I have been working on this entry for quite some time and I hope it serves as a resource for patients who need guidance. Before beginning any physical exercise regimen, consult your doctor and make sure you are able to perform the exercises safely.
If you are reading this, I assume that you have suffered a dislocation/subluxation of your sternoclavicular joint. If you have not contacted a medical professional yet, I urge you to do so immediately. In addition, a posterior SCJ dislocation is a serious, potentially life-threatening injury that must be treated. To that end, this article will only discuss anterior SCJ dislocations.
The first step is reduction and immobilization. Your doctor will attempt to perform a closed reduction to place the medial end of the clavicle back in its proper position. In many cases, closed reduction will fail and the joint will dislocate/sublux again. This isn’t a huge concern because there are no vital structures in front your clavicle, only behind. Your shoulder girdle will be immobilized in either a sling or a figure of eight brace for 6-8 weeks. After this time period, there are three different possible scenarios: 1. The SCJ is healed, stable, and reduced, 2. The SCJ has healed in a subluxed position but is stable, 3. The SCJ has healed but remains unstable. The first two scenarios are ideal and rehabilitation can commence immediately. The third scenario depends on whether the residual instability is painful or not. If the SCJ is painful and unstable, then a decision must be made regarding treatment. Instability that remains after a lengthy period of immobilization may be resolved by surgery or regenerative injection therapy (prolotherapy, platelet rich plasma, mesenchymal stem cells). That is a decision that must be made by consulting with your doctor. In general, spontaneous SCJ dislocations have poor outcomes when treated surgically. Traumatic dislocations have good to excellent outcomes depending on the surgical technique. The difference between spontaneous and traumatic is the following: spontaneous means your clavicle decided to randomly pop out and say hello, while traumatic means you dislocated it after falling or taking a hit. Spontaneous dislocations will usually be painless while traumatic dislocations are accompanied by tremendous pain. It’s my opinion that conservative treatment should always be attempted before more invasive procedures. I recommend the following order of treatment:
- Immobilization – let the connective tissue heal.
- Physical therapy - the SCJ may have healed/become stable or remain unstable. Either way, physical therapy will help retrain the muscles of the shoulder girdle and take some pressure off the SCJ. If the joint is unstable but painless, then no further treatment is needed unless you wish to play an overhead sport or a sport that puts a tremendous strain on the SCJ.
- Regenerative injection therapy – there are many names for this treatment: prolotherapy, sclerotherapy, etc. but the idea is to get your body to heal the connective tissue to a shorter length and stabilize the joint. This is a great option for people who wish to avoid the risks of surgery, but it is also takes a long time to achieve significant results.
- Surgery - many different techniques exist to stabilize the SCJ and some of them can be found in the ’Knowledge’ section of this website.
I will begin this section under the assumption that your SCJ has been treated and is currently pain free. It is not a replacement for physical therapy, but rather a mix of exercises that I have personally found to be useful. You should always consult your doctor and physical therapist before attempting any exercise or stretch that has not been prescribed.
The first step is to regain shoulder ROM. I will spare you the technical details and tell you which stretches to perform.
- Pendulum stretch – Start with the pendulum stretch, it will relax the shoulder muscles and keep the capsule from becoming short.
- Sleeper stretch – The sleeper stretch will lengthen the external rotators and restore proper posterior gliding of the humerus on the glenoid fossa.
- Pec minor stretch on swiss ball – The pec minor becomes extremely short when your arm is placed in a sling or if you push far more than you pull during weight lifting.
- Lat stretch on swiss ball – I like to perform the last stretch on a swiss ball because it lets you roll the ball around and create a variety of angles. To increase the stretching, tilt your pelvis away from the arm being stretched. You should feel a stretch go all the way down from your armpit to the bottom of your rib cage.
- Pull-up bar stretch – Only progress to the pull-up bar stretch once you feel comfortable with the lat stretch on the swiss ball. Do not actually hang from the bar. Stack some blocks up underneath it, grasp the bar and then slowly and gently lower yourself into a stretch by bending your knees and feel a stretch through your chest and lats. Keep the weight of your body supported by your legs.
- Tricep stretch – This is a common stretch I’m sure you’ve done in the past. Perform it slowly and do not push the range of motion on this one. You should let off the stretch if you feel discomfort or if you feel the muscles locking up and spasming. At that point, you won’t be stretching the muscles, you’ll be stressing the ligaments of the SCJ instead.
- Scalene stretch – Perform this while sitting down. This is a good stretch to help prevent thoracic outlet syndrome. It can become tight in SCJ dislocations due to the attachment points of the scalene muscles. If you feel numbness or tingling in your arms/fingers, etc. let off the stretch and tell your doctor.
- Trap stretch – Do not apply too much pressure in this position. All you’re looking for is a nice, comfortable stretch. The traps can become chronically tight in the body’s effort to protect the SCJ by protracting and elevating the shoulder girdle, taking the stress off the anterior portion of the joint capsule.
- SCM stretch – Do not turn your head too much with this one. You should feel a light stretch in the front of your neck on one side.
- Levator scapulae stretch – when this muscle is tight, the scapula will be elevated and pulled medially. Do not pull down hard on your head, apply very light pressure and discontinue/see your doctor if you feel numbness/tingling anywhere.
Scapular stabilization exercises
If the shoulder blades do not move properly, the SCJs will be exposed to abnormal forces. By stabilizing the scapulae, we establish a solid base for the shoulder girdle to rest upon the rib cage and it will allow the SCJs to function optimally.
The main thing we need to establish is proper scapular retraction and posterior tilting. After an anterior SCJ dislocation, the body will guard itself and resist scapular retraction because it places a lot of stress on the anterior SCJ capsule. We must train this movement pattern in order to tell our body that is safe to perform scapular retraction. If the shoulder girdle remains in a guarded, protracted position, it may lead to impingement and rotator cuff problems. Perform the following exercises with a light theraband or tubing.
- Retraction plus external rotation – first retract your shoulder blades and then externally rotate your arms. With time, you will be able to retract as your externally rotate and it will become one fluid movement.
- Horizontal pull-apart -Keep the palms facing the ground and retract your shoulder blades as your arms come out to the side.
- Diagonal pull-apart – Make sure to keep your thumb pointed up on the arm going up. This will prevent any possible shoulder impingement.
PNF movement patterns (sword),
Progress to lying WTYL.
Typical exercises to avoid
- Barbell bench press – If you’re a powerlifter, you knew this was going to be number one on the list. No one can tell you what to do with your body, but just be aware that in order to protect your shoulders you must maintain a fully retracted position on the bench. Combine this full retraction with hundreds of pounds going straight down. It will expose the SCJ ligaments to tremendous forces and you may injure yourself again. There are plenty of alternative discussed later.
- Barbell Back squats – This is another exercise where your shoulder blades have to be held tightly in a retracted position. Combine that with thoracic extension to keep your chest up in the hole and you have a lot of forces acting on the SCJ in the anterior direction. There are plenty of other exercises to replace this with.
- Barbell Front squat – You’re resting the bar across your collarbone, avoiding this is common sense.
- Dumbbell flies – These place a huge amount of strain on the SCJs and can easily injure them. I would avoid this.
- Behind the neck anything – Not only is bringing the bar down behind your head bad for your rotator cuffs, it also places a strain on your SCJ. Be nice to your body and bring the bar down in front to your chest when performing shoulder presses and pullups.
- ***Shoulder presses – I put stars next to this one because it is conditional. If you lack the proper ROM needed to perform an overhead press correctly, then you should stay away from it because it will probably end up hurting you. On the other hand, if you have the proper ROM and it does not cause any discomfort, it is a great way to strengthen the shoulder girdle. A word of advice, don’t let the weight get too far behind you or it will place a lot of stress on the SCJ capsule that is already maximally taut.
- ***Dips – This is another conditional exercise. It exposes the SCJs to a lot of force and is notorious for injuring shoulders when not performed properly. Take it very slow on this one and ease into it. If it causes you pain in your sternum or SCJs, discontinue it.
A word of advice on the above exercises: If you’re a powerlifter and some of these lifts are your life, then ease back into them slowly and accept the risks you’re taking by performing them. NO ONE can tell you what to do with your body and you are the best judge of what is appropriate. If you are a bodybuilder or weight lifting enthusiast, please read on and consider the following replacement exercises. They will still induce muscular hypertrophy and some are quite challenging.
Replace barbell bench press with: Push-up variations including pushups with chains and weight vests. The scapulae are free to move while performing pushups and they are not maximally retracted for extended periods of time. They are excellent for promoting scapular stability and they are far safer than bench press exercises, which are usually improperly performed.
Replace barbell back/front squats with: Trap-bar deadlifts. They allow you to get into a squat-like position, but you hold onto the weight, allowing your shoulder blades to remain neutral and offers extra work to your upper back and grip.
Replace DB flies with: Partial ROM cable cross-over. I feel that these offer more control over the entire range of motion and they’re easier to bail out of if things go wrong. I wouldn’t take the ROM very far, just focus on a good contraction and then stretch the muscle out between sets.
There are a ton of exercises out there to replace risky ones with and here is a small list.
Lower: Lunges, unilateral DB lunges, reverse lunges, elevated reverse lunges, leg press machines, leg curl machines, glute ham raise, sled dragging/pulling, all kinds of deadlift variations (without pain), one leg squats, goblet squats, KB swings, swiss ball leg curls, glute bridges, reverse hyperextensions, TKEs, etc.
Upper: Push ups (with bands, chains, weight vests, different angles, one leg, etc.), KB swings, unilateral DB bench press on swiss ball, pull-up variations, pulldowns, all kinds of curls and extensions (overhead extensions are a little risky, use common sense, if it hurts don’t do it), DB rows of all kinds, renegade rows, etc.
Core: Planks, glute bridges, side bridge, pallof press, woodchops, cable lifts, leg raises, etc.
There are a ton of exercises you can come up with in order to train around your weak spot. If you need some help brain storming, drop me a comment and we can come up with some more.
****This is still being edited.