Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Job Classification

In most duration tables, five job classifications are displayed. These job classifications are based on the amount of physical effort required to perform the work. The classifications correspond to the Strength Factor classifications described in the United States Department of Labor's Dictionary of Occupational Titles. The following definitions are quoted directly from that publication.

Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Sprains and Strains, Acromioclavicular Joint


Related Terms

  • AC Separation
  • Shoulder Separation

Differential Diagnosis

Specialists

  • Occupational Therapist
  • Orthopedic (Orthopaedic) Surgeon
  • Physiatrist (Physical Medicine and Rehabilitation Specialist)
  • Physical Therapist
  • Sports Medicine Physician

Comorbid Conditions

Factors Influencing Duration

Dominant versus non-dominant side injury and degree of separation are important factors in determining disability. Returning to work duties that require manual dexterity, lifting, or carrying will require a longer period of recovery. Surgical repair of the injury will increase disability time. Especially if work responsibilities require manual dexterity, repetitive use of the joint, or heavy lifting overhead using the affected arm.

Medical Codes

ICD-9-CM:
840.0 - Sprains and Strains of Shoulder and Upper Arm, Acromioclavicular Joint (Ligament)

Overview

An acromioclavicular (AC) joint sprain is the result of injury to the ligaments crossing from the collarbone (clavicle) to the acromion, or upper part of the shoulder blade. An AC joint sprain results from excessive or abnormal forces that injure the ligaments without causing a shoulder dislocation or fracture. A strain is the result of overuse or injury of the muscles (muscle tear) supporting the AC joint; it is not as serious as a sprain but may cause pain. The AC joint is an important joint because it is the only true bony attachment of the arm to the rest of the skeleton. The joint is relatively small and normally fairly rigid.

A sprain of the ligaments of the AC joint results in varying degrees of looseness (laxity) and deformity of the joint. Sprains are graded as to the severity of ligament damage and resulting separation of the joint. In grade I, or first-degree AC joint sprains, some stretching of ligament fibers has occurred, but without any disruption of the joint. In grade II, or second-degree sprains, the damage is greater, resulting in some fibers being torn and minimal disruption, or displacement, of the joint. Grade III, or third-degree sprains, include a complete disruption (dislocation) of the joint because all the ligament fibers are torn (ruptured). Grade IV through VI sprains are much rarer, are of much greater severity, and are discussed under acromioclavicular dislocations.

Acromioclavicular sprains occur most often during contact sports, but any impact to the top of the shoulder or a fall onto the shoulder can injure the joint if the force is greater than the ligaments can accommodate. Most often, the force is focused on the tip of the shoulder. Shoulder injuries from falling onto an outstretched arm are more likely to result in a humeral neck fractures or glenohumeral joint dislocations, and a heavy object falling on the shoulder is more likely to result in a fracture.

Sprains and strains of the acromioclavicular joint are often incorrectly confused with shoulder (glenohumeral) dislocation.

Source: Medical Disability Advisor



Causation and Known Risk Factors

Individuals at greatest risk for an AC dislocation include athletes in contact or collision sports (e.g., downhill skiing, rugby, ice hockey, football), or workers participating in activities that could result in falls onto the shoulder or contact with an object while moving; much less commonly, having an object fall on the shoulder or falling onto the outstretched hand and arm may result in an AC joint sprain.

Source: Medical Disability Advisor



Diagnosis

History: Individuals usually report a direct blow to the tip of the shoulder, either from a fall (e.g., landing on the side of the shoulder in a football tackle), or from a push or stumble (e.g., being checked into a wall when playing ice hockey). Individuals may complain of pain and weakness, and note a bump on the top of the shoulder. The bump is caused by depression of the scapula relative to the clavicle and swelling (edema) of the joint itself. Pain may radiate into the base of the neck or down the arm. The individual often carries the arm across the chest, cradling it under the elbow.

Physical exam: Direct visual comparison with the uninjured shoulder reveals an asymmetry of the two joints. Often abrasions can be observed across and somewhat behind the joint. Moving the shoulder-joint complex reveals weakness of the shoulder, limited active shoulder range of motion, and painful assisted range of motion. Close observation of range of motion and elicited pain helps to distinguish AC sprains and strains from other common shoulder pathologies. The bump or high-riding tip of the clavicle may be repositioned (reduced) into its normal anatomical position by the individual or the doctor, but this maneuver can be painful.

Tests: X-rays of the AC joint are taken to establish position of the acromion and clavicle and to rule out associated fractures. In rare severe trauma cases, an MRI, CT scan, or nerve conduction studies may be needed to evaluate damage to the surrounding tissue. Ultrasound may be used in some cases to further evaluate or confirm findings obtained by physical exam or x-ray.

Source: Medical Disability Advisor



Treatment

Grade I injuries are treated with a sling and gradual range of motion and strengthening exercises. Cold therapy and pain medications may be indicated.

Grade II injuries may be treated with a sling, a harness, and physical therapy. Use of a special harness that applies pressure to the clavicle to hold it in position while the ligaments heal can be effective, but it is uncomfortable. Careful attention must be paid to the skin under the straps to avoid pressure sores and skin infection. Ice, pain medication, and physical therapy are added when appropriate.

Grade III injuries may be treated with a sling, strapping, or surgery; they may also be treated with pain management, early physical therapy, and acceptance of the deformity. Surgery is more likely to be suggested if the individual is intolerant of the strapping device, does not want to have the bump remain on the top of the shoulder, or if lifestyle demands include heavy overhead work. The surgical procedure is open reduction, internal fixation (ORIF). The bones are realigned and a metal screw may be inserted, or material such as sutures, synthetic graft material, or wire may be used to hold the joint in position. If a metal screw is used, it may be removed later.

Grade IV, V, and VI injuries are typically treated with surgery to repair the ligaments and fix the joint in its proper place for healing, followed by physical therapy.

All methods of treatment may require up to 6 to 8 weeks of treatment time. After the dislocation is healed, pain in the joint may be treated with corticosteroid injection.

Source: Medical Disability Advisor



ACOEM

ACOEM's Practice Guidelines, the gold standard in effective medical treatment of occupational injuries and illnesses, are provided in this section to complement the disability duration guidelines.*
 
Shoulder Disorders
 
* The relationship between the MDGuidelines (MDA) content and ACOEM's guidelines is approximate and does not always link identical diagnoses. The user should consult the diagnostic codes in both guidelines, as well as the clinical descriptions, before assuming an equivalence.

Source: ACOEM Practice Guidelines



Prognosis

Normal joint function should return after grade I and most grade II injuries in about 6 to 8 weeks. Grade III, IV, V, and VI dislocations treated surgically require more extensive therapy for full recovery. Aggressive therapy often cannot begin until 6 weeks after surgery.

Grade II and III injuries not treated surgically to reduce the dislocation leave the individual with a permanent bump on the tip of the shoulder. Surgery leaves a scar about 2 inches long.

Source: Medical Disability Advisor



Rehabilitation

Rehabilitation of acromioclavicular sprain or strain depends greatly on the severity of the injury. For example, in some cases, individuals may require immobilization in a sling for a short period to control pain (Rizzo), whereas in other cases, individuals may require prolonged use of a sling, in conjunction with supervised exercise.

Individuals with a grade I or II injury may be instructed in range of motion exercises for the hand, wrist, and elbow. Modalities such as ice may be used when necessary to control pain and edema. Once the acute pain is relieved, the individual is instructed in shoulder range of motion and strengthening exercises. Generally painful movements such as horizontal adduction and full passive flexion are avoided initially (Rizzo). The rehabilitation process may warrant the observation and guidance of a physical therapist or occupational therapist until the individual progresses to an independent exercise program.

Individuals with a grade III injury may be managed operatively or nonoperatively (Rizzo). If managed nonoperatively, the individual may be instructed in range of motion exercises for the hand, wrist, and elbow during a period of immobilization. After the initial immobilization period, the individual is instructed in shoulder range of motion exercises and progressed to exercises that strengthen the arm and shoulder (Rizzo). All exercises need to be limited to the pain-free arc of motion. Strengthening exercises progress in intensity as the individual's pain decreases and strength improves, which generally occurs gradually over 6 to 12 weeks (Rizzo). Individuals are instructed in a home program that reflects the exercise regimen prescribed during rehabilitation. If managed operatively, rehabilitation will proceed as described for grades IV, V, and VI.

Individuals with a grade IV, V, or VI injury are generally treated surgically. (See acromioclavicular dislocation). Rehabilitation protocols are guided by the treating physician. The general focus of rehabilitation is to reduce pain and regain full function of the shoulder girdle.

FREQUENCY OF REHABILITATION VISITS
Nonsurgical
SpecialistSprains and Strains, Acromioclavicular Joint
Physical or Occupational TherapistUp to 12 visits within 6 weeks
Surgical
SpecialistSprains and Strains, Acromioclavicular Joint
Physical or Occupational TherapistUp to 8 visits within 4 weeks
The table above represents a range of the usual acceptable number of visits for uncomplicated cases. It provides a framework based on the duration of tissue healing time and standard clinical practice.

Source: Medical Disability Advisor



Complications

Chronic pain and decreased joint function develop in some individuals, especially those who have degenerative arthritis. AC joint arthritis may be treated by a Mumford procedure, in which the distal clavicle is surgically resected to remove the diseased joint (arthropathy). If the end of the clavicle is damaged, it may need to be removed surgically to reduce the chance of developing arthritis. A small cushion of tissue (meniscus) between the bone ends may be dislodged during the injury and may require surgery to repair or remove. Any fractures around the shoulder area complicate recovery.

Skin abrasions are common with this injury and require careful monitoring during treatment to prevent infection. Careful attention must be given to the skin around the bump to observe stretching (tenting) and tearing. Treatment may be necessary to prevent further damage to the skin and soft tissue around the bump.

Chronic pain from the injury after nonoperative (conservative) treatment may be an indication for removal of the end of the clavicle (excision of the distal clavicle).

Skin and bursa infections may develop in the area of an abrasion. Damage to the nerves and vessels in the clavicular area is less likely, but it can occur.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

Individuals must avoid lifting, carrying, pulling, pushing, or reaching to perform overhead work for 6 to 8 weeks. Individuals prescribed a sling or harness may find their movements and manual dexterity temporarily limited. Individuals may require temporary job reassignment. Company policy on medication usage should be reviewed to determine if pain medication use is compatible with job safety and function.

Source: Medical Disability Advisor



Failure to Recover

If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case.

Regarding diagnosis:

  • What grade of sprain (I, II, III, or higher) did the individual sustain?
  • What was mechanism of injury?
  • Does individual complain of pain and weakness?
  • Was a bump detectable on the top of the shoulder?
  • Was individual carrying arm across chest, cradling it under elbow?
  • On visual exam of both shoulders, was asymmetry noted?
  • Did physical exam reveal weakness of forearm, limited active range of motion, and painful assisted range of motion of AC joint?
  • Has individual undergone x-ray of affected area?
  • Was it necessary for individual to undergo MRI, CT, or other imaging? Nerve conduction studies?
  • Have conditions with similar symptoms been ruled out

Regarding treatment:

  • Is individual's treatment appropriate for grade of injury?
  • Has enough time elapsed for treatment to be effective for the level of sprain/strain diagnosed?
  • Is individual being treated with sling, ice, and pain medication?
  • Has individual been prescribed a sling or harness? Is individual using it?
  • Has individual been prescribed physical therapy? Was surgery performed?

Regarding prognosis:

  • Is individual active and compliant in rehabilitation?
  • Does individual engage in a home exercise program?
  • Is individual's employer able to accommodate any necessary restrictions?
  • Does individual have conditions that may affect ability to recover?
  • Does individual have complications such as damage to the end of the clavicle or dislodged meniscus?
  • Did individual develop infection in the skin or bursa?
  • Did individual experience associated damage to nerves or blood vessels?

Source: Medical Disability Advisor



References

Cited

Rizzo, Thomas, et al., eds. "Chapter 9 - Acromioclavicular Injuries." Essentials of Physical Medicine and Rehabilitation. 2nd ed. Philadelphia: Saunders, Elsevier, 2008.

Source: Medical Disability Advisor






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