Case Study: Divorcing Fact from Fiction In A Shoulder Separation Case

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A*, a 27 year old male, walked in the clinic and immediately said he has a shoulder separation.

“Not a shoulder dislocation, because shoulder dislocation pops out of the socket and drops downwards, but the opposite of it. Mine pops up and there’s a bump on my shoulder. I googled; I have a shoulder separation.”

Now, if you had to look up what a shoulder separation is, don’t worry. So did I – and found that a ‘shoulder separation’ is what we in the healthcare field call ‘Acromioclavicular (AC) joint instability’.

A ‘shoulder separation’ is what happens when the ligaments around the shoulder joint are unable to stabilise the joint during movements. This could be due to a fall or a direct injury to the shoulder and the ligaments never got the chance to heal properly, which is what happened with A’s case.

4 years ago he was playing handball, tripped, and landed on his right shoulder. He felt a bump and his shoulder “popped” upwards, and he could not move his arm immediately after. Acupuncture was done for about 2 months, but his shoulder has never felt as stable since. Plus, there have been recurrent episodes of “popping” over the years and many forms of disturbances in his daily life like difficulty reaching out to get his parking ticket, disruption of his boxing classes (shoulder keeps popping out), and stopping pull ups at the gym.

First Visit 

  • The first thing was to rule out any serious injuries or anything else that would necessitate further investigations (ie: X-Ray/MRI/CT Scan) or a referral to an orthopaedic for surgical interventions. 
  • We then assessed the integrity of the shoulder ligaments and tendons, making sure if they’re all still holding the shoulder stable with movements, and doing what they’re supposed to do. We found that he did have instability over his AC joint, with some muscles that needed working on as they were not able to stabilise the shoulder when the movement demands it, hence the “bump” he feels, and the shoulder “popping” upwards and the pain when it happens.
  • Treatment focused a lot on strengthening his rotator cuff muscles with some modifications done towards his usual gym routine. He had no pain or discomfort throughout the entire session. When we checked in with him a few days after the session, he’s been back to the gym, shoulder felt sore, but stable and stronger.

Our First Roadblock

He came back a week later, with a popping episode that occurred the past week at the gym, and this was where things got tricky. 

He was about to do pull ups, jumped upwards to hang onto the pull-up bar, landed awkwardly and put too much pressure on the right arm when he straightened it out, causing instability of the AC joint, and the same “popping” upwards of the shoulder. There was intense pain and he had to “pop” it back down. He has not been to the gym since, and pain has been gradually reducing. This was one of the WORST popping episodes he’s had in a while.

On assessment:

  • Right shoulder was very tender to touch, shoulder range was limited. We were not able to perform a few shoulder movements (especially external rotation) as he was very hesitant and fearful (he jumped up on the bed at one point and gave me the shock of my life), and there was sharp pain with certain movements and shoulder felt VERY unstable. 
  • That day was mainly focused on isometric strengthening (strengthening without changing the length of the muscle) as we very badly needed the right muscles to start working and stabilising the shoulder. He felt slightly unstable during the initial few reps, but pain reduced and strength increased after a few reps. 
  • That day, we sent him off with NO pull ups that week, but still continuing our shoulder exercises, until we reviewed him again in a weeks time.

We had to stay at isometric strengthening in various positions and angles for a while and since then, things started looking better. His shoulder has been gradually feeling stronger and more stable, has not had any “popping” sensation during boxing and workouts and the gym. We started seeing progress again…

Our Second Speedbump

5 weeks later, he came in saying that he was playing futsal a few days ago, when he wanted to score, he kicked and lifted his R arm up.

He felt his shoulder “pop” upwards slightly. Shoulder did not feel loose or unstable but he had to get out of that position.

The biggest difference though with this episode and the previous was that there was no pain during and immediately after. He only felt slightly sore the next morning when he woke up, but other than that shoulder felt stable. Only thing though, was that he did not manage to score that goal! 🙁

From that session, we had to reduce his range with certain exercises, but we did not have to dial the exercises down. We started focusing on boxing specific movements, at a slower speed and getting his body and shoulder used to being in those positions.

Where we are NOW…

It’s now close to 2 months, with him coming in once a week and, currently:

  • He’s able to manage pull ups now with equal force on both arms. He’s also able to fully straighten and hang on the pull-up bar without feeling as though his shoulder might “pop”.
  • He is still currently boxing, able to go above shoulder height now with 80-90% force with no instability or pain or popping during and after, even with consecutive punches.
  • He has also since sparred with someone else for the first time with no limitations coming from his shoulder.
  • He has gone back to futsal without any “popping incidents” when scoring and has managed to score some goals while at it!

The BIGGEST THING he’s shared with me since his shoulder started feeling more stable and stronger, is that he started thinking about chasing his dreams.

“Oh, what’s your dream?”

“I’m thinking of trying out MMA, la.”

It took him awhile to be able to share this, now that he’s seen and felt progress with his shoulder and now that the dream feels achievable. I could only imagine, having a dream that seems unreachable and not wanting to share it with people because it seems so far-fetched. This is huge coming from a guy who when told that I play squash, in turn told me he doesn’t think he’ll be able to do it cause his hand is “cacat” (unable to function normally again). Look at where he is, and where he will be heading to. His road towards MMA has only just barely begun!

At some point during sessions, I felt like we went 2 steps forwards and then one step backwards. Yes, there was obvious progress in terms of how he felt about his shoulder and what he could physically achieve with movement and exercises, but we’ve also had trees falling and blocking the road that we had to find other ways to bypass that tree.

That’s the thing about recovery though, isn’t it? It’s not always fast, it’s not always upwards moving. As much as I wish I have magic hands, oftentimes we can’t make you feel better in just one session. There will be times when we’ll hit a setback, and we’ve gotta sidetrack, tackle that first and then regroup and realign expectations and our goals. What’s most important during rehabilitation is that both practitioner and practice member have to be on the same page and aligned towards achieving the same thing.


*Name & details undisclosed for privacy purposes.  

[This article was written by Daphne, our physiotherapist who specialises in musculoskeletal rehabilitation for those with chronic/recurrent injuries.]