In the Treatment Room: Florida State's Christian Ponder Separates Shoulder in Loss to Clemson Tigers

In the 40-24 loss to the Clemons Tigers in Death Valley, the Seminoles may have lost more than the game. Late in the fourth quarter, Christian Ponder suffered a separated his throwing shoulder while forcing Clemson Safety DeAndre McDaniel out of bounds during his return of Ponder's fourth interception of the game. Ponder could have easily tried to tackle him high, dive at the turf or simply get out of the way. Instead, he decided to take McDaniel head on. Unfortunately, as soon as Ponder stood up after the hit, it was clear that he had injured his shoulder. The positioning of his arm on the sideline suggested that he was in pain.

In this edition of 'In the Treatment Room,' TNation takes a closer look at shoulder separations and what this might mean for Christian Ponder and the remainder of the Seminoles' season.

Unfortunately, the shoulder is one of the more complicated joints in the body, which is also why it is one of the most dynamic joints in the body. Think about all of the various directions you can move your shoulder and compare that to your knee or hip. The ability of the shoulder to have so much movement results from the multiple boney and muscular elements in that area as illustrated in this image:

http://www.niams.nih.gov/Health_Info/Shoulder_Problems/images/shoulder_qa.gif

Photo from here.

The three primary bones that make up the shoulder joint are the humerus (your upper arm), the clavicle (your collar bone) and the scapula (that triangular bone on your). We must also consider that sandwiched between all of that is your rib cage. The other important elements to note in the photo are the rotator cuff (which is composed of the tendons of the four muscles listed above) the bursa (which is a fluid filled sac that acts as a cushion) and the Acromioclavicular Joint (the is where a portion of the scapula and clavicle come together). Here are two other images of the shoulder that demonstrate the complexity of the joint and show the neurovascular tissues that run through that area:

                       http://www.ganfyd.org/images/d/d9/Shoulder.pngShoulder joint

Photos from here and here.

Typically, when athletes suffer a shoulder separation, it occurs at the Acromioclavicluar (AC) joint. The AC joint is a key part of the shoulder in that it allows rotation in three different planes: moving your arm out to your side (abduction and adduction), rotation of the clavicle and permitting your scapula to move away from your body. The joint is supported by two ligaments: AC ligament and Coracoclavicular. The upper portion (superior) of the AC ligament is the most important ligament in stabilizing the joint for daily activities.  You can feel your AC joint by running your fingers out to the lateral edge of your clavicle. Lift your arm out to your side. Where you feel that flexion/rotation point is your AC joint.

A shoulder separation typically occurs when there is a direct blow to the shoulder, just like Ponder's hit, or falling on to an outstretched arm, like Lance Armstrong falling off his bike. Keep in mind that a shoulder separation and dislocation are two entirely different injuries. A dislocation occurs when the head of the humerus is forced out of the joint. This is the injury that athletes get their shoulder "popped back in." The separation occurs, as described above, at the acromioclavicular joint. The most common presenting sign of the separation is pain, which can be quite severe. Other signs of trauma to the shoulder may also be apparent.

If a shoulder separation is suspected, an X-ray is typically performed to help grade the injury and to identify and possible fractures.

Here is a normal shoulder x-ray:

http://stemcelldoc.files.wordpress.com/2009/02/shoulder_x-ray_2.jpg

Photo from here.

Here is an image of a separated shoulder:

http://blog.brianschiff.com/wp-content/uploads/2009/07/ac_joint2.jpg

Photo from here.

As you can see in the image on the bottom, there joint between the acromion and clavicle is...separated. There isn't that nice alignment that we see in the upper image.

AC Separations are graded based on the severity using the Rockwood Classification:

Grade I: A sprain without a complete tear of either ligament.

Grade II: Tear of the AC ligament with an intact coracoclavicular ligament. The end of the clavicle is not raised.

Grade III: The AC and Coracoclavicular ligaments are both torn. The end of the clavicle is raised 5mm.

Grade IV: The end of the clavicle is pushed behind the AC joint. There is usually a clear deformity at the end of the clavicle.

The treatment of a shoulder separation is dependent on the grade of the tear. As these injuries are quite painful, they are treated with NSAIDs (Motrin etc) and Narcotics and ice. With Type I injuries, a sling is typically used until range of motion exercises can be done without pain. Type II injuries usually require a sling for one to two weeks followed by rehabilitation. Some say that heavy lifting and contact sports should be avoided for 6-12 weeks after this kind of injury. But as we saw with Sam Bradford, he returned rather quickly...but re-injured his shoulder. If the ligament isn't allowed to completely heal, you can easily turn a Grade II sprain into a Grade III.

In general, Grade III and higher separations require surgery. Depending on the type of individual, some Grade III injuries may be managed medically. Surgery typically involves an open procedure (meaning not arthroscopic) to repair the damaged ligaments and structures. This can either be done with various devices screwed across the joint. Patients will remain in a sling for approximately 2 weeks, after which rehab will begin. If a non-absorbent screw is used, it will be removed 6 weeks after the original surgery.

Grade I and Grade II injuries usually do very well and recover to pre-injury ability. Some individuals do report chronic mild pain, but are typically not significant.

We don't have the full details of Ponder's injury yet. It will be likely that he gets an MRI to evaluate the extent of damage to the ligaments involved. Let's hope that it is only a Grade I or II sprain, avoiding surgery. Given Ponder's potential, one would hope that the athletic trainers and coaching staff will shut him down for the rest of the season. Forcing the issue with a shoulder separation can lead to disastrous results. Ask Oklahoma. If Ponder is able to return, Florida would likely be the first game that he would be available. With the potential that he has demonstrated and the trajectory that this offense has shown, let Ponder recover and look toward a better year next year.

What are your thoughts? Was last night Ponder's last game of the season? Should it be his last game?

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