What Works
Scapular Dyskinesis-Based Exercise Therapy (SDBET) HIGH
Structured exercise targeting shoulder blade stabilizers — starting with the arm by your side (short-lever), progressing to overhead movements only after blade control is established. This is the cornerstone treatment for all grade separations and prevents shoulder blade dysfunction developing after the injury.
Exercise Prescription — Shoulder Blade Foundation
Scapular squeeze: Sit or stand, gently squeeze shoulder blades together and hold 3 seconds — 2×10, 3× daily. Serratus punch: Lie on back, push arm straight toward ceiling (punching the sky), then let shoulder blade flatten back down — 2×10, daily. Low row with band: Pull light band toward hip with elbow close to body — 2×12, daily. Prone Y/T: Face down, raise arms in Y and T shapes alternately (thumbs up) — 2×10 each, 3× per week. Pain guide: 0–3/10 during; no delayed pain >24h after.
Brief Sling Immobilization (3–14 days) HIGH
Sling offloads arm weight from the healing ligaments acutely. The goal is to wean off as soon as resting pain resolves — not to use it as a prolonged crutch. Prolonged sling use beyond pain management risks stiffness and actually contributes to the blade dysfunction you're trying to prevent.
Sling Protocol
Use for comfort during the first 3–14 days. Begin gentle blade exercises (scapular squeeze, pendulums) from Day 1 — the sling does not mean rest. Wean off sling as soon as pain at rest settles, typically by day 7–14 for Type I/II, day 7–21 for Type III.
Conservative Management for Type III (surgery is not the first move) HIGH
Two 2024–2025 meta-analyses (Bosco 2025, N=397; Giai Via/Li 2024, N=244) confirm identical long-term shoulder function between structured conservative management and surgical reconstruction. Conservative management returns contact sport athletes to play 73 days faster on average (52 vs 125 days). The surgical discussion belongs at 6 weeks only if structured rehab has genuinely failed.
Tier 2 — Moderate Evidence
Blood Flow Restriction (BFR) Training MODERATE
During the first 4 weeks when overhead loading is restricted, BFR maintains the muscle-building stimulus using light weights with the arm by your side. Protocol: 30-15-15-15 repetitions, 20–40% of your max weight, cuff at 40–80% limb occlusion pressure. Maintains deltoid and rotator cuff muscle mass without applying shear stress to the healing joint.
BFR Protocol — Upper Extremity (Weeks 1–4)
Apply cuff to upper arm at 40–80% limb occlusion pressure. Suitable for: bicep curls, tricep pressdowns, cable rows (short-lever), forearm exercises. Continue lower body training unrestricted throughout recovery.
NSAIDs (Short-term) MODERATE
5–7 days of anti-inflammatory medication for acute pain in the first week. Not a substitute for active rehabilitation — pain control should enable movement, not replace it.
Manual Therapy (Adjunct) MODERATE
Hands-on treatment from a physical therapist reduces pain and aids movement restoration. The mechanism is neurophysiological — it influences pain signals and improves movement confidence — not structural realignment. Effective as an adjunct to active exercise in the first 4–6 weeks.
Heavy Slow Resistance (HSR) for Secondary Tendinopathy MODERATE
If rotator cuff tendinopathy develops due to altered mechanics after ACJ injury, HSR loading is first-line: 3–4 sets of 6–8 reps at 70–85% max weight, 3-second lift / 4-second lower cadence. Applies mechanotransduction (how physical stress triggers tissue repair) to rebuild tendon capacity.
Tier 3 — Clinical Experience / Emerging
ACJ Protective Padding on Return to Contact Sport EMERGING
Custom or standardized donut-shaped pads worn over the AC joint distribute impact forces away from the joint during contact. Based on expert consensus and case series — no RCT evidence, but logical mechanical rationale for rugby, hockey, and football.
Intra-articular Corticosteroid Injection EMERGING
For chronic symptomatic ACJ arthritis unresponsive to exercise — short-term pain relief only, not a curative treatment. Not appropriate for acute separations.
What Doesn't Work
- Rest + sling alone (without shoulder blade exercises): Leads to shoulder blade dysfunction in up to 70% of Type III cases. Rest is not treatment.
- Premature overhead loading before shoulder blade control is established: Applies pathological forces to the incompletely healed joint — pain-free range of motion is not the only criterion for progression.
- Routine surgery for all Type III injuries: Two 2024–2025 meta-analyses (N=397 and N=244) show no functional advantage at 2+ year follow-up. Adds surgical complication risk. Delays return to sport by an average 73 days compared to conservative management.
Exercise Prescription
Full exercise progression is integrated above within each treatment recommendation. Key progression gates: Week 0–2 (arm by side only), Weeks 3–6 (elbow-height pushing), Weeks 6+ (criterion-based overhead, not calendar-based).