AC3 Separated Shoulder

"JPMM" <[email hidden]> wrote in message
"]news:[email hidden]...

Quoted message said:

I'm 43 and have a AC Type 3 Separated Shoulder. My doctor
has prescribed rest for several weeks followed by PT. I
have a considerable hump/bump on my shoulder. Will this go
away w/ time or reduce in size? Do you typically regain
full use of your shoulder? What's the recovery period?

I had a type 1 in on e shoulder and a type 2 in the other.
Both were quite consistently painful for about 2 weeks and
almost overnight the pain disappeared, total recovery after
3 weeks I'd say. I have no permanent lumps or bumps and both
healed completely with no loss of use. Your type 3 is much
more serious becuase the clavicle is completely separated
from the shoulder ligaments. I know several people who have
had this and most of them have permanent bumps. This is the
clavicle sticking up, no longer positioned correctly in the
shoulder joint. You can get surgery to re-position the
clavicle in the correct spot, but I'm not sure it's
necessary. The guys I know with type 3's just left it
(doctor's decision) and they don't complain about long-term
usage problems. Some complain of an aching pain from time to
time, but nothing acute.

Cheers,

Scott..

"JPMM" <[email hidden]> wrote in message
"]news:[email hidden]...

Quoted message said:

I'm 43 and have a AC Type 3 Separated Shoulder. My doctor
has prescribed rest for several weeks followed by PT. I
have a considerable hump/bump on my shoulder. Will this go
away w/ time or reduce in size? Do you typically regain
full use of your shoulder? What's the recovery period?

I had a severe AC2 on my left and an AC2 on my right on two
seperate (pun) occasions. If I recall correctly I was road
riding in about 3-4 weeks but took almost 2 months before I
felt fully recovered on the Mt. Bike. Before the seperations
I used to do heavy bench pressing in the gym. Those days are
over... I can still bench do fly's ect but I have to use
lighter weights and more reps (what I should be doing for
cycling). This may or may not be associated to the AC
seperations but since I had the shoulder seperations it
seems that my Rotator Cuff (sp?) on both sides sometimes
give me problems.

I can still feel the bump on the left side. That seperation
occurred in 1995 so I doubt it will be going away. The right
feels normal. Other than the benching and occasional RC
problems I have fully recovered. Still spend many hours on
the road bike and still ride my MTB hard as ever...

Be sure to give it time to recover. It is so hard to not get
on the bike too soon! If you do you will only set yourself
back. Be patient, riding a trainer sitting up with the arm
in a sling can be helpful...

Cheers,

-p

At age 48, I managed to separate both - 1 completely (3),
and 1severely (2). Surgery was the only option with the
first. After that, no bump, but you can't use me as an
example of bilateral symmetry any longer. However, with the
intricate rewiring and bone grafting by my surgeon, I have
greater mobility in that one than the other.

The real value to surgery is being able to buy shirts with
sleeves the same length. ;-)
--
Bonne route,

Sandy Paris FR

"JPMM" <[email hidden]> a écrit dans le message de :
"]news:[email hidden]...

Quoted message said:

I'm 43 and have a AC Type 3 Separated Shoulder. My doctor
has prescribed rest for several weeks followed by PT. I
have a considerable hump/bump on my shoulder. Will this go
away w/ time or reduce in size? Do you typically regain
full use of your shoulder? What's the recovery period?

when hit by car while training I ended up with a seriously
damaged shoulder resulting in trigeminal neuralgia. no known
cure and believe me. it sucks. didn't even know I had it for
4 years. all because the muscles over compensated for the
torn ones and ligaments. then the neck starts to tighten and
impact the nerve bundles going to that side of the head. you
don't want this in your lifetime.

don't let them act like its no big deal see all the
specialists you can before you are told to do nothing.
especially a good orthopedic that specializes in shoulders
and necks. I was told to do nothing for 4 years before I
found the experienced orthopedic who diagnosed me correctly.

"JPMM" <[email hidden]> wrote in message
"]news:[email hidden]...

Quoted message said:

I'm 43 and have a AC Type 3 Separated Shoulder. My doctor
has prescribed rest for several weeks followed by PT. I
have a considerable hump/bump on my shoulder. Will this go
away w/ time or reduce in size? Do you typically regain
full use of your shoulder? What's the recovery period?

Quoted message said:

"JPMM" <[email hidden]> wrote in message
"]news:[email hidden]...

Quoted message said:

I'm 43 and have a AC Type 3 Separated Shoulder. My doctor
has prescribed rest for several weeks followed by PT. I
have a considerable hump/bump on my shoulder. Will this
go away w/ time or reduce in size? Do you typically
regain full use of your shoulder? What's the recovery
period?

I had a similar incident a few years ago. No, the bump will
not go away unless you have surgery. My doctor offered me
the option of surgery, and I turned it down. He said the
surgery would let me heal faster and there would be no bump.
I took the rest and PT option and I am happy with the
results. I shoot a bow fairly regularly and after the
accident it took me about 2 months before I could start
shooting, a much lighter draw weight bow, and about 6 months
until I was back to my usual draw weight. I also played
quite a bit of racketball and the injury did not affect my
play at all. The PT is really important and will make a big
difference.
-------------
Alex

"JPMM" <[email hidden]> wrote in message
"]news:[email hidden]...

Quoted message said:

I'm 43 and have a AC Type 3 Separated Shoulder. My doctor
has prescribed rest for several weeks followed by PT. I
have a considerable hump/bump on my shoulder. Will this go
away w/ time or reduce in size? Do you typically regain
full use of your shoulder? What's the recovery period?

I went through this 9 years ago. I was advised that if I
wanted surgery, it should be done within a couple of weeks
of the accident. I was also advised that surgery might limit
my range of motion. I opted to pass on that, and I'm living
with "the bump". No particular issues with it. I do shoulder
shrugs with heavy weights regularly to build up muscle in
the area so the knob won't look quite so prominent. You can
always tell the ladies that you had it done to give them
something to hang on to.

Good luck.

Chuck Davis

Quoted post said:

Originally posted by Jpmm
I'm 43 and have a AC Type 3 Separated Shoulder. My doctor
has prescribed rest for several weeks followed by PT. I have
a considerable hump/bump on my shoulder. Will this go away
w/ time or reduce in size? Do you typically regain full use
of your shoulder? What's the recovery period?

I crashed very badly on April 1 2002 and suffered a 3rd category AC separation in addition to a broken wrist. When consuting with a couple doctors, one advised me that the surgery would just reduce the bump without helping with mobility. He was really trying sell me on the idea of the surgery. He said my shoulder "step" was the worst he'd ever seen. The other said the surgery wasn't necessary at all. My shoulder seems to be sinking down over the last two years. The shoulder shrugs with weight posted earlier seem to be very helpful though. I've regained full use of my shoulder except for heavy benching and dips. Both of these exercises isolate the shoulder in a very compromising way. The biggest bummer is that my bib shorts fall down on my left side. Good luck with recovery. It's really not that bad. 4 weeks tops.

[email hidden] (JPMM) wrote in message news:<[email hidden]>...

Quoted message said:

I'm 43 and have a AC Type 3 Separated Shoulder. My doctor
has prescribed rest for several weeks followed by PT. I
have a considerable hump/bump on my shoulder. Will this go
away w/ time or reduce in size? Do you typically regain
full use of your shoulder? What's the recovery period?

I had a crash in 1987 and had a grade 3++ AC separation
which means that all the ligaments are torn and the clavical
just sticks up as a big bump on the shoulder, the arm also
hangs lower. Once you sever the connection between the
clavical and the acromium the integrity of the shoulder
girdle is destroyed. After time the pain will go away but
you will have a permanant deformation and you will
definately lose anywhere from 15 to 25 percent of the
strength of the shoulder. You will feel the bones move apart
everytime you pull or push with the affected arm. I had a
bad doctor who advised me not to have an operation and after
six months I was miserable and unhappy so I went to an
orthopod at Columbia Prespyterian Hospital in New York who
operated on me and except for several months of rehab and a
thin cosmetic scar I am fine. I advise you to have the
problem corrected as you don't want to spend the rest of
your life impaired that way. If you were an athlete you
would be surgically treated immediately and cured, aren't
you entitled to the same good medical care as an athlete.
Believe me, in the long run you will be happy you had the
problem corrected.

Al

"Alan Lowich" <[email hidden]> wrote in message
"]news:[email hidden]...

Quoted message said:

[email hidden] (JPMM) wrote in message

news:<[email hidden]>...

Quoted message said:

Quoted message said:

I'm 43 and have a AC Type 3 Separated Shoulder. My
doctor has prescribed rest for several weeks followed by
PT. I have a considerable hump/bump on my shoulder. Will
this go away w/ time or reduce in size? Do you typically
regain full use of your shoulder? What's the recovery
period?

I had a crash in 1987 and had a grade 3++ AC separation
which means that all the ligaments are torn and the
clavical just sticks up as a big bump on the shoulder, the
arm also hangs lower. Once you sever the connection
between the clavical and the acromium the integrity of the
shoulder girdle is destroyed. After time the pain will go
away but you will have a permanant deformation and you
will definately lose anywhere from 15 to 25 percent of the
strength of the shoulder. You will feel the bones move
apart everytime you pull or push with the affected arm. I
had a bad doctor who advised me not to have an operation
and after six months I was miserable and unhappy so I went
to an orthopod at Columbia Prespyterian Hospital in New
York who operated on me and except for several months of
rehab and a thin cosmetic scar I am fine. I advise you to
have the problem corrected as you don't want to spend the
rest of your life impaired that way. If you were an
athlete you would be surgically treated immediately and
cured, aren't you entitled to the same good medical care
as an athlete. Believe me, in the long run you will be
happy you had the problem corrected.

I had the same thing and left it go. There's a lump and the
arm hangs ever so slightly lower. No descernable loss of
strength. I didn't bother both PT because I know that most
people heal normally without it. PT just speeds recovery to
full motion.

[email hidden] (JPMM) wrote in message news:<[email hidden]>...

Quoted message said:

I'm 43 and have a AC Type 3 Separated Shoulder. My doctor
has prescribed rest for several weeks followed by PT. I
have a considerable hump/bump on my shoulder. Will this go
away w/ time or reduce in size? Do you typically regain
full use of your shoulder? What's the recovery period?

There is something I forgot to tell you and it is perhaps
the most important reason that you should get your shoulder
repaired. Since in your present condition your clavical is
no longer connected to your acromium and it is out of
alignment, if you crash again on that shoulder (which you
surely will if you keep riding) your shoulder may be torn in
the downward position not compressing and breaking the
clavical as normally happens. The total force of impact will
be redirected to tearing your shoulder from your body since
the clavical will not be in position to absorb the energy.
In this situation you run the very real risk of tearing the
main artery and or the nerve to your shoulder and arm, this
would be a terrible result. Three years after my shoulder
repair I crashed on the same shoulder and broke my clavical
which I am grateful for, I don't know what would have
happened had I not had the repair done. I am not trying to
frighten you but you need to be aware of this.

Al

[QUOTE]Originally posted by Alan Lowich
[B][email hidden] (JPMM) wrote in message news:<[email hidden]>...

Quoted message said:

I'm 43 and have a AC Type 3 Separated Shoulder. My doctor
has prescribed rest for several weeks followed by PT. I
have a considerable hump/bump on my shoulder. Will this go
away w/ time or reduce in size? Do you typically regain
full use of your shoulder? What's the recovery period?

BJC <[email hidden]> wrote in message news:<[email hidden]>...

Quoted message said:

Originally posted by Alan Lowich [email hidden] (JPMM)
wrote in message
news:<[email hidden]>...

Quoted message said:

I'm 43 and have a AC Type 3 Separated Shoulder. My
doctor has prescribed rest for several weeks followed by
PT. I have a considerable hump/bump on my shoulder. Will
this go away w/ time or reduce in size? Do you typically
regain full use of your shoulder? What's the recovery
period?

Another point, my doctor explained there was a real chance
of developing arthritis in the affected shoulder as a
result of going under the knife.

--My surgeon and other sports orthopods have advised me
different.

In the older versions of the AC repair where they used a pin
to attach the clavical to the acromium it was possible for
calcium callus to fill in the area across the joint but that
technique is no longer used and the clavical is attached in
a different manner by transferring the corocoid acromial
ligament to the clavical and slightly shortening the end of
the clavical making it impossible for any calcium to impair
the repair. The latest methods of making this repair are
very good and the other older 400 methods are no longer used
by up to date surgeons. I had mine done 18 years ago and I
have full motion and strength and absolutely no pain. Talk
to a couple of competent up to date orthopods and decide for
yourself. Good Luck.

Al

There are several different surgical procedures described
for this injury. It is also appropriate to not treat this
injury surgically. Each option has benefits and risks
associated with it. These vary from individual to
individual. In part this is because the amount of deformity
produced by a complete AC separation varies depending on the
individual's anatomy and their tolerance of the problems
varies with the demands they make on their shoulder.. Most
orthopedists currently avoid repairing most of these as it
is difficult to show that surgery leads to an improved
result compared to those treated non-surgically. As time
goes by, in most people, the size of the "bump" gets
smaller.. Clearly the decision to repair or not is something
that you need to discuss with doctors individually. I would
actually suggest considering getting several opinions before
opting for surgery.

Grade 2 AC separations are not treated surgically. Grade 1
separations are not treated surgically acutely. Rarely
people will have persistent pain at the AC joint after
having a Grade 1 injury. These can be treated by excising
the distal clavicle to obliterate the joint. Personally I
would wait a LONG time before considering this. Maybe a
year or so.

Generally all these injuries do well regardless of method of
treatment. There are 2 major concerns. One is development of
adhesive capsulitis or frozen shoulder syndrome. This is a
risk after any shoulder injury and the risk increases with
age. This is the primary reason to suggest PT although to
avoid this problem all that needs to be done is range of
motion exercises which can be taught to patients pretty
quickly so extended PT is not usually needed except perhaps
in the elderly sedentary patient. This can start very soon
after the injury. There is no reason to wait several weeks.
The second concern is development of impingement syndromes.
This actually probably goes up with surgical treatment. This
is a late complication.

--
Mike Murray MD "JPMM" <[email hidden]> wrote in message
"]news:[email hidden]...

Quoted message said:

I'm 43 and have a AC Type 3 Separated Shoulder. My doctor
has prescribed rest for several weeks followed by PT. I
have a considerable hump/bump on my shoulder. Will this go
away w/ time or reduce in size? Do you typically regain
full use of your shoulder? What's the recovery period?

Although I can't say that this has never happened, it is
certainly not a complication of unrepaired AC separation
that has been noted in medical teaching. I would not
consider it a "real" risk.

--
Mike Murray MD

Alan Lowich said:

There is something I forgot to tell you and it is perhaps
the most important reason that you should get your
shoulder repaired. Since in your present condition your
clavical is no longer connected to your acromium and it is
out of alignment, if you crash again on that shoulder
(which you surely will if you keep riding) your shoulder
may be torn in the downward position not compressing and
breaking the clavical as normally happens. The total force
of impact will be redirected to tearing your shoulder from
your body since the clavical will not be in position to
absorb the energy. In this situation you run the very real
risk of tearing the main artery and or the nerve to your
shoulder and arm, this would be a terrible result.

I agree with most of what you say Doctor but I had a really
severe separation which would not reduce no matter how long
I waited. Although the pain subsided I knew that I needed
surgery after reading Sports surgeon Dr. William Southmayd's
book on sports injuries and writing to him about it. I also
consulted Dr. Neer and Dr. Louis Bigliani both of Columbia
Presbyterian Hospital and both agreed that surgery was in
order to return me to my full potential. As Dr. Southmayd
and Dr. Neer agree, a severe AC separation where all the
ligaments are severed and the arm hangs low and the clavical
sticks up like a flagpole surgery is required in their
opinion, this is not a broken collarbone that can be ignored
but an injury that cries out for repair. Fortunately there
are more capable sports minded physicians who can and do
return these patients to near full capability today. Dr
Bigliani made the repair in 1986 and thankfully I am still
feeling great with full range of motion and almost full
strength. I am disatisfied and angry with the first
orthopedist who did nothing to heal me and simply told me to
live with it and not scar my body. As you say doctor it pays
to listen to your own body and seek several opinions.

Al

"Mike Murray" <[email hidden]>
wrote in message news:<sNBbc.65046$w54.397507@attbi_s01>...

Quoted message said:

There are several different surgical procedures described
for this injury. It is also appropriate to not treat this
injury surgically. Each option has benefits and risks
associated with it. These vary from individual to
individual. In part this is because the amount of
deformity produced by a complete AC separation varies
depending on the individual's anatomy and their tolerance
of the problems varies with the demands they make on their
shoulder.. Most orthopedists currently avoid repairing
most of these as it is difficult to show that surgery
leads to an improved result compared to those treated non-
surgically. As time goes by, in most people, the size of
the "bump" gets smaller.. Clearly the decision to repair
or not is something that you need to discuss with doctors
individually. I would actually suggest considering getting
several opinions before opting for surgery.

Grade 2 AC separations are not treated surgically. Grade 1
separations are not treated surgically acutely. Rarely
people will have persistent pain at the AC joint after
having a Grade 1 injury. These can be treated by excising
the distal clavicle to obliterate the joint. Personally I
would wait a LONG time before considering this. Maybe a
year or so.

Generally all these injuries do well regardless of method
of treatment. There are 2 major concerns. One is
development of adhesive capsulitis or frozen shoulder
syndrome. This is a risk after any shoulder injury and the
risk increases with age. This is the primary reason to
suggest PT although to avoid this problem all that needs
to be done is range of motion exercises which can be
taught to patients pretty quickly so extended PT is not
usually needed except perhaps in the elderly sedentary
patient. This can start very soon after the injury. There
is no reason to wait several weeks. The second concern is
development of impingement syndromes. This actually
probably goes up with surgical treatment. This is a late
complication.

--
Mike Murray MD "JPMM" <[email hidden]> wrote in message
"]news:[email hidden]...

Quoted message said:

I'm 43 and have a AC Type 3 Separated Shoulder. My
doctor has prescribed rest for several weeks followed by
PT. I have a considerable hump/bump on my shoulder. Will
this go away w/ time or reduce in size? Do you typically
regain full use of your shoulder? What's the recovery
period?

Just as I said in my note, the consideration to treat this
surgically needs to be individualized. It is not so much a
matter of the "severity" of the injury as we are talking
about Grade 3 injuries, i.e. all of the same severity. It is
really more of an issue of the individual's anatomy, the
demands they will make on the shoulder, their individual
surgical risks and cost to the patient. In some individuals
a complete AC separation will leave the end of the clavicle
resting several inches above the acromion. Even these
patient may do well from a functional point of view, i.e.
they will be able to move the shoulder normally and have
little pain, but the size of the deformity will lean you
towards treating it surgically if only for cosmetic reasons.
In general though most patients will have a resting position
for the clavicle that is only elevated above the acromion a
small amount. In this case non-surgical management makes
more sense. Interestingly, in contrast to the implication of
the note below, "capable sports minded physicians" are
probably less likely to treat these surgically for several
reasons; longer healing time, increase risk for subsequent
impingement syndrome, risks of surgery, etc. It has been my
experience that far more of these are treated surgically
unnecessarily then are treated inappropriately non-
surgically. Perhaps this has much to do with the fact that
doctors are paid more to do surgery or just the fact that
they do surgery because they like to. I would be wary of any
suggestion that surgery should be considered that was given
too rapidly and didn't take into consideration all the
things I have listed in my notes. The surgery does not need
to be done urgently and can be done delayed with no loss.

The bottom line is most can be treated without surgery
although some may do better with surgery. Most will have
good results treated either way. A few will have bad results
treated either way. Predicting which method will produce the
best result is difficult and needs to be individualized.
--
Mike Murray MD

"Alan Lowich" <[email hidden]> wrote in message
"]news:[email hidden]...

Quoted message said:

I agree with most of what you say Doctor but I had a
really severe separation which would not reduce no matter
how long I waited. Although the pain subsided I knew that
I needed surgery after reading Sports surgeon Dr. William
Southmayd's book on sports injuries and writing to him
about it. I also consulted Dr. Neer and Dr. Louis Bigliani
both of Columbia Presbyterian Hospital and both agreed
that surgery was in order to return me to my full
potential. As Dr. Southmayd and Dr. Neer agree, a severe
AC separation where all the ligaments are severed and the
arm hangs low and the clavical sticks up like a flagpole
surgery is required in their opinion, this is not a broken
collarbone that can be ignored but an injury that cries
out for repair. Fortunately there are more capable sports
minded physicians who can and do return these patients to
near full capability today. Dr Bigliani made the repair in
1986 and thankfully I am still feeling great with full
range of motion and almost full strength. I am disatisfied
and angry with the first orthopedist who did nothing to
heal me and simply told me to live with it and not scar my
body. As you say doctor it pays to listen to your own body
and seek several opinions.

Al

"Mike Murray" <[email hidden]>
wrote in message

news:<sNBbc.65046$w54.397507@attbi_s01>...

Quoted message said:

Quoted message said:

There are several different surgical procedures
described for this

injury.

Quoted message said:

Quoted message said:

It is also appropriate to not treat this injury
surgically. Each option

has

Quoted message said:

Quoted message said:

benefits and risks associated with it. These vary from
individual to individual. In part this is because the
amount of deformity produced by

a

Quoted message said:

Quoted message said:

complete AC separation varies depending on the
individual's anatomy and their tolerance of the problems
varies with the demands they make on

their

Quoted message said:

Quoted message said:

shoulder.. Most orthopedists currently avoid repairing
most of these as

it

Quoted message said:

Quoted message said:

is difficult to show that surgery leads to an improved
result compared

to

Quoted message said:

Quoted message said:

those treated non-surgically. As time goes by, in most
people, the size

of

Quoted message said:

Quoted message said:

the "bump" gets smaller.. Clearly the decision to repair
or not is something that you need to discuss with
doctors individually. I would actually suggest
considering getting several opinions before opting for
surgery.

Grade 2 AC separations are not treated surgically. Grade
1 separations

are

Quoted message said:

Quoted message said:

not treated surgically acutely. Rarely people will have
persistent pain

at

Quoted message said:

Quoted message said:

the AC joint after having a Grade 1 injury. These can be
treated by excising the distal clavicle to obliterate
the joint. Personally I

would

Quoted message said:

Quoted message said:

wait a LONG time before considering this. Maybe a year
or so.

Generally all these injuries do well regardless of
method of treatment. There are 2 major concerns. One is
development of adhesive capsulitis

or

Quoted message said:

Quoted message said:

frozen shoulder syndrome. This is a risk after any
shoulder injury and

the

Quoted message said:

Quoted message said:

risk increases with age. This is the primary reason to
suggest PT

although

Quoted message said:

Quoted message said:

to avoid this problem all that needs to be done is range
of motion

exercises

Quoted message said:

Quoted message said:

which can be taught to patients pretty quickly so
extended PT is not

usually

Quoted message said:

Quoted message said:

needed except perhaps in the elderly sedentary patient.
This can start very soon after the injury. There is no
reason to wait several weeks.

The

Quoted message said:

Quoted message said:

second concern is development of impingement syndromes.
This actually probably goes up with surgical treatment.
This is a late complication.

--
Mike Murray MD "JPMM" <[email hidden]> wrote in
message
"]news:[email hidden]...

Quoted message said:

I'm 43 and have a AC Type 3 Separated Shoulder. My
doctor has prescribed rest for several weeks followed
by PT. I have a considerable hump/bump on my shoulder.
Will this go away w/ time or reduce in size? Do you
typically regain full use of your shoulder? What's the
recovery period?

Count me in the camp of Dr William Southmayd who says that in his
opinion all grade 3 separations should be surgically repaired for the
following two reasons:
1) " The shoulder joint is so damaged that it can't repair
itself. Specifically, there is no way for the bones to
realign themselves. The gap is too large"
2) "If you don't have surgery, there is almost 100 percent
chance that your shoulder will lose some mobility. Also
the shoulder structure will be permanently weakened."

Also Dr. Charles Neer and Dr. Louis Bigliani agreed with
this opinion. I realize that there are physicians like
yourself who disagree with this view and I certainly
respect that.

Mike Murray" <[email hidden]>
wrote in message news:<Yphcc.195141$po.1012951@attbi_s52>...

Quoted message said:

Just as I said in my note, the consideration to treat this
surgically needs to be individualized. It is not so much a
matter of the "severity" of the injury as we are talking
about Grade 3 injuries, i.e. all of the same severity. It
is really more of an issue of the individual's anatomy,
the demands they will make on the shoulder, their
individual surgical risks and cost to the patient. In some
individuals a complete AC separation will leave the end of
the clavicle resting several inches above the acromion.
Even these patient may do well from a functional point of
view, i.e. they will be able to move the shoulder normally
and have little pain, but the size of the deformity will
lean you towards treating it surgically if only for
cosmetic reasons. In general though most patients will
have a resting position for the clavicle that is only
elevated above the acromion a small amount. In this case
non-surgical management makes more sense. Interestingly,
in contrast to the implication of the note below, "capable
sports minded physicians" are probably less likely to
treat these surgically for several reasons; longer healing
time, increase risk for subsequent impingement syndrome,
risks of surgery, etc. It has been my experience that far
more of these are treated surgically unnecessarily then
are treated inappropriately non-surgically. Perhaps this
has much to do with the fact that doctors are paid more to
do surgery or just the fact that they do surgery because
they like to. I would be wary of any suggestion that
surgery should be considered that was given too rapidly
and didn't take into consideration all the things I have
listed in my notes. The surgery does not need to be done
urgently and can be done delayed with no loss.

The bottom line is most can be treated without surgery
although some may do better with surgery. Most will have
good results treated either way. A few will have bad
results treated either way. Predicting which method will
produce the best result is difficult and needs to be
individualized.
--
Mike Murray MD

"Alan Lowich" <[email hidden]> wrote in message
"]news:[email hidden]...

Quoted message said:

I agree with most of what you say Doctor but I had a
really severe separation which would not reduce no
matter how long I waited. Although the pain subsided I
knew that I needed surgery after reading Sports surgeon
Dr. William Southmayd's book on sports injuries and
writing to him about it. I also consulted Dr. Neer and
Dr. Louis Bigliani both of Columbia Presbyterian
Hospital and both agreed that surgery was in order to
return me to my full potential. As Dr. Southmayd and Dr.
Neer agree, a severe AC separation where all the
ligaments are severed and the arm hangs low and the
clavical sticks up like a flagpole surgery is required
in their opinion, this is not a broken collarbone that
can be ignored but an injury that cries out for repair.
Fortunately there are more capable sports minded
physicians who can and do return these patients to near
full capability today. Dr Bigliani made the repair in
1986 and thankfully I am still feeling great with full
range of motion and almost full strength. I am
disatisfied and angry with the first orthopedist who did
nothing to heal me and simply told me to live with it
and not scar my body. As you say doctor it pays to
listen to your own body and seek several opinions.

Al

"Mike Murray" <[email hidden]>
wrote in message

news:<sNBbc.65046$w54.397507@attbi_s01>...

Quoted message said:

Quoted message said:

There are several different surgical procedures
described for this

injury.

Quoted message said:

Quoted message said:

It is also appropriate to not treat this injury
surgically. Each option

has

Quoted message said:

Quoted message said:

benefits and risks associated with it. These vary from
individual to individual. In part this is because the
amount of deformity produced by

a

Quoted message said:

Quoted message said:

complete AC separation varies depending on the
individual's anatomy and their tolerance of the
problems varies with the demands they make on

their

Quoted message said:

Quoted message said:

shoulder.. Most orthopedists currently avoid repairing
most of these as

it

Quoted message said:

Quoted message said:

is difficult to show that surgery leads to an improved
result compared

to

Quoted message said:

Quoted message said:

those treated non-surgically. As time goes by, in most
people, the size

of

Quoted message said:

Quoted message said:

the "bump" gets smaller.. Clearly the decision to
repair or not is something that you need to discuss
with doctors individually. I would actually suggest
considering getting several opinions before opting for
surgery.

Grade 2 AC separations are not treated surgically.
Grade 1 separations

are

Quoted message said:

Quoted message said:

not treated surgically acutely. Rarely people will
have persistent pain

at

Quoted message said:

Quoted message said:

the AC joint after having a Grade 1 injury. These can
be treated by excising the distal clavicle to
obliterate the joint. Personally I

would

Quoted message said:

Quoted message said:

wait a LONG time before considering this. Maybe a year
or so.

Generally all these injuries do well regardless of
method of treatment. There are 2 major concerns. One
is development of adhesive capsulitis

or

Quoted message said:

Quoted message said:

frozen shoulder syndrome. This is a risk after any
shoulder injury and

the

Quoted message said:

Quoted message said:

risk increases with age. This is the primary reason to
suggest PT

although

Quoted message said:

Quoted message said:

to avoid this problem all that needs to be done is
range of motion

exercises

Quoted message said:

Quoted message said:

which can be taught to patients pretty quickly so
extended PT is not

usually

Quoted message said:

Quoted message said:

needed except perhaps in the elderly sedentary
patient. This can start very soon after the injury.
There is no reason to wait several weeks.

The

Quoted message said:

Quoted message said:

second concern is development of impingement
syndromes. This actually probably goes up with
surgical treatment. This is a late complication.

--
Mike Murray MD "JPMM" <[email hidden]> wrote in
message -"]news:[email hidden]-
gle.com...
> I'm 43 and have a AC Type 3 Separated Shoulder. My
> doctor has prescribed rest for several weeks
> followed by PT. I have a considerable hump/bump on
> my shoulder. Will this go away w/ time or reduce in
> size? Do you typically regain full use of your
> shoulder? What's the recovery period?

"If you don't have surgery, there is almost 100 percent
chance that your shoulder will lose some mobility. Also the
shoulder structure will be permanently weakened."

The above statement is clearly not true. I have seen several
patients and have many bike racing friends who have had
Grade 3 AC separations that were treated non-surgically that
have full range of motion and no loss of strength compared
to the contralateral side. The statement does not match my
personal experience. In fact, it also appears to be in
contrast to the group experience as there is literature that
has evaluated this question. The majority of articles
indicate that end strength and range of motion does not vary
between the operative and non-operative groups.

A blanket recommendation for surgery also ignores the fact
that many patients treated surgically develop problems
secondary to the surgery; rupture of the repair, painful
syndromes related to the implanted materials, need for
subsequent surgery to remove metal, need for subsequent
surgery to resect the distal clavicle due to persistent
pain, restricted range of motion, impingement syndromes,
infections, etc.

There have been 2 consensus opinion surveys, for what they
are worth. In 1974, Powers and Bach found that most
advocated surgical repair. In 1992, Cox reported that 72.2%
favored non-operative, symptomatic management. This change
was prompted by a series of retrospective studies that
showed no outcome differences between operative and non-
operative groups. In addition, the patients treated non-
surgically returned to full activity (work or athletics)
sooner than the surgically treated groups. It would appear
that the doctors Mr. Lowich is quoting are hanging on to an
idea that many feel is outdated.

Clearly you can find people on both sides of this issue but
the weight of current opinion falls on the non-operative
side for most patients.

Below are some links from a quick internet search on
the subject.

ncbi.nlm.nih.govquery.fcgiOpen ↗
db=PubMed&dopt=Abstract&list_uids=97363803 ortho-ortho-Open ↗
u.net/l9/61.htm worldortho.comabstractOpen ↗
s/u_limb/larsen.html
ajsm.highwire.org699Open ↗ http-
://www.worldortho.com/database/abstracts/u_limb/taft.html
worldortho.comdias.htOpen ↗
ml worldortho.combjerOpen ↗
neld.html stoneclinic.comacjoint2.htmOpen ↗

"Alan Lowich" <[email hidden]> wrote in message
"]news:[email hidden]...

Quoted message said:

Count me in the camp of Dr William Southmayd who says that
in his opinion all grade 3 separations should be
surgically repaired for the following two reasons:
1) " The shoulder joint is so damaged that it can't repair
itself. Specifically, there is no way for the bones to
realign themselves. The gap is too large"
2) "If you don't have surgery, there is almost 100 percent
chance that your shoulder will lose some mobility. Also
the shoulder structure will be permanently weakened."

Also Dr. Charles Neer and Dr. Louis Bigliani agreed with
this opinion. I realize that there are physicians like
yourself who disagree with this view and I certainly
respect that.

Mike Murray" <[email hidden]>
wrote in message

news:<Yphcc.195141$po.1012951@attbi_s52>...

Quoted message said:

Quoted message said:

Just as I said in my note, the consideration to treat
this surgically

needs

Quoted message said:

Quoted message said:

to be individualized. It is not so much a matter of the
"severity" of

the

Quoted message said:

Quoted message said:

injury as we are talking about Grade 3 injuries, i.e.
all of the same severity. It is really more of an issue
of the individual's anatomy,

the

Quoted message said:

Quoted message said:

demands they will make on the shoulder, their individual
surgical risks

and

Quoted message said:

Quoted message said:

cost to the patient. In some individuals a complete AC
separation will leave the end of the clavicle resting
several inches above the acromion. Even these patient
may do well from a functional point of view, i.e.

they

Quoted message said:

Quoted message said:

will be able to move the shoulder normally and have
little pain, but the size of the deformity will lean you
towards treating it surgically if

only

Quoted message said:

Quoted message said:

for cosmetic reasons. In general though most patients
will have a

resting

Quoted message said:

Quoted message said:

position for the clavicle that is only elevated above
the acromion a

small

Quoted message said:

Quoted message said:

amount. In this case non-surgical management makes more
sense. Interestingly, in contrast to the implication of
the note below,

"capable

Quoted message said:

Quoted message said:

sports minded physicians" are probably less likely to
treat these

surgically

Quoted message said:

Quoted message said:

for several reasons; longer healing time, increase risk
for subsequent impingement syndrome, risks of surgery,
etc. It has been my experience

that

Quoted message said:

Quoted message said:

far more of these are treated surgically unnecessarily
then are treated inappropriately non-surgically. Perhaps
this has much to do with the

fact

Quoted message said:

Quoted message said:

that doctors are paid more to do surgery or just the
fact that they do surgery because they like to. I would
be wary of any suggestion that

surgery

Quoted message said:

Quoted message said:

should be considered that was given too rapidly and
didn't take into consideration all the things I have
listed in my notes. The surgery does

not

Quoted message said:

Quoted message said:

need to be done urgently and can be done delayed with
no loss.

The bottom line is most can be treated without surgery
although some may

do

Quoted message said:

Quoted message said:

better with surgery. Most will have good results treated
either way. A

few

Quoted message said:

Quoted message said:

will have bad results treated either way. Predicting
which method will produce the best result is difficult
and needs to be individualized.
--
Mike Murray MD

"Alan Lowich" <[email hidden]> wrote in message
"]news:[email hidden]...

Quoted message said:

I agree with most of what you say Doctor but I had a
really severe separation which would not reduce no
matter how long I waited. Although the pain subsided I
knew that I needed surgery after reading Sports
surgeon Dr. William Southmayd's book on sports
injuries and writing to him about it. I also consulted
Dr. Neer and Dr. Louis Bigliani both of Columbia
Presbyterian Hospital and both agreed that surgery was
in order to return me to my full potential. As Dr.
Southmayd and Dr. Neer agree, a severe AC separation
where all the ligaments are severed and the arm hangs
low and the clavical sticks up like a flagpole surgery
is required in their opinion, this is not a broken
collarbone that can be ignored but an injury that
cries out for repair. Fortunately there are more
capable sports minded physicians who can and do return
these patients to near full capability today. Dr
Bigliani made the repair in 1986 and thankfully I am
still feeling great with full range of motion and
almost full strength. I am disatisfied and angry with
the first orthopedist who did nothing to heal me and
simply told me to live with it and not scar my body.
As you say doctor it pays to listen to your own body
and seek several opinions.

Al

"Mike Murray"
<[email hidden]> wrote in

message

Quoted message said:

Quoted message said:

news:<sNBbc.65046$w54.397507@attbi_s01>...

Quoted message said:

> There are several different surgical procedures
> described for this

injury.

Quoted message said:

> It is also appropriate to not treat this injury
> surgically. Each

option

Quoted message said:

Quoted message said:

has

Quoted message said:

> benefits and risks associated with it. These vary
> from individual

to

Quoted message said:

Quoted message said:

Quoted message said:

> individual. In part this is because the amount of
> deformity

produced by

Quoted message said:

Quoted message said:

a

Quoted message said:

> complete AC separation varies depending on the
> individual's anatomy

and

Quoted message said:

Quoted message said:

Quoted message said:

> their tolerance of the problems varies with the
> demands they make on

their

Quoted message said:

> shoulder.. Most orthopedists currently avoid
> repairing most of

these as

Quoted message said:

Quoted message said:

it

Quoted message said:

> is difficult to show that surgery leads to an
> improved result

compared

Quoted message said:

Quoted message said:

to

Quoted message said:

> those treated non-surgically. As time goes by, in
> most people, the

size

Quoted message said:

Quoted message said:

of

Quoted message said:

> the "bump" gets smaller.. Clearly the decision to
> repair or not is something that you need to discuss
> with doctors individually. I

would

Quoted message said:

Quoted message said:

Quoted message said:

> actually suggest considering getting several
> opinions before opting

for

Quoted message said:

Quoted message said:

Quoted message said:

> surgery.
>
> Grade 2 AC separations are not treated surgically.
> Grade 1

separations

Quoted message said:

Quoted message said:

are

Quoted message said:

> not treated surgically acutely. Rarely people will
> have persistent

pain

Quoted message said:

Quoted message said:

at

Quoted message said:

> the AC joint after having a Grade 1 injury. These
> can be treated by excising the distal clavicle to
> obliterate the joint. Personally I

would

Quoted message said:

> wait a LONG time before considering this. Maybe a
> year or so.
>
> Generally all these injuries do well regardless of
> method of

treatment.

Quoted message said:

Quoted message said:

Quoted message said:

> There are 2 major concerns. One is development of
> adhesive

capsulitis

Quoted message said:

Quoted message said:

or

Quoted message said:

> frozen shoulder syndrome. This is a risk after any
> shoulder injury

and

Quoted message said:

Quoted message said:

the

Quoted message said:

> risk increases with age. This is the primary reason
> to suggest PT

although

Quoted message said:

> to avoid this problem all that needs to be done is
> range of motion

exercises

Quoted message said:

> which can be taught to patients pretty quickly so
> extended PT is not

usually

Quoted message said:

> needed except perhaps in the elderly sedentary
> patient. This can

start

Quoted message said:

Quoted message said:

Quoted message said:

> very soon after the injury. There is no reason to
> wait several

weeks.

Quoted message said:

Quoted message said:

The

Quoted message said:

> second concern is development of impingement
> syndromes. This

actually

Quoted message said:

Quoted message said:

Quoted message said:

> probably goes up with surgical treatment. This is a
> late

complication.

Quoted message said:

Quoted message said:

Quoted message said:

>
>
> --
> Mike Murray MD "JPMM" <[email hidden]> wrote in
> message -"]news:[email hidden]-
> oogle.com...
> > I'm 43 and have a AC Type 3 Separated Shoulder. My
> > doctor has prescribed rest for several weeks
> > followed by PT. I

have a

Quoted message said:

Quoted message said:

Quoted message said:

> > considerable hump/bump on my shoulder. Will this
> > go away w/ time

or

Quoted message said:

Quoted message said:

Quoted message said:

> > reduce in size? Do you typically regain full use
> > of your

shoulder?

Quoted message said:

Quoted message said:

Quoted message said:

> > What's the recovery period?

Dr. Murray,

My engineering intuition tells me that a repaired joint has
more structural integrity than a broken joint, maybe I am of
the old school in believing this but I do and respectufully
disagree with you.

Al

"Mike Murray" <[email hidden]>
wrote in message news:<kOAcc.82810$w54.479628@attbi_s01>...

Quoted message said:

"If you don't have surgery, there is almost 100 percent
chance that your shoulder will lose some mobility. Also
the shoulder structure will be permanently weakened."

The above statement is clearly not true. I have seen
several patients and have many bike racing friends who
have had Grade 3 AC separations that were treated non-
surgically that have full range of motion and no loss of
strength compared to the contralateral side. The statement
does not match my personal experience. In fact, it also
appears to be in contrast to the group experience as there
is literature that has evaluated this question. The
majority of articles indicate that end strength and range
of motion does not vary between the operative and non-
operative groups.

A blanket recommendation for surgery also ignores the fact
that many patients treated surgically develop problems
secondary to the surgery; rupture of the repair, painful
syndromes related to the implanted materials, need for
subsequent surgery to remove metal, need for subsequent
surgery to resect the distal clavicle due to persistent
pain, restricted range of motion, impingement syndromes,
infections, etc.

There have been 2 consensus opinion surveys, for what they
are worth. In 1974, Powers and Bach found that most
advocated surgical repair. In 1992, Cox reported that
72.2% favored non-operative, symptomatic management. This
change was prompted by a series of retrospective studies
that showed no outcome differences between operative and
non-operative groups. In addition, the patients treated
non-surgically returned to full activity (work or
athletics) sooner than the surgically treated groups. It
would appear that the doctors Mr. Lowich is quoting are
hanging on to an idea that many feel is outdated.

Clearly you can find people on both sides of this issue
but the weight of current opinion falls on the non-
operative side for most patients.

Below are some links from a quick internet search on the
subject.

ncbi.nlm.nih.govquery.fcgiOpen ↗
e&db=PubMed&dopt=Abstract&list_uids=97363803 ortho-ortho-Open ↗
u.net/l9/61.htm worldortho.comabstraOpen ↗
cts/u_limb/larsen.html
ajsm.highwire.org699Open ↗ ht-
tp://www.worldortho.com/database/abstracts/u_limb/taft.ht-
ml worldortho.comdiOpen ↗
as.html worldortho.comu liOpen ↗
mb/bjerneld.html stoneclinic.comacjoint2.htmOpen ↗

"Alan Lowich" <[email hidden]> wrote in message
"]news:[email hidden]...

Quoted message said:

Count me in the camp of Dr William Southmayd who says
that in his opinion all grade 3 separations should be
surgically repaired for the following two reasons:
1) " The shoulder joint is so damaged that it can't
repair itself. Specifically, there is no way for the
bones to realign themselves. The gap is too large"
2) "If you don't have surgery, there is almost 100
percent chance that your shoulder will lose some
mobility. Also the shoulder structure will be
permanently weakened."

Also Dr. Charles Neer and Dr. Louis Bigliani agreed with
this opinion. I realize that there are physicians like
yourself who disagree with this view and I certainly
respect that.

Mike Murray" <[email hidden]>
wrote in message

news:<Yphcc.195141$po.1012951@attbi_s52>...

Quoted message said:

Quoted message said:

Just as I said in my note, the consideration to treat
this surgically

needs

Quoted message said:

Quoted message said:

to be individualized. It is not so much a matter of
the "severity" of

the

Quoted message said:

Quoted message said:

injury as we are talking about Grade 3 injuries, i.e.
all of the same severity. It is really more of an
issue of the individual's anatomy,

the

Quoted message said:

Quoted message said:

demands they will make on the shoulder, their
individual surgical risks

and

Quoted message said:

Quoted message said:

cost to the patient. In some individuals a complete AC
separation will leave the end of the clavicle resting
several inches above the acromion. Even these patient
may do well from a functional point of view, i.e.

they

Quoted message said:

Quoted message said:

will be able to move the shoulder normally and have
little pain, but the size of the deformity will lean
you towards treating it surgically if

only

Quoted message said:

Quoted message said:

for cosmetic reasons. In general though most patients
will have a

resting

Quoted message said:

Quoted message said:

position for the clavicle that is only elevated above
the acromion a

small

Quoted message said:

Quoted message said:

amount. In this case non-surgical management makes
more sense. Interestingly, in contrast to the
implication of the note below,

"capable

Quoted message said:

Quoted message said:

sports minded physicians" are probably less likely to
treat these

surgically

Quoted message said:

Quoted message said:

for several reasons; longer healing time, increase
risk for subsequent impingement syndrome, risks of
surgery, etc. It has been my experience

that

Quoted message said:

Quoted message said:

far more of these are treated surgically unnecessarily
then are treated inappropriately non-surgically.
Perhaps this has much to do with the

fact

Quoted message said:

Quoted message said:

that doctors are paid more to do surgery or just the
fact that they do surgery because they like to. I
would be wary of any suggestion that

surgery

Quoted message said:

Quoted message said:

should be considered that was given too rapidly and
didn't take into consideration all the things I have
listed in my notes. The surgery does

not

Quoted message said:

Quoted message said:

need to be done urgently and can be done delayed with
no loss.

The bottom line is most can be treated without surgery
although some may

do

Quoted message said:

Quoted message said:

better with surgery. Most will have good results
treated either way. A

few

Quoted message said:

Quoted message said:

will have bad results treated either way. Predicting
which method will produce the best result is difficult
and needs to be individualized.
--
Mike Murray MD

"Alan Lowich" <[email hidden]> wrote in message
-"]news:[email hidden]-
m...
> I agree with most of what you say Doctor but I had a
> really severe separation which would not reduce no
> matter how long I waited. Although the pain subsided
> I knew that I needed surgery after reading Sports
> surgeon Dr. William Southmayd's book on sports
> injuries and writing to him about it. I also
> consulted Dr. Neer and Dr. Louis Bigliani both of
> Columbia Presbyterian Hospital and both agreed that
> surgery was in order to return me to my full
> potential. As Dr. Southmayd and Dr. Neer agree, a
> severe AC separation where all the ligaments are
> severed and the arm hangs low and the clavical
> sticks up like a flagpole surgery is required in
> their opinion, this is not a broken collarbone that
> can be ignored but an injury that cries out for
> repair. Fortunately there are more capable sports
> minded physicians who can and do return these
> patients to near full capability today. Dr Bigliani
> made the repair in 1986 and thankfully I am still
> feeling great with full range of motion and almost
> full strength. I am disatisfied and angry with the
> first orthopedist who did nothing to heal me and
> simply told me to live with it and not scar my body.
> As you say doctor it pays to listen to your own body
> and seek several opinions.
>
> Al
>
>
>
> "Mike Murray"
> <[email hidden]> wrote in

message news:<sNBbc.65046$w54.397507@attbi_s01>...

Quoted message said:

Quoted message said:

> > There are several different surgical procedures
> > described for this

injury.

Quoted message said:

Quoted message said:

> > It is also appropriate to not treat this injury
> > surgically. Each

option has

Quoted message said:

Quoted message said:

> > benefits and risks associated with it. These vary
> > from individual

to

Quoted message said:

Quoted message said:

> > individual. In part this is because the amount of
> > deformity

produced by a

Quoted message said:

Quoted message said:

> > complete AC separation varies depending on the
> > individual's anatomy

and

Quoted message said:

Quoted message said:

> > their tolerance of the problems varies with the
> > demands they make on

their

Quoted message said:

Quoted message said:

> > shoulder.. Most orthopedists currently avoid
> > repairing most of

these as it

Quoted message said:

Quoted message said:

> > is difficult to show that surgery leads to an
> > improved result

compared to

Quoted message said:

Quoted message said:

> > those treated non-surgically. As time goes by, in
> > most people, the

size of

Quoted message said:

Quoted message said:

> > the "bump" gets smaller.. Clearly the decision to
> > repair or not is something that you need to
> > discuss with doctors individually. I

would

Quoted message said:

Quoted message said:

> > actually suggest considering getting several
> > opinions before opting

for

Quoted message said:

Quoted message said:

> > surgery.
> >
> > Grade 2 AC separations are not treated surgically.
> > Grade 1

separations are

Quoted message said:

Quoted message said:

> > not treated surgically acutely. Rarely people will
> > have persistent

pain at

Quoted message said:

Quoted message said:

> > the AC joint after having a Grade 1 injury. These
> > can be treated by excising the distal clavicle to
> > obliterate the joint. Personally I

would

Quoted message said:

Quoted message said:

> > wait a LONG time before considering this. Maybe a
> > year or so.
> >
> > Generally all these injuries do well regardless of
> > method of

treatment.

Quoted message said:

Quoted message said:

> > There are 2 major concerns. One is development of
> > adhesive

capsulitis or

Quoted message said:

Quoted message said:

> > frozen shoulder syndrome. This is a risk after any
> > shoulder injury

and the

Quoted message said:

Quoted message said:

> > risk increases with age. This is the primary
> > reason to suggest PT

although

Quoted message said:

Quoted message said:

> > to avoid this problem all that needs to be done is
> > range of motion

exercises

Quoted message said:

Quoted message said:

> > which can be taught to patients pretty quickly so
> > extended PT is not

usually

Quoted message said:

Quoted message said:

> > needed except perhaps in the elderly sedentary
> > patient. This can

start

Quoted message said:

Quoted message said:

> > very soon after the injury. There is no reason to
> > wait several

weeks. The

Quoted message said:

Quoted message said:

> > second concern is development of impingement
> > syndromes. This

actually

Quoted message said:

Quoted message said:

> > probably goes up with surgical treatment. This is
> > a late

complication.

Quoted message said:

Quoted message said:

> >
> >
> > --
> > Mike Murray MD "JPMM" <[email hidden]> wrote in
> > message news:4ca95d27.0403290936.71442ce6@posting-
> > .google.com...
> > > I'm 43 and have a AC Type 3 Separated Shoulder.
> > > My doctor has prescribed rest for several weeks
> > > followed by PT. I

have a

Quoted message said:

Quoted message said:

> > > considerable hump/bump on my shoulder. Will this
> > > go away w/ time

or

Quoted message said:

Quoted message said:

> > > reduce in size? Do you typically regain full use
> > > of your

shoulder?

Quoted message said:

Quoted message said:

> > > What's the recovery period?