach              T2               N/A       T2
  Behind-the-back reach       T8               N/A       T10

  Elbow extension-flexion                      10-140    3-140

Strength
  External rotator muscles    5/5                        4/5
  Latissimus dorsi muscle     4+/5                       4+/5
  Lower trapezius muscle      3+/5                       <3/5 (b)
  Middle trapezius muscle     4/5                        <3/5 (b)
  Rhomboid muscles            4/5                        4/5
  Serratus anterior muscle                               <3/51 (b)

ROM and                       Post-op          Post-op
Strength                      Week 14          Week 20

Range of motion ([degrees])

  Glenohumeral joint          Passive          Active
    Flexion                   165              170
    Abduction                 172              168
    ER (90[degrees] ABD)      100              101
    ER (0[degrees] ABD)        80              N/A
    IR (90[degrees] ABD)       64               61

  Overhead reach              T2               T2
  Behind-the-back reach       T12              T10

  Elbow extension-flexion     0-140            0-140

Strength
  External rotator muscles    4/5              4+/5
  Latissimus dorsi muscle     4+/5             5/5
  Lower trapezius muscle      3/5              4+/5
  Middle trapezius muscle     3/5              4+/5
  Rhomboid muscles            4/5              4+/5
  Serratus anterior muscle                     4+/5

(a) Pre-op = preoperative, post-op = postoperative, ER = external
rotation, IR = internal rotation, ABD = abduction, N/A = not
available.

(b) Scapular winging present with the extremity in the manual muscle
testing position.

Table 2.
Outline of Home Exercise Program Throughout Physical Therapy
Intervention, With Data Compiled From Patient's Daily Exercise
Log (a)

                                  Sets x Repetitions

                                  Post-op           Post-op
                                  Weeks 7-8         Weeks 9-13

AROM
  Scaption-mirror feedback        1 x 20            1 x 20
  Scapular clock (12, 3, 6, 9)    1 x 10 each       1 x 10 each
                                    direction         direction

PROM
  Supine flexion                  1 x 20            1 x 20
  ER (shoulder 0[degrees] ABD)    1 x 20            1 x 20
  ER (Shoulder 30[degrees] ABD)   1 x 20            1 x 20 (60[degrees]
                                                      shoulder ABD)
  Side-lying IR                                     3 x 20 s
  Codmans                         1.4 kg x 2 min
  Prone flexion

Shoulder isometrics
  ER                              2 x 10 x 5 s      2 x 10 x 5 s
  IR                              2 x 10 x 5 s      2 x 10 x 5 s
  Flexion                         2 x 10 x 5 s      2 x 10 x 5 s
  Extension                       2 x 10 x 5 s      2 x 10 x 5 s
  ABD                             2 x 10 x 5 s      2 x 10 x 5 s
  Adduction                       2 x 10 x 5 s      2 x 10 x 5 s
  Scapular depression             2 x 10 x 5 s      2 x 10 x 5 s
  Scapular retraction             2 x 10 x 5 s      2 x 10 x 5 s
AROM, Thera-Band
  Wrist flexion                   Green 2 x 20      Green 2 x 20
  Wrist extension                 Green 2 X 20      Green 2 x 20
  Radial deviation                Green 2 x 20      Green 2 x 20
  Pronation                       Green 2 x 20      Green 2 x 20
  Supination                      Green 2 x 20      Green 2 x 20

Elbow flexion                     3 x 12 x 3.6 kg   3 x 15 x 4.5 kg

Elbow extension                   3 x 12 x 3.6 kg   3 x 15 x 4.5 kg

Cane pronation/supination         20                20

Push-up plus                      2 x 10 (hands     2 x 10 (hands
                                    table height)     to floor)

Swiss ball, UE support
  Bent at waist                   2 x 1 min         2 x 1 min
  Ball at shoulder height

AROM patterns
  Saw                                               1 x 20
  Behind back                                       1 x 20
  Behind head                                       1 x 20
  Across shoulder                                   1 x 20
  Overhead                                          1 x 20

Sport cord decline                                  Black 3 x 12

Shrugs

Cable column
  Elbow flexion
  Elbow extension
  Decline row

Prone shoulder extension/ER
  Horizontal ABD

Ball catch release (90[degrees]
  shoulder flexion)

                                  Sets x Repetitions

                                  Post-op Weeks 14-17

AROM
  Scaption-mirror feedback
  Scapular clock (12, 3, 6, 9)

PROM
  Supine flexion
  ER (shoulder 0[degrees] ABD)
  ER (Shoulder 30[degrees] ABD)   1 x 20 (90[degrees] shoulder ABD)

  Side-lying IR                   3 x 20 s
  Codmans
  Prone flexion                   20 x 3 s

Shoulder isometrics
  ER                              Endrange 2 x 10 x 5 s
  IR
  Flexion
  Extension
  ABD
  Adduction
  Scapular depression
  Scapular retraction
AROM, Thera-Band
  Wrist flexion                   Blue 3 x 15
  Wrist extension                 Blue 3 x 15
  Radial deviation                Blue 3 x 15
  Pronation                       Blue 3 X 15
  Supination                      Blue 3 x 15

Elbow flexion

Elbow extension

Cane pronation/supination

Push-up plus                      2 x 12 (feet elevated 15.2 cm)

Swiss ball, UE support
  Bent at waist                   2 x 1 min
  Ball at shoulder height         2 X 1 min

AROM patterns
  Saw                             1 x 20
  Behind back                     1 x 20
  Behind head                     1 x 20
  Across shoulder                 1 x 20
  Overhead                        1 x 20

Sport cord decline

Shrugs                            3 x 15 x 4.54 kg

Cable column
  Elbow flexion                   3 x 10 x 27.2 kg
  Elbow extension                 3 x 10 x 31.8 kg
  Decline row                     3 X 12 x 27.2 kg

Prone shoulder extension/ER       2 x 10 x 2 s
  Horizontal ABD                  2 x 10 x 2 s

Ball catch release (90[degrees]   2 x 30 s x 0.9 kg
  shoulder flexion)

(a) Post-op = postoperative, AROM = active range of motion,
PROM = passive range of motion, ER = external rotation, IR =
internal rotation, UE = upper extremity, ABD = abduction.

Table 3.
Home Exercise Program for Postoperative Weeks 14-22

Exercises                           Sets x Repetitions

Body blade (palm down)              2 x 30 s each direction
  90[degrees] shoulder flexion
  90[degrees] shoulder abduction
  90[degrees] shoulder scaption

Quadruped horizontal abduction      1 x 10-mirror cues for
                                      scapular position
Weight training program
  Latissimus muscle pull down       2 x 12 x 31.8 kg
  Triceps muscle extension          2 x 12 x 22.7 kg
  Seated row                        2 x 12 x 36.3 kg
  Biceps muscle curl                2 x 12 x 18.1 kg
  Horizontal adduction              2 x 12 x 50.8 kg
  Horizontal abduction              2 x 12 x 39.5 kg
  Seated deltoid muscle flys        2 x 12 x 18.1 kg
  Shrugs                            2 x 12 x 13.6 kg
  Horizontal standing flys          2 x 90 s x 0.23 kg