Journal of Orthopaedic & Sports Physical Therapy

Official Publication of the Orthopaedic and Sports Physical Therapy Sections of the American Physical Therapy Association

A Taping Technique for the Treatment of ~cromioc~avicu~ar Sprains: A Case Study Joint
lenniferI. Shamus, MS, PT, CSCS ' Eric C. Shamus, PT, CSCS *

he shoulder is a complex anatomical structure that is comprised of several joints that permit a great deal of mobility without sacrificing the inherent stability (1.3). Among the joints enabling this to occur is the acromioclavicular joint. It assists motion through clavicular rotation and enhances stability through its ligamentous attachments between the shoulder girdle and the trunk. Unfortunately, the structures that allow the acromioclavicular joint to be so dynamic also make it the most frequently sprained joint in the shoulder (7). When an acromioclavicular joint sprain occurs, the results are normally intense pain, swelling, tenderness, a noticeable stepoff deformity, and a decrease in shoulder function (3,9,lO,l2). Most individuals with acromioclavicular joint sprains seek medical attention. For the benefit of communication between health care professionals, acromioclavicular joint sprains are categorized as Grade I, 11, and 111. This classification is based on the extent of ligamentous injury and other soft tissue damage that occurs. Treatment guidelines for Grade I and I1 sprains are well established in the literature. On the other hand, controversy has long surrounded Grade I11 injuries (1,9,lO,l2). In this particular injury, there is complete tearing of the acromioclavicular and coracoclavicular ligaments with possible tearing of the deltoid and trapezius attachments (7,9). Ten years ago, standard treatment consisted of surgi-

Conservative treatment of Grade 11 acromioclavicular joint injuries usually consists of 1 immobilization of the arm in a sling for 2-4 weeks followed by physical therapy. The initial phase of rehabilitation is greatly hindered by the fact that initial sling removal ofien exacerbates a patient's symptoms. This increase in pain leads to muscle guarding and spasms which, in turn, limit the extent of range of motion and strengthening exercises that can be performed. The purpose of this article is to describe a taping technique aimed at reducing a patient's pain in order to facilitate more rapid gains in range of motion, strength, and function. Two case studies are presented to better describe the indications for its use and demonstrate its intended results. The initial outcomes are promising for increasing patients' tolerance to physical therapy and, thus, decreasing their length of stay.

Key Words: acromioclavicular joint, taping, rehabilitation

Director of Orthopaedics, HealthSouth Sports Medicine and Rehabilitation Center, Plantation, FL; Adjunct Professor, Broward Community College, Ft. Lauderdale, FL, and Lynn University, Boca Raton, FL. Address for correspondence: 17571 SW 7th Street, Pembroke Pines, F 33029. L Academic Clinical Coordinator of Education; Professor, Lynn University, Boca Raton, FL; Physical Therapist, Comprehensive Physical Therapy and Rehabilitation Center, Ft. Lauderdale, F L

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cal stabilization via internal fixation. Today, more physicians are advocating conservative treatment consisting of immobilization in a sling and physical therapy (1.7). Due to an increase in physical therapy referrals for Grade 111 acromioclavicularjoint injuries, therapists need to exchange information regarding their experiences with effective treatment strategies. Rehabilitating this injury is challenging because, in the early stages, just the weight of the arm hanging at a patient's side can be quite painful. This discomfort often makes patients apprehensive and inhibits the rehabilitation process. It is the purpose of this article to describe to clinicians a viable method for controlling a patient's pain. Two case studies will be presented to demonstrate its effectiveness and influence on restoration of function.

Anatomy and Kinesiology

The acromioclavicular joint articulation consists of a convex facet on the distal end of the clavicle and a concave facet on the acromion ( 5 9 ) . A cartilaginous disk is often present to aid in shock absorption ( I ,3,6,8). The joint's weak capsule is reinforced by the superior and inferior acromioclavicular ligaments (1). Stability is also provided by the coracoclavicular ligaments, more specifically referred to as the conoid and trapezoid (2,6). This design creates a synovial joint with three degrees of freedom (6). This joint's primary function is to maintain the articulation between the clavicle and the scapula during elevation of the upper extremity ( 1 ) . More specifically, as the scapula rotates upwardly around the anteriorposterior axis, the proximal end of the clavicle elevates, which forces the
Volume 25 Number 6 June 1997 JOSPT

-----coracoclavicular ligaments to become taut and produce clavicular rotation (6). Due to the clavicle's crank shaft design, this rotation elevates the distal end of the clavicle and allows for an additional 30" of scapular rotation (3). Consequently, patients with acromioclavicular joint sprains usually complain of increasing pain with active movement of the arm, but, specifically, those which involve shoulder flexion or abduction greater than 90" (7,9)

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C A.S E-. S T U D Y

Acromioclavicular Joint Taping

Athletic trainers have utilized t a p ing techniques to provide stability and protection to joints for years. However, their'method for taping the acromioclavicular joint is very tedious

FIGURE 1. Hypafix tape in place.

FIGURE 2. Application of the first piece of leukotape.

Discomfort often makes patients apprehensive and inhibits the rehabilitation process.
and time consuming (11). The following taping technique was developed to be time-effective and to provide enough support for the arm to decrease pain. It also does not interfere with normal shoulder motion. The technique is described in detail below:
1)The sling is removed and the shoulder is exposed for taping. 2)Skin prep is applied if the patient has a known sensitivity to tape. (If a patient has known allergies to tape, taping procedures are not recommended.) 3) Hypafix tape is measured and cut to fit from: a) the insertion of the middle deltoid inferiorly to 2.5 cm proximal
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pulled posteriorly to secure it near to the acromioclavicularjoint suthe spine of the scapula. This piece of periorly; tape should minimize superior trans6 the coracoid process of the scap ) lation of the distal end of the clavicle ula anteriorly to the spine of the and act as an anchor for the first scapula posteriorly. piece of tape (Figures 3 and 4). 4)These pieces of tape are then laid gently on the skin in respective or- 8)Steps 6 and 7 are repeated to provide extra reinforcement and to exder (Figure 1). tend the tape's effectiveness over 5)Leukotape is then measured and time. cut to form two pieces 0.5 cm shorter than the first piece of hypafix tape and two pieces 0.5 cm shorter than the second piece of hypafix tape. 6)The first piece of leukotape is anchored at the insertion of the deltoid and pulled superiorly with a considerable amount of force so that the arm is firmly supported. At the same time, the joint should be approximated with the other hand by supporting the elbow and pushing the humerus superiorly. The patient's shoulder must be relaxed. Wrinkles in the hypafix tape should appear if this part of the procedure is done correctly. Be careful not to tape the upper trapezius muscle belly, because not only does it interfere with muscle recruitment, it is very uncomfortable (Figure 2). 7)The second piece of leukotape is FIGURE 3. Application of the second piece of leukostarted over the coracoid process and tape.

CASE

STUDY

I
FIGURE 4. Top view, beiore the application oi the
reiniorcement pieces.

pate in his usual recreational activities, namely golf and racquetball. On a pain scale of 0-10, 10 being the highest, Patient A rated his pain as a 10. Objective Data General observation revealed a slightly obese male with an obvious stepoff deformity at the acromioclavicular joint. Goniometric measurements of the left shoulder's active range of motion indicated the greatest limitations in flexion and abduction at 75" and 102", respectively. Strength was graded as 2+/5 for flexion; 3-/5 for abduction and adduction; 3/5 for external rotation; and 3+/5 for ex-

RESULTS

9) Patients are instructed to monitor

the area for signs of redness and to remove the tape if any irritation occurs. For tape-sensitive persons, it is recommended that the tape be worn for 1 hour the first day, 2 hours the second day, etc.

CASE STUDY 1
Patient A is a 47-year-old male who sustained a thirddegree acromioclavicular joint injury after falling down a flight of stairs and landing on his left shoulder. Immediate care included X-rays, which were negative for a fracture, Tylenol 3@,and a sling. Two weeks later, the patient was referred to physical therapy.

Physical Therapy: Initial Evaluation

Patient History Patient A denied any prior injuries to the left shoulder. His right shoulder, however, had sustained a similar injury 10 years ago that had been surgically repaired. At the present time, the patient reported that he had returned to his desk job, but was unable to partici-

At the beginning of the second day, Patient A reported that his pain had decreased to 1/ 10 without the use of medications. In addition, he reported that he did not need the support of the sling as long as the tape was in place. The patient attempted to remove the tape between sessions and found that the pain increased to 4/10. From that time on, the patient elected to wear the tape continuously between sessions, and it was replaced at the beginning of each visit. Range of motion was measured at the end of each therapy session. With two treatments of taping, active range of motion values for shoulder flexion and abduction increased to (4). 90" and 107", respectively. After six treatment sessions, active range of motion was pain free and equal to the opposite side: 175" of flexion and 180" of abduction. It was at this time that taping was discontinued. With an additional four visits, strength testing showed that shoulder flexors, abductors, and external rotators were 4+/5, internal rotators were 5-/5, and extensors were 5/5. The patient reported that he was able to carry his briefcase in his left hand without difficulty and had returned to playing racquetball. His schedule Treatmat Each treatment seshad not yet permitted him to play sion began with the taping procedure golf. With the doctor's approval, the previously described. Pain-free, activepatient was discharged with a home assisted range of motion exercises exercise program. and submaximal isometrics were then initiated. The patient was progressed to a warm-up on the upper body erCASE STUDY 2 gometer followed by closed chain activities and progressive-resisted exPatient B is a 25year-old male ercises below 90" (7,9). The last stage who was knocked to the ground of his rehabilitation included isokiwhen a 125pound door struck his netic training of the rotator cuff and right shoulder. The patient was use of the Eagle equipment. All of rushed to the emergency room, the sessions ended with an AirCast where it was determined radiographi(AirCast, Summit, NJ) cryocuff filled cally that no fractures were sustained, with ice water for 15 minutes. Ultrabut a Grade 111 acromioclavicular sound and electrical stimulation were joint sprain had occurred. Treatment included immobilization in a sling, not utilized in an attempt to isolate pain medication, and a referral to an the effects of the taping procedure.

With the tape on, the patients reported marked symptom relief and an increased ability to sleep through the night.

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CASE

STUDY

orthopaedic specialist. The insurance company elected to send the patient to a chiropractor. After 2 weeks of treatment with no improvement, the insurance company sent the patient to an orthopaedic surgeon. It was at this time that the patient was referred to physical therapy.

Physical Therapy: Initial Evaluation

Patiat History Patient B denied any prior shoulder injuries. He reported that he was currently unable to work secondary to the physical nature of his job. In addition, he expressed that he hoped to return to swimming and basketball after his injuly healed. This patient rated his pain as 8/10 on a scale of 0-10. He was not taking any pain o r anti-inflammatory medications at the time. OhjpCtivp Data General inspection revealed a young man in good physical condition with a visible s t e p off deformity. Active range of motion measurement. were 135" of right shoulder flexion and 120" of abduction. Strength in flexion and abduction was 3+/5, internal rotation was 5/5, and external rotation was 4/5. The acromioclavicular shear test was positive for pain and laxity in the joint (4). Trpatmat Physical therapy for Patient R also began with taping, followed by the upper body ergometer, pulleys, theratubing, standing and prone progressive-resisted exercises, isokinetics, and an AirCast cryocuff filled with ice water for 15 minutes (7,9). For the first six treatments, all exercises were performed below 90".

range of motion was found to be e q ~ ~tol the opposite extremity: 180" a of flexion and abduction. Taping was discontinued after this visit. Strength increased to 5/5 for the shoulder extensors, abductors, and internal and external rotators, and 4+/5 for the flexors after a total of six treatments. The physical therapist recommended three additional visits to begin overhead and work-specific exercises, which were approved by the physician and the insurance carrier. However, the patient elected not to return to therapy and, instead, returned to work.

SUMMARY
From the results of these two case studies, the benefit. of taping appear promising. Not only was one patient able to minimize the use of prescription painkillers, both were able to discard their slings without any increase in symptoms. The ability to wean the patient. from their slings quickly helped decrease the risks of immobilization on the shoulder, elbow, and wrist. Furthermore, the t a p ing seemed to contribute to the rapid achievement of range of motion, strength, and function by decreasing the muscle guarding and spasms. In the era of utilization review, decreasing a patient's length of stay is crucial to the success of a business. It is important to keep in mind the limitations of these case studies. Primarily, they are just that-case studies. More subjects will have to be obtained and assigned to randomized treatment and control groups in order for statistical significance and correlation coefficients to be calculated. In addition, these two patients were immediately immobilized in slings and referred to physical therapy within 2 weeks after sustaining their injuries. It is likely that the results would be less dramatic if treatment had been initiated in the later stages when a pain cycle had already set in. It is not the purpose of this paper to promote discharge from the sling prior to 2 weeks postinjury. A necessary amount of healing must take place before aggressive treatment can ensue. Furthermore, when these patients did discontinue the use of their slings, they were instructed to avoid lifting anything with the involved arm. If compliance had been an issue, the patients would have been instructed to wear the sling between treatment.. In conclusion, there is an obvious need for further research in this area. The authors encourage physical therapists to explore the benefits of this taping technique and extend its

DISCUSSION
Although it is possible that the exercises and the ice were solely responsible for the decrease in pain, it is unlikely. First, both patients stated that they felt immediate relief from their pain after the taping procedure. Furthermore, both elected to keep the tape on the first night despite the therapist's instructions to remove it before going to bed. With the tape on, the patients reported marked .symptom relief and an increased ability to sleep through the night. Second, patients with the same diagnosis rarely experience such a dramatic decrease in pain after one treatment. Patient A decreased from 10/ 10 to 1/10, and Patient R reported a decrease from 8/10 to I/ 10. With this rapid decrease in pain, muscle guarding and spasms were minimized and range of motion, strength, and function were more quickly achieved. Full, pain-free range of motion was attained by Patient A in six visits and by Patient B in three visits. Overall, physical therapy was needed 10 times over a 4week period by Patient A and six times over a %week period by Patient B. These statistics for the number of treatments required for acromioclavicular joint sprains are less than the recorded averages for South Florida (5).

RESULTS
At the beginning of the second session, the patient reported that the tape "relieved the pressure" and his pain had decreased to 1/ 10. He also elected not to wear the sling when the tape was on. By the third treatment, Patient B was pain free. At this time, goniometric measurement. were taken and active

application to Grade I and I1 sprains as well. It is only through the c o l l a b rative efforts of all individuals in the field that new advances will be made.
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REFERENCES
1. Andrews JR, Harrelson GL: Physical Rehabilitation of the Injured Athlete, pp 368-4 17. Philadelphia: W.B. Saunders Company, 1 99 1 2. Kessler RM, Hertling 0 : Management of Common Musculoskeletal Disorders: Physical Therapy Principles and Methods, pp 274-535. Philadelphia: Harper & Row, 1983 3. Kisner C, Kolby LA: Therapeutic Exer6.

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cise. Foundations and Techniques (2nd Ed), pp 24 1-255. Philadelphia: F.A. Davis Company, 1990 Magee DJ: Orthopaedic Physical Assessment (2nd Ed), p 177. Philadelphia: W.B. Saunders Company, 1992 Meyers 0 : Discussion of the outcome studies conducted by HealthSouth Corporation on South Florida, November, 1995 (personal communication) Norkin C, Levangie P: Joint Structure and Function: A Comprehensive Analysis, pp 762-164. Philadelphia: F.A. Davis Company, 1983 Prentice WE: Rehabilitation Techniques in Sports Medicine, pp 207-208. St. Louis: Times Mirror/ Mosby College Publishers, 1 990 Tomberlin JP: Evaluation, Treatment

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and Prevention of Shoulder Disorders: An Integrated Approach, p 13. Philadelphia: The Saunders Group, 1993 Tomberlin IP, Saunders HD: Evaluation, Treatment and Prevention of Musculoskeltal Disorders (3rd Ed), pp 103105. Chaska, MN: The Saunders Group, 1994 TorgJS, Vegso]I, Torg E: Rehabilitation of Athletic Injuries: An Atlas of Therapeutic Exercise, pp 172-1 74. Chicago: Year Book Medical Publishers, Inc., 1987 Urso W, Gross L, Barber M: Certified athletic trainers, Plantation, FL (interview) Whiteside JA, Andrew JR: On the field evaluation of common athletic injuries. Part IV: Evaluation of the shoulder girdle. Sports Med Update 7(1):26-27, 1992

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