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SHOULDER INJURIES
A hard tackle or fall can leave you with a painful bump on top of your shoulder. Find out what an AC joint injury is, how it recovers, and when you may need surgery.
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It is that time of the season. The ground is hard, the tackle counts are up, finals are close enough to smell, and every weekend we see a version of the same story walk into the clinic. You went into a tackle, or came out the wrong side of one, and hit the deck with your arm pinned by your side, straight onto the point of your shoulder. There was a sharp jolt, maybe a click. Now there is a tender bump on top of your shoulder, reaching across your body hurts, and sleeping on that side is out of the question. A quick search convinced you it was a rotator cuff tear. Much of the time, it is not. It is your AC joint.
“At PEAK, we call all our patients Athletes, not because of fitness level but because of mindset: our job is to help you reach your goal, whatever that is.”
Here is the good news up front: most AC joint injuries recover very well without surgery, and with the right plan most people are back playing the sport they love. Here is what is actually going on, what the evidence says about surgery, and how we get you back out there.
The AC joint, short for acromioclavicular joint, is the small joint on the very top of your shoulder where your collarbone meets the tip of your shoulder blade. You can feel it as a slight ridge a few centimetres in from the edge of your shoulder. It is a low-motion joint held together by a set of strong ligaments, and its job is to transfer force between your arm and the rest of your body. That is exactly why it cops the impact when your shoulder hits the ground first.
When those ligaments are sprained or torn, the injury is graded on how far the collarbone has shifted relative to the shoulder blade.
Clinicians use the Rockwood classification, which runs from grade one, a sprain with the joint still sitting normally, through grade two and three, where progressively more ligaments tear and a visible step or bump appears, up to the rare high grades where the collarbone is significantly displaced.
The vast majority of the injuries we see from footy, netball falls and bike stacks are grades one to three. This is also sometimes called a separated shoulder, which sounds dramatic but is a different and usually far less serious injury than a dislocated shoulder.
And it is common. In a landmark study of English professional rugby union published in the American Journal of Sports Medicine, Headey and colleagues found the AC joint was the single most commonly injured shoulder structure, accounting for around 32 percent of all shoulder injuries. The same dataset showed dislocations and instability were the shoulder problems that cost the most time away, which is a useful reminder that not every shoulder that hits the ground is the same injury, and getting the diagnosis right early matters.
The mechanism is nearly always compression: something drives the point of the shoulder down while the collarbone stays put. The classic culprits we see in Brisbane are:
This is the question everyone asks once they have seen the bump, so let us deal with it properly. For grades one and two, the answer is almost never. These are treated with a short period of relative rest and a progressive rehab program, and they do well.
Grade three is where the internet gets noisy, and it is where the evidence is genuinely reassuring. The Canadian Orthopaedic Trauma Society ran a multicentre randomised trial comparing surgical fixation with non-operative treatment for complete AC joint dislocations.
Surgery produced straighter X-rays, but it did not produce better shoulders: at two years both groups scored in the good to excellent range on function, and the non-operative group actually recovered faster in the early months.
More recent systematic reviews and meta-analyses of randomised trials in higher grade injuries have reached the same broad conclusion: for most people, structured rehab matches surgery on function, without the operation.
Two honest caveats. First, the rare high-grade injuries, and some grade threes in specific athletes such as dedicated overhead or collision athletes with ongoing symptoms, are legitimate surgical conversations, and we refer promptly when that is the case.
Second, the bump: if you develop a visible step, rehab will restore your strength and function, but the bump itself often stays. It is a cosmetic souvenir, not a sign the shoulder is weak or unfixed. Plenty of front rowers and cyclists are running around with one on each side.
As a rough guide to timeframes, a grade one usually settles in one to two weeks, a grade two in three to six weeks, and a grade three commonly takes six to twelve weeks to return to contact sport, sometimes longer.
The right answer for you depends on your sport, your position and what your shoulder has to tolerate, which is exactly what your rehab plan should be built around.
Blane is a Senior Physiotherapist at PEAK with a strength and conditioning background, years working with rugby teams, and personal experience on the wrong end of this topic: he had shoulder stabilisation surgery in 2020 and worked his way back to the rugby field six months later.
“The two mistakes I see are opposites,” Blane says. “Half the players ignore it, strap it, and keep playing until the shoulder is so irritable they cannot train at all. The other half see the bump, assume the worst, and think they need an operation and a season on the sidelines. Nearly always the truth is in the middle. Having rehabbed my own shoulder back to contact rugby, I can tell you the thing that gets you back is not the sling and it is not luck. It is doing the strength work properly, progressing contact in stages, and having a clear test to pass before you take the field. When an Athlete does that, the shoulder they come back with is often more robust than the one they injured.”
If you have hurt your shoulder on the weekend and are waiting to be seen, these will not go wrong:
AC joint injuries fit our Pain, Prevention, Performance philosophy neatly.
Pain comes first: in the early days that can mean a sling briefly for comfort, taping to offload the joint, gentle range of movement work, and clear guidance on what to avoid, which is mainly heavy pressing and sleeping on that side. Most joints settle quickly once they are not being provoked.
Then prevention, which is where the real work lives. We progressively rebuild the shoulder: scapular control, rotator cuff and pressing strength, then horizontal and overhead loading, because the best protection against re-injury on a footy field is a shoulder strong enough to absorb contact. This is also where we address anything that set you up for the injury, from tackle technique to a pressing program that was aggravating the joint.
Then performance. For contact athletes that means staged return: controlled contact drills before full training, full training before selection, and strength benchmarks compared against your other side before we clear you. The goal is not just to get you back for one game. It is to get you through finals and into next season with a shoulder you never have to think about.
No referral is needed to book. If your shoulder met the ground harder than you would have liked this season, do not wait until finals week to deal with it. Book in with our team and let us help you finish the season strong, and maybe experience something you never felt possible.
Our sports physiotherapists at PEAK’s Brisbane CBD clinic see tackle-sport shoulders all winter. We will work out exactly what you have injured and what grade it is, refer for imaging only when it will change the decision, and give you a straight answer on the surgery question based on the evidence above. Then we build the rehab plan that gets you back: hands-on treatment and taping to settle the pain, a progressive strength program to armour the shoulder, and a staged return to contact with clear benchmarks, so you run back out there confident rather than hopeful.
Sources referenced: Headey et al., American Journal of Sports Medicine 2007 (epidemiology of shoulder injuries in English professional rugby union: AC joint the most common shoulder injury at 32 percent; dislocation and instability the most severe); Canadian Orthopaedic Trauma Society, multicentre randomised trial of operative versus non-operative treatment of acute complete AC joint dislocation (better radiographic alignment with surgery but no clinical superiority at two years, faster early recovery without surgery); Lameire et al., Orthopaedic Journal of Sports Medicine (systematic review and meta-analysis of randomised trials, operative versus non-operative management of type III to V AC joint dislocations: comparable functional outcomes); Rockwood classification of AC joint injuries.
From Pain to Performance. Get Back to What You Love.