Q: Our granddaughter separated her shoulder playing volleyball. They put her in a sling and said to rest it. That's it. Seems like that's how this problem was treated 40 years ago in my day. Haven't they come up with anything new or better than that in all this time?

A: The acromioclavicular (AC) joint has come back into sharp focus in recent days. Because of changes in surgical technology, new advances have been made in the surgical treatment of this problem. You mentioned this condition by its more commonly used name: shoulder separation.

A shoulder separation is a fairly common injury, especially in certain sports. Most shoulder separations are actually injuries to the acromioclavicular (AC) joint. The AC joint is the connection between the scapula (shoulder blade) and the clavicle (collarbone). Shoulder dislocations and AC joint separations are often mistaken for each other. But they are very different injuries.

For more complete information on AC joint separation, see A Patient's Guide to Acromioclavicular Joint Separation.

AC joint separations are graded from mild to severe, depending on which ligaments are sprained or torn. The mildest type of injury is a simple sprain of the AC ligaments. Physicians call this a grade one injury. A grade two AC separation involves a tear of the AC ligaments and a sprain of the coracoclavicular ligaments. A complete tear of the AC ligaments and the coracoclavicular ligaments is a grade three AC separation. This injury results in the obvious bump on the shoulder.

Treatment for a grade one or grade two separation usually consists of pain medications and a short period of rest using a shoulder sling. Just as you experienced 40 years ago and just as your granddaughter has been advised today.

Today athletes are more likely to be put in a rehabilitation program directed by a physical or occupational therapist. Restoration of normal alignment, posture, motion, and strength help athletes (and others) regain function needed for daily and sports activities.

The treatment of grade three AC (chronic or unstable) separations is more controversial. There is no "gold standard" or best known approach to the problem of an unstable AC joint. One of the reasons why it is difficult to identify a gold standard in the surgical treatment of grade three AC separations is the wide variation in the pattern of injuries.

The anatomic complexity of the joint is another reason why treatment is not straight forward or cut and dry. For example, with all of the ligaments connecting everything together, injury to even one ligament shifts the load and strain on the joint. In turn, the rest of the soft tissues surrounding the AC joint are adversely affected by these changes.

Surgical management of acromioclavicular joint dislocations (shoulder separation) has been updated in the last few years. New techniques, improved fixation hardware, and the study of the biomechanics behind these injuries has led to better surgical treatment of these complex AC joint injuries.

But before surgery is considered, almost everyone (no matter what grade their separation is) starts out with conservative (nonoperative) care. Only if the joint remains chronically painful or unstable is surgery considered as an option, but it is indeed a viable alternative.

Reference: Cory Edgar, et al. An Update on the Surgical Management of Acromioclavicular Joint Injuries. In Current Orthopaedic Practice. November/December 2011. Vol. 22. No. 6. Pp. 488-493.