Student Name: Dr Gerhardus CoetzerStudent No: 1999061854

Patient No: 3Date: 10/09/2011

Diagnosis: AC Joint Ligament Strain Gr 1

PATIENT DETAILS

• 27 year old male patient • Professional rugby player

COMPLAINT

• Complaining of pain in right shoulder after tackling another player.

• Painful to lift up shoulder and horizontal flexion.

FURTHER HISTORY

• FAMILY HISTORY– Normal

• MEDICAL HISTORY– Normal

• EXERCISE– Professional rugby player during in season– 2 sets of weight training per week– 5 x functional exercise and contact sessions

CLINICAL EXAMINATION• Observation– Normal

• Passive Movements– Most pain with horizontal flexion– Minimal pain with abduction

• Active – Same as above

• Against Resistance– Same as above– Strength is equal bilateral – More pain experienced with resistance

SPECIAL INVESTIGATIONS

• Paxinos Test – Positive (AC Joint compression)– No Ultra sound done– No MRI scan done

BIOMECHANICAL EXAMINATION

• Biomechanical Examination– Normal

• X-Ray– Normal

SUMMARY

• CLINICAL– Patient has a GR 1 AC joint sprain of the right shoulder

• PERSONAL– Patient is worried about the time that he will not be

able to train.– Worried about loss of match fitness – Worried about loss of match fees

• CONTEXTUAL– Professional rugby player with a GR 1 AC joint sprain

of the right shoulder

PROBLEM LIST

• ACTIVE– Reducing inflammation restoring pain free R.O.M

• PASSIVE– Improving strength and stability in the AC joint

capsule through isometric weight training– Maintain cardio vascular fitness

PLAN• Rested injury for 3 days• Started with daily sessions of physiotherapy U/S

to reduce inflammation and improving R.O.M through stretching.

• Isometric weight training as soon as pain allows. As prescribed by bio kinetics.

• To return to sport as soon as there is pain free R.O.M, isometric weight training and functional exercise.

• Strapping the AC joint when returning to contact.

PROGRESSION

• The patient started weight training after 10 days since original injury.

• Progressed to contact and playing again in 3 weeks.

DISCUSSIONAnatomy of the AC Joint

• BONES– Consists of distal part of clavical and acromion of the

scapula.– The boney part of the clavical has a slightly convexed

facet where as the acromion has a slightly concave facet.

– Both articular surfaces are covered by fibro-cartelidge. The lateral end of the clavical tend to override the cromion, which together with the slope of their articulating surfaces favours displacement of the acromion downwards and under the clavical in dislocations.

• JOINT CAPSULE– The AC joint is covered by the joint capsule which is a

fibrous capsule. – The capsule is thickest and strongest above where it is

reinforced by the fibres of trapezius.

• LIGAMENTS– Apart from the capsular thickening the strength of the

AC joint is provided by an extra capsular accessory ligament, the coracoclavicular ligament.

– The coracoclavicular ligament is made up by 2 different ligaments, named the trapezoid ligament, anterolateral and the conoid ligament posteromedial.

DISCUSSION (cont)AC Joint Injuries

DISCUSSION (cont)Management

• Management is based on the general principles of management of ligamentous injuries.

• Applying ice and wearing a sling for pain relief is usually the first step.

• Isometric strengthening should be commenced once pain permits.

• GR 3 injuries is controversial, most of these injuries have been treated surgically.

• A new study has proven that immobilisation through the use of a K-wire has similar outcomes as to more invasive surgery. (Bernd et al, 2009)

• Return to sport is possible when there is no further localised tenderness and full pain free R.O.M.

LEARNING EXPERIENCE

• Learnt the correct management and classification of AC joint injuries.

REFERENCED TEXT

1. Anatomy and Human Movement – Structure and Function. 5th Edition

– Nigel Palastanga, Derek Field, Roger Soames

2. Clinical Sport Medicine. 3rd Edition– Peter Brukner, Karim Khan

3. Mid-term outcomes comparing temporary K-wire fixation versus PDS augmentation of Rockwood grade III acromioclaciular joint seperations.

– Bernd A Leidel, Volker Braunstein, Susann Pilotto, Wolf Mutschler, Chlodwig Korchoff, 2011.