Acromioclavicular (AC) joint injuries are common in the athletic setting.1 The variety of AC joint injuries can be classified using the Rockwood classification scale.1,2 The classification system is composed of six different injury types, where the higher numbered type represents an increase in severity.1,2 According to the Rockwood classification scale, a type III injury is classified by the complete disruption of the AC joint capsule and associated ligaments, as well as a complete rupture of the coracoclavicular ligaments.1,2 The disruption results in an increase of the coracoclavicular space by 25% to 100% and is the first classification type to be recognized as a dislocation.1,2 In conjunction with local pain and swelling, the clinician will notice a decrease in active and passive shoulder range of motion, as well as a decrease in strength and function.2 At this time, there is no definitive treatment for type III AC joint injuries.2–4
A key treatment decision for type III AC joint injuries is whether to opt for conservative or surgical intervention. Although the two options are drastically different, researchers suggest following a conservative treatment option results in greater patient satisfaction.5 When choosing a conservative approach, the interventions include immobilization, cryotherapy, nonsteroidal anti-inflammatory drugs (NSAIDs), and rest until active rehabilitation can begin.3 Most conservative treatment plans do not incorporate any manual therapy techniques. This case study is focused on an aggressive nonsurgical treatment of a type III AC joint injury through the application of two manual therapy techniques: Mulligan Concept and Positional Release Therapy (PRT).
The Mulligan Concept is a manual therapy technique that includes the use of sustained joint glides coupled with active physiologic joint motion to restore pain-free functional ability.6 Although not clearly elucidated, the possible mechanism of action may be the correction of positional faults within the joint.6,7 A tenet of the Mulligan Concept is the PILL response (Pain-free glide, Instantaneous relief, Long-Lasting result).6 As such, the Mulligan Concept can be used as a treatment-based evaluation to determine the capacity of the technique as a therapeutic intervention.
To determine whether the Mulligan Concept is indicated as a treatment, the clinician must first establish that there is limited or painful active motion for the patient. In the context of the AC joint, the most common limited active motions are flexion/elevation and horizontal adduction.6 Once a limited range of motion has been found, the clinician applies force to the joint that is specific to the area. The force is applied and maintained through the range of motion as the patient actively tries to achieve the full pain-free range of motion.6 Although each treatment of joint-specific range of motion limitations has a base guideline to follow, there is license for the clinician to use clinical reasoning skills to adjust the direction and amount of pressure being applied during the mobilization to elicit the PILL response.6 If there is an increase in pain-free range of motion elicited through one repetition, then the Mulligan Concept is indicated as an effective treatment for the injury and/or existing positional fault. In this way, the Mulligan Concept acts robustly as a treatment-based evaluation.
PRT is an indirect, passive manual therapy technique used to treat myofascial tissues.8 Stimulated myofascial tissues can present in two forms: trigger points or tender points.8 Trigger points are taut bands of muscle or muscle fascia creating a hyperirritable spot that results in local and possibly referred pain.8 Tender points are small palpable nodules ranging in size from 0.25 to 1 cm located in the fascial, muscular, or subcutaneous tissues that cause only local pain.8 Treatment of either lesion with PRT is conducted by placing the patient into the position of comfort, which is indicated by continuous evaluation of feedback from the area being treated. The position of comfort is achieved by passively moving the structure being treated through all three planes of motion to attain a maximal decrease in tissue tonicity.8
Patient-rated outcomes are used to track patient pain, function, or disability, thereby assessing the effectiveness of an intervention on a patient's condition. In turn, appropriately selected interventions should lead to significant improvements on patient-rated outcomes. Significant improvements can be determined by achieving a minimal clinically important difference (MCID). A MCID is the calculated level of change on a patient-rated outcome, which demonstrates a meaningful change to the patient's condition.9
The Numeric Rating Scale (NRS) is used to assess the significance of a patient's pain on a 0 (no pain) to 10 (worst pain imaginable) scale.10 The scale can be used to assess the patient's perceived pain over a 24-hour period by asking for a pain rating at worst, best, and now.11 The calculated MCID for the NRS is 2 points.10 The Disablement in the Physically Active scale is used to assess the active patient's perception of disablement following injury.9 A score between 0 and 64 is calculated based on responses to 16 questions relating to various disablement domains. A lower score represents less disablement and the calculated MCID is 9 points for acute injuries and 6 points for chronic injuries.12 The Disabilities in the Arm, Shoulder, and Hand Sport subscale (DASH-S) is a sport-specific subscale of the DASH designed to assess upper extremity function in athletic populations.13 The Global Rating of Change is used to assess the patient's perception of the effectiveness of an intervention in addressing dysfunction.14 The suggested MCID for a 15-point scale (−7 to +7) is 5 points.14 The Patient-Specific Functional Scale (PSFS) is used to allow patients to assess their functional abilities related to tasks deemed meaningful by the patient. The functional activities are rated on a 0 (unable to perform activity) to 10 (able to perform activity at the same level before injury or problem) scale. The MCID for averaged PSFS scores is 2 points.15
A left-handed 20-year-old male NCAA division three collegiate baseball pitcher suffered a traumatic right AC injury during a snowboarding accident. The patient lost control and landed directly on the AC joint with his arm adducted; he experienced a popping sensation near the AC and noted immediate disability of the affected extremity. Due to pain, deformity, and disability, he reported to the emergency department immediately following the incident. Two days after injury, the patient was evaluated by an athletic trainer and referred to an orthopedic physician for further evaluation. Using weighted x-rays, the physician diagnosed the patient as having a type III AC sprain of his non-throwing right shoulder (Figure 1). Seven days after injury, the patient was first evaluated by the treating athletic training clinician.
Weighted x-ray of patient's injured acromioclavicular joint.
The patient presented to the athletic training clinic 7 days after injury with a chief complaint of pain and loss of function in the arm. Scores on patient-rated outcomes at the onset of initial evaluation revealed significant disablement of the affected upper extremity (Tables 1–2). Visually, the patient exhibited labored movement of the extremity and a gross separation of the AC joint with the lateral clavicle tenting the skin. Additionally, the patient's shoulder forward flexion range of motion was limited to 143° and the patient noted a 6 of 10 score on the NRS during the motion. Shoulder abduction range of motion was limited to 93°. Shoulder flexion, abduction, and internal rotation were graded 4 of 5 for strength and the patient noted increased pain with internal rotation. The patient demonstrated limitations in other motions (ie, shoulder horizontal adduction), but formal measurements were not recorded at the time of evaluation.
Patient-Rated Outcomes Measures
Patient-Specific Functional Scale Scores
The clinician used the Mulligan Concept mobilization with movement for the AC joint as an evaluative tool seeking a PILL response.6 The patient was seated on a plinth with the clinician kneeling behind the patient on the plinth. The clinician applied a caudal and posterior glide of the lateral clavicle using his hand.6 The glide was sustained while the patient actively attempted shoulder forward flexion. The application of this glide did not elicit a PILL response, so the clinician attempted a caudal and slightly anterior glide while the patient attempted shoulder forward flexion. The caudal and slightly anterior glide elicited a PILL response (Figure 2).
Hand placement for the mobilization with movement for the acromioclavicular glide with a forward flexion movement by the patient.
The production of the PILL response indicated that the Mulligan Concept mobilization with movement with the caudal and anterior glide could be a possible effective intervention. Therefore, the clinician maintained the glide while the patient actively performed shoulder forward flexion for three sets of ten, going as far into the range of motion as possible while maintaining the pain-free nature of the movement. Following the three sets, the patient reported 0 of 10 on the NRS for shoulder forward flexion and demonstrated shoulder forward flexion and abduction increases to 180° and 103°, respectively.
Further, the patient reported tenderness in the anterior scalene. A tender point scan revealed tender points in the right anterior scalene that the patient reported were 5 of 10 on the NRS during palpation. The tender points were treated using PRT. The patient was placed supine with his head off the end of the plinth and supported by the clinician. The clinician, using feedback from the myofascial structures in the form of fasciculation, positioned the anterior scalene into a position of comfort by placing the head into cervical flexion, rotation away from the affected side, and lateral flexion toward the affected side. Following the PRT treatment, the tenderness to palpation of the tender spots had been reduced to 2 of 10 on the NRS.
Finally, the patient was taped using 5 cm Cover-Roll stretch (BSN Medical, Hamburg, Germany) and 3.8 cm Leukotape P (BSN Medical) to maintain the glide and provide downward compression to the AC joint. Two strips of Cover-Roll were placed from the tip of the lateral acromion to approximately the mid-section of the clavicle and covered the anterior-posterior distance from approximately 1.5 cm below the clavicle to the posterior edge of the acromion. The caudal anterior glide described previously was applied and a strip of Leukotape was applied with the same direction and force as the glide. A second strip of Leukotape was layered similar to the first. Additionally, a third strip was pulled directly medial to lateral across the AC joint while the clinician applied caudal compression to the lateral clavicle for downward compression of the AC joint. This strip was applied for comfort only and was not used with the intent to maintain the Mulligan Concept glide. The patient reported a +5 improvement on the 15-point Global Rating of Change.
Eight days after injury, during treatment session two, the patient reported an average NRS score of 3 during the past 24 hours and an 81.25 on the DASH-S at the beginning of the treatment session. The clinician again used the Mulligan Concept mobilization with movement and PRT treatments. The clinician and patient performed the same AC joint mobilization with movement as the previous day for three sets of ten repetitions with overpressure. To address an additional complaint of pain and dysfunction in shoulder horizontal adduction, the clinician performed the same glide and the patient performed two sets of ten repetitions with overpressure into horizontal adduction at 90º of glenohumeral forward flexion.6 The clinician again performed a tender point scan of the upper quarter.8 Tender points were identified in the right rhomboid major. The clinician again used PRT to treat the myofascial dysfunction. The patient was placed prone on a plinth. The clinician placed the rhomboid into a position of comfort by grasping the lateral border of the scapula near the axilla and translating the scapula medially. The position was tweaked in multiple directions following fasciculation feedback from the myofascial unit. A round of PRT reduced the tenderness to palpation from a 6 to a 2.
Eleven days after injury, the patient reported an average NRS score of 1.7 and 3 at worst in the past 24 hours. The patient performed a cardiovascular work-out on this day. Fourteen days following injury, 1 week after initial treatment and at treatment session three, the patient reported robust improvements on all patient-rated outcomes from initial presentation (Tables 1–2). The patient performed a 40 pitch workout, with the tape still applied, at approximately 70% intensity without pain. Following the workout, the patient reported mild discomfort during the pitch workout when reaching up and across diagonally with his glove hand, the injured extremity side, to catch a ball thrown to that side of his body. The same Mulligan Concept glide was applied while the patient performed a diagonal pattern similar to the D1 PNF flexion pattern, with the alteration of internal rotation instead of external rotation at the end. This motion simulated catching a ball across the body motion. The clinician and patient performed four sets of ten repetitions of mobilization with movements in this manner.
The patient was cleared for full participation by the team physician the following day, 15 days after injury. The patient still exhibited a moderate elevation of the lateral end of the clavicle, but was fully functional. During baseball activity, a strip of Cover-Roll and Leukotape was placed across the AC joint similar to the third strip described earlier. The strip was applied for comfort. The patient returned 20 days after injury for final evaluation and discharge. Range of motion in all directions was comparable bilaterally. Mild strength deficits were present (4+/5) in shoulder forward flexion and abduction, but otherwise the patient demonstrated equal strength bilaterally. The patient was discharged to full baseball activity after three treatment sessions over 7 and 20 days after initial injury. No other treatment interventions (eg, pain medications, ice, or progressive resistive exercise) were used after the initial evaluation by the treating athletic training clinician.
At 20 days following injury, patient-rated outcomes were recorded (Tables 1–2) and the patient was discharged. Follow-up outcome measures were recorded at 1 week and 1 month after discharge. Throughout the course of treatment, MCIDs were met or exceeded at multiple time points (Tables 1–2).
While opting to follow a conservative approach for a type III AC joint injury, the aggressive application of both the Mulligan Concept mobilization with movement and PRT vastly improved the patient's functionality and pain level after the first treatment. Although conservative treatment for low and moderate grade AC joint injuries suggest following a PRICE (Protection Rest Ice Compression Elevation) and exercise approach,1–3,5 the results from this case study suggest the integration of the Mulligan Concept mobilization with movement and PRT are robust interventions not often included in the treatment plans. Further, the results of the current case report support the outcomes of a similar recent case report.16 The clinician used a similar treatment plan of the Mulligan Concept and PRT to treat a type II AC injury in a collegiate diver, who demonstrated improvements on similar patient-rated outcomes (eg, Disablement in the Physically Active and Global Rating of Change scales and NRS) compared to the current patient.16
Conservative treatment and return to play plans for type III AC joint injuries follow similar elongation of the protocol for lower type AC joint injuries.1 Generally, type I–III AC joint injuries are treated with an initial 1 to 2 weeks of immobilization followed by active strengthening exercises when able.1 The entire return to play process can commonly require 4 to 8 weeks.1 In this case, the patient completed a 40 pitch workout at 70% intensity with no pain after three treatment sessions over a 7-day period of time from the initial treatment. The following day, the patient was cleared for full participation by the team physician. When compared to the traditional timeline of return to play, the patient was able to return to full activity significantly earlier with the use of Mulligan Concept mobilization with movement and PRT than the standard PRICE, immobilization, and strength protocol. In addition to the rapid return to full activity, the patient maintained improvements through follow-up visits at both the 1-week and 1-month mark following discharge and was able to compete fully in the NCAA baseball season. A possible confounding factor in the current case is the delay in treatment by the treating clinician. The patient was not seen by the treating clinician until 1 week after injury. Significant alterations to the outcomes may have occurred if the patient had been seen immediately by the treating clinician. However, the patient did deny ice and NSAID use during the initial week.
The combination of Mulligan Concept mobilization with movement and PRT as a treatment intervention significantly aided the patient's return to both pain-free activities of daily living and full participation in an expedited time frame. The focus of the Mulligan Concept mobilization with movement is to address movement restrictions related to a joint. One theory regarding the mechanism of action of mobilization with movements is the positional fault hypothesis.17 It is suggested that bony incongruences, or positional faults, exist at joints following injury.17 In the current case, the disruption of the AC and coracoclavicular ligaments resulted in displacement of the distal clavicle. Additionally, the derangement to the AC joint may have resulted in an impingement or alteration of the fibrocartilaginous disc within the joint. Together, these disruptions likely altered the biomechanics of the AC, glenohumeral, and scapulothoracic articulations, as best demonstrated by the loss of shoulder range of motion.
In addition to the positional fault hypothesis, a neurophysiological paradigm might explain the mobilization with movement mechanism of action.17 Application of mobilization with movements may have central nervous system pain modulating components along with motor system and joint position sense facilitation characteristics.17 Even though the Mulligan Concept mechanism of action has yet to be definitely elucidated in the literature, a significant clinical response was seen in the current patient. Once the Mulligan Concept mobilization with movement was applied and maintained through the range of motion, normal function was restored. The tape application following mobilization was used to maintain the integrity of the joint once the clinician removed his hands. After proper arthokinematic movement had been restored, the clinician changed focus of treatment to the soft tissues that may have been affected due to the trauma.
During the trauma, the soft tissues of the body are responsible to dissipate any force placed on the body. Following Jones' strain-counterstrain model, the body can fall into a spastic and dysfunctional state when resisting outside forces acting on the body.8 The resulting spasm can lead to a multitude of complications, such as prolonged somatic dysfunction locally but also remotely through regional interdependence and facilitated segments. Regional interdependence describes the concept that dysfunction in one area of the body can affect other remote areas of the body.18 A facilitated segment results when there is an overflow of neural impulses to the spinal column from an injury.8 The spinal cord cannot handle the prolonged flooding of impulses caused by the injury and, as a result, the associated vertebral segments can be affected on the contralateral side and a neural segment above the injury. The combination of the two conditions can significantly decrease the ability to recover and rehabilitate properly. PRT focuses on addressing the hypersensitive trigger points and tender points in the soft tissue.8 In the initial screening, the problem area for the patient was the anterior scalene. This may have been a result from the initial injury or a by-product of sustained somatic dysfunction. The clinician used PRT to down regulate the hypersensitive structure, thus increasing range of motion and decreasing pain. During the following treatment session, the patient noted tender points in the rhomboids, which may have been the result of increased activity without the full stability of the AC joint. Although the prophylactic use of tape is enough to maintain a functionally stable state for the AC joint, there is still some intrinsic instability that cannot be accounted for, which may have affected the work done by the rhomboids. Again, the use of PRT was indicated to treat the trigger points or tender points along the medial border of the scapula. In this case, the only two structures that the patient complained about were the anterior scalene and rhomboids. However, it would not be uncommon to see other soft tissue structures affected through direct connection with the AC joint (eg, the upper trapezius or deltoid) due to the deltotrapezius aponeurosis, which shares comingled fibers with the superior ligament of the AC capsular complex.19
Implications for Clinical Practice
No clear advantage to surgical or conservative management of type III AC joint injuries has emerged in the literature. As such, the clinician and patient selected a conservative, yet aggressive, approach in treating the injury. Considering the expedited return to play and improvement in patient-rated outcomes, the results of this case suggest an aggressive manual therapy-based approach using the Mulligan Concept and PRT may be a conservative treatment option of choice.
Use of the Mulligan Concept and PRT on a type III AC joint injury resulted in robust improvements in patient rated outcomes and function and an expedited return to full participation. The authors suggest the clinical integration of the Mulligan Concept and PRT into the evaluation and treatment of suspected low to moderate severity (type I–III) AC joint injuries. Future research is warranted to compare manual therapy-based treatments, similar to those applied in this case, to the traditional PRICE and therapeutic exercise protocols. Additionally, longer follow-up periods (years) are necessary to determine long-term outcomes. Further clinical inquiries are needed to investigate the effectiveness of the Mulligan Concept and PRT in a wide variety of musculoskeletal conditions in the athletic training clinic setting. Also, further translational and laboratory research is needed to advance the understanding of the mechanisms of action at play in the Mulligan Concept and PRT.
- Court-Brown CM, Heckman JD, McQueen MM, Ricci WM, Tornetta P, McKee MD. Rockwood and Green's Fractures in Adults. Philadelphia: Wolters Kluwer Health; 2015.
- Rollo J, Raghunath J, Porter K. Injuries of the acromioclavicular joint and current treatment options. Trauma. 2005;7:217–223. doi:10.1191/1460408605ta349oa [CrossRef]
- Beitzel K, Cote MP, Apostolakos J, et al. Current concepts in the treatment of acromioclavicular joint dislocations. Arthroscopy. 2013;29:387–397. doi:10.1016/j.arthro.2012.11.023 [CrossRef]
- Modi CS, Beazley J, Zywiel MG, Lawrence TM, Veillette CJH. Controversies relating to the management of acromioclavicular joint dislocations. Bone & Joint Journal. 2013;95:1595–1602. doi:10.1302/0301-620X.95B12.31802 [CrossRef]
- Hootman JM. Acromioclavicular dislocation: conservative or surgical therapy. J Athl Train. 2004;39:10–11.
- Hing W, Hall T, Rivett DA, Vicenzino B, Mulligan B. The Mulligan Concept of Manual Therapy: Textbook of Techniques. Philadelphia: Elsevier Health Sciences; 2015.
- Hubbard TJ, Hertel J. Anterior positional fault of the fibula after sub-acute lateral ankle sprains. Man Ther. 2008;13:63–67. doi:10.1016/j.math.2006.09.008 [CrossRef]
- D'Ambrogio KJ, Roth GB. Positional Release Therapy: Assessment & Treatment of Musculoskeletal Dysfunction. St. Louis: Mosby; 1997.
- Vela LI, Denegar CR. Transient disablement in the physically active with musculoskeletal injuries, part I: a descriptive model. J Athl Train. 2010;45:615–629. doi:10.4085/1062-6050-45.6.615 [CrossRef]
- Farrar JT, Young JP Jr, LaMoreaux L, Werth JL, Poole RM. Clinical importance of changes in chronic pain intensity measured on an 11-point numerical pain rating scale. Pain. 2001;94:149–158. doi:10.1016/S0304-3959(01)00349-9 [CrossRef]
- McCaffery M, Beebe A. Pain: Clinical Manual for Nursing Practice. St. Louis: Mosby; 1989.
- Vela LI, Denegar CR. The Disablement in the Physically Active Scale, part II: the psychometric properties of an outcomes scale for musculoskeletal injuries. J Athl Train. 2010;45:630–641. doi:10.4085/1062-6050-45.6.630 [CrossRef]
- Hudak PL, Amadio PC, Bombardier C, et al. Development of an upper extremity outcome measure: the DASH (disabilities of the arm, shoulder and hand) [corrected]. Am J Ind Med. 1996;29:602–608. doi:10.1002/(SICI)1097-0274(199606)29:6<602::AID-AJIM4>3.0.CO;2-L [CrossRef]
- Kamper SJ, Maher CG, Mackay G. Global rating of change scales: a review of strengths and weaknesses and considerations for design. J Man Manip Ther. 2009;17:163–170. doi:10.1179/jmt.2009.17.3.163 [CrossRef]
- Young IA, Cleland JA, Michener LA, Brown C. Reliability, construct validity, and responsiveness of the neck disability index, patient-specific functional scale, and numeric pain rating scale in patients with cervical radiculopathy. Am J Phys Med Rehabil. 2010;89:831–839. doi:10.1097/PHM.0b013e3181ec98e6 [CrossRef]
- Buonopane MP. Case study: a nontraditional treatment approach to acute acromioclavicular joint injury care. International Journal of Athletic Therapy & Training. 2015;20:6–10. doi:10.1123/ijatt.2014-0108 [CrossRef]
- Vicenzino B, Hing W, Rivett D, Hall T. Mobilisation with Movement: the art and science of its application. In: Vicenzino B, Hing W, Hall T, Rivett D, eds. Mobilisation with Movement: the Art and the Science. London: Churchill Livingstone; 2011:9–23.
- Sueki DG, Cleland JA, Wainner RS. A regional interdependence model of musculoskeletal dysfunction: research, mechanisms, and clinical implications. Jof Man Manip Ther. 2013;21:90–102. doi:10.1179/2042618612Y.0000000027 [CrossRef]
- Fraser-Moodie JA, Shortt NL, Robinson CM. Injuries to the acromioclavicular joint. J Bone Joint Surg, Br. 2008;90:697–707. doi:10.1302/0301-620X.90B6.20704 [CrossRef]
Patient-Rated Outcomes Measures
|ACTIVITY||INITIAL||SESSION 2||OUTCOMES (NO TX)||SESSION 3||DISCHARGE||1-WK F/U||1-MO F/U|
Patient-Specific Functional Scale Scoresa
|ACTIVITY||INITIAL||SESSION 2||OUTCOMES (NO TX)||SESSION 3||DISCHARGE||1-WK F/U||1-MO F/U|
|Put shirt on without pain||6||8b||10b||10||10||10||10|
|Put sock on without pain||4||10b||8||10c||10||10||10|
|Carry book bag||2||6b||10b||10||10||10||10|
|Throw off mound||0||0||0||7b||10b||9||10|
|Hit off a tee||0||0||0||6a||9a||10||10|