AC3 Separated Shoulder

On 4/6/04 7:16 PM, in article
[email hidden], "Alan Lowich"

Quoted message said:

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

So there is nothing in your engineering education and
background where your intuition pointed you in one
direction, but upon careful consideration and study the
opposite turned out to be true?

Baird

Quoted message said:

"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hanging on to an idea that many feel is outdated.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 ↗
ve&db=PubMed&dopt=Abs tract&list_uids=97363803 ortho-ortho-Open ↗
u.net/l9/61.htm worldortho.comabstrOpen ↗
acts/u_limb/larsen.html
ajsm.highwire.org699Open ↗
worldortho.comtaftOpen ↗
.html worldortho.comu limOpen ↗
b/dias.html worldortho.comabstractsOpen ↗
/u_limb/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:

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

needs

Quoted message said:

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

the

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:

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

and

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:

> 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:

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

resting

Quoted message said:

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

small

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:

> sports minded physicians" are probably less likely to
> treat these

surgically

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:

> 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:

> 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:

> 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:

> 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:

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

few

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]...
>> 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.

Quoted message said:

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

option has

Quoted message said:

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

to

Quoted message said:

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

produced by a

Quoted message said:

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

and

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 it

Quoted message said:

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

compared to

Quoted message said:

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

size 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:

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

for

Quoted message said:

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

separations are

Quoted message said:

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

pain 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:

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

capsulitis or

Quoted message said:

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

and 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:

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

weeks. The

Quoted message said:

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

actually

Quoted message said:

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

complication.

Quoted message said:

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

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

or

Quoted message said:

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

shoulder?

Quoted message said:

>>>> What's the recovery period?

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

Quoted message said:

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.

Well the thing your "engineering intuition" is misleading
you on is the wrong notion that we are made of modular parts
like a machine. We are not; surgery causes irreversible
damage and scarring to healthy tissue. So there is a
tradeoff between the damage the surgury causes and the
benefits it can potentially create.

Shayne Wissler

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

Quoted message said:

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.

Did you work on the Shuttle?

Point is that as Dr. Murray pointed out, everyone is an
individual and in some cases you'd be right. In MOST of the
cases he'd be right. As a person that has gotten three
separations over the years I can tell you that even pretty
extreme one's effectively disappear in time if you are
actively using them.

The real question is are you putting in enough in the way of
PT to deal with your particular case if you aren't one of
the few who will require surgery.

And as someone that worked with doctors who use knives, I
can tell you that I'd always avoid them if possible.

"Shayne Wissler" <[email hidden]> wrote in message
news:ahLcc.206115$Cb.1802703@attbi_s51...

Quoted message said:

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

Quoted message said:

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.

Well the thing your "engineering intuition" is misleading
you on is the wrong notion that we are made of modular
parts like a machine. We are not; surgery causes
irreversible damage and scarring to healthy tissue. So

there

Quoted message said:

is a tradeoff between the damage the surgury causes and
the benefits it

can

Quoted message said:

potentially create.

And there's no way of knowing what the end result is going
to be after you operate. Shortening muscles and ligaments
doesn't leave them at the length you repair them and you
can't tell with any certainty what the end result is going
to be. Same with bone structures that require repairs.
Doctors do what their experience tells them is most likely
to work. That doesn't mean it will.

Even a surgery as simple as repair of a separation can end
up with the results nothing like what you hoped. Even
doctors with long term experience are only better on the
average then doctors who never did it before.

At least lawyers make a fat living off of the fact that the
human body is so variable in its responses.

Following your logic there should be no surgery for fear of
a bad outcome, we should just wait for our broken joints to
disappear in time.

"Tom Kunich" <[email hidden]> wrote in message news:<4-
[email hidden]>...

Quoted message said:

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

Quoted message said:

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.

Did you work on the Shuttle?

Point is that as Dr. Murray pointed out, everyone is an
individual and in some cases you'd be right. In MOST of
the cases he'd be right. As a person that has gotten three
separations over the years I can tell you that even pretty
extreme one's effectively disappear in time if you are
actively using them.

The real question is are you putting in enough in the way
of PT to deal with your particular case if you aren't one
of the few who will require surgery.

And as someone that worked with doctors who use knives, I
can tell you that I'd always avoid them if possible.

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

Quoted message said:

Following your logic there should be no surgery for fear
of a bad outcome, we should just wait for our broken
joints to disappear in time.

You mean like they always did in the past before they
started putting knives in people with separated shoulders?

Alan Lowich said:

My engineering intuition tells me [...]

Intuition? Good. Data? Better.

Being persuaded by new evidence isn't flip-flopping, it's
learning. Holding to an opinion in the face of overwhelming
evidence isn't consistency, it's stubbornness.

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

Quoted message said:

Alan Lowich said:

My engineering intuition tells me [...]

Intuition? Good. Data? Better.

Being persuaded by new evidence isn't flip-flopping, it's
learning. Holding to an opinion in the face of
overwhelming evidence isn't consistency, it's
stubbornness.

Frankly, I think this criticism is unfair, Robert. Data is
not independently valuable, without the application of
reasoning. Reasoning, based on predetermined models, without
intuition, advances nowhere.

To the particular point in the thread, the choices of
surgical intervention or abstention do not lead to plain
results. Without surgery, or with it, the resulting body
can't be compared to anything else - bodies seem to be
rather unique.

If one judges success by range of motion, then not cutting
is best - you wouldn't believe how flexible an unattached
joint can be ! Presence or absence of a knob is cosmetic. I
am not ready to use that as a valid index of success leaves
me unimpressed. Pain is generally not of concern, except
very early on, as there is not usually nerve damage.

In my own case, I decided on surgery for one shoulder and
not for the other. Different treatments for different
presentations. Nearly the same final results, and I'm
getting older, anyway - lots older - so I won't guess
whether there is any natural process influencing.

When the fashion of treatment changes, the data also become
skewed. You get more data, less information. And a good
orthopedic surgeon, whom you trust, and who is open to the
patient's objectives and input, is not closed minded. The
two paths are viable, different, and do nothing to diminish
the validity of either one or the other.

Maybe it's like the belief that loose balls, not held in a
cage, is a better/worse technology. Opinions seem to differ
greatly, but with a shoulder, you can't just revise your
choice after making the first choice.

When my separations occurred, it was a couple of days before
I was on the bike, again. It's interesting to note, that the
weight of the body, leaning forward, puts the parts in their
proper places, really handily. But pulling on the bars just
elongates one side, while the other one works fine :-)
--
Bonne route,

Sandy Paris FR

Sandy said:

Robert Chung a écrit

Quoted message said:

Alan Lowich said:

My engineering intuition tells me [...]

Intuition? Good. Data? Better.

Being persuaded by new evidence isn't flip-flopping, it's
learning. Holding to an opinion in the face of
overwhelming evidence isn't consistency, it's
stubbornness.

Frankly, I think this criticism is unfair, Robert. Data is
not independently valuable, without the application of
reasoning. Reasoning, based on predetermined models,
without intuition, advances nowhere.

[good points snipped]

Right. However, in this case, the data were collected and
analysis done expressly to develop practice guidelines and
the conventional therapy before that was surgical, so one
can't say that researchers were starting tabula rasa in the
absence of context, experience, reasoning, or intuition. In
a normative-based field like healthcare it takes a lot to
shift treatment pradigms. Most physicians hate "evidence-
based medicine" because of the unfortunate connotations it
carries, and herding cats is easier than getting them to
change their behavior, so when you do see them change, it
means the evidence has to be pretty compelling.

Nonetheless, guidelines are only guidelines; you had surgery
on one shoulder, you didn't on the other, and I'm guessing
you thought pretty deeply about each decision. That's
exactly as it should be: the evidence from the patient in
front of you trumps a guideline and a good physician will
always make a treatment decision for an individual patient,
not for a population of potential patients--but that's not
what Alan was asserting. If he had said that on careful
weighing of alternatives, in his particular case, he and his
physician opted for a surgical intervention, I wouldn't have
said anything. Rather, he said that his engineering
intuition gave him insight that trumped carefully collected
and analyzed evidence, and that surgery was flatly
preferred.

Speaking of subtle, someone (hi there) passed this link on
to me: atbash.net000046.htmlOpen ↗

Robert Chung said:

Speaking of subtle, someone (hi there) passed this link on
to me: atbash.net000046.htmlOpen ↗

That was a rather disappointing link.

Ewoud Dronkert said:

Robert Chung said:

Speaking of subtle, someone (hi there) passed this link
on to me: atbash.net000046.htmlOpen ↗

That was a rather disappointing link.

Try this one: 216.239.51.104searchOpen ↗
et/blog/archives/000046.html

In article <[email hidden]>,

Robert Chung said:

Ewoud Dronkert said:

Robert Chung said:

Speaking of subtle, someone (hi there) passed this link
on to me: atbash.net000046.htmlOpen ↗

That was a rather disappointing link.

Try this one: 216.239.51.104searchOpen ↗
.net/blog/archives/000046.html

The cached versions of pages often eliminate the images,
so I located a site that still had it up. completewasteoftime.blogs.combagtagOpen ↗
thumb.gif

Subtle? thepoorman.netthe war presideOpen ↗
nt_big.jpg

--
tanx, Howard

Q: Why did the metalhead cross the road?
R: Because he's a gullible moron who'll buy
anything with a skull on it.

remove YOUR SHOES to reply, ok?

Hey
I had a good friend of mine separate his shoulder in a bad bike accident about a year ago. He was coming down a hill and got tangled up with another biker and he hit the ground rolling shoulder first. Pretty nasty deal. He ended up having surgery on it immediately I am not sure what category of a separation it was though. I remember he was a bit timid after he got back on his bike at first but now hes totally fine. I am not a doctor but I would definitely recommend getting surgery just to make sure you don't have any issues later on in life. Also, get a good brace for after the surgery. I gave my buddy a hard time all the time for his brace because he wore his all the time but he swore up and down saying that it helped a ton with the healing process. So if he is correct it might be worth a shot! Here is the link: shoulder brace
I wish you the best of luck!

trevor022 said:

Hey I had a good friend of mine separate his shoulder in a bad bike accident about a year ago.  He was coming down a hill and got tangled up with another biker and he hit the ground rolling shoulder first.  Pretty nasty deal.  He ended up having surgery on it immediately I am not sure what category of a separation it was though.  I remember he was a bit timid after he got back on his bike at first but now hes totally fine.  I am not a doctor but I would definitely recommend getting surgery just to make sure you don't have any issues later on in life.  Also, get a good brace for after the surgery.  I gave my buddy a hard time all the time for his brace because he wore his all the time but he swore up and down saying that it helped a ton with the healing process.  So if he is correct it might be worth a shot!  Here is the link: shoulder brace I wish you the best of luck!

Well, it's been a bit over 9 years since anyone posted in this thread. I'll bet they've healed in the interim.

Lol o man did not even look at the date.
My bad!