Acromioclavicular joint injury/AC joint sprain?

Hello,

July 24th I was surfing in Hawaii on vacation when a wave pulled me under as I was heading to shore flipping me upside down hitting my left shoulder and head on something underwater (I'm assuming it was the bottom of the ocean floor). The impact occured to the back of my shoulder just above the tie in of the posterior delt right around the area where the spine of the scapula becomes the acromion process. The impact was not particularly harsh, however it was the second time I had wiped out that day and my head and the back of my shoulder where I hit was fairly sore so I called it quits.

The pain at the time wasn't severe enough to make me instantly think I had any serious injury, however I compete in strongman so I am always worried about any injury that may take me out of training. To my memory I had full, pain free range of motion other than the soreness localized at the back of my shoulder where I hit that felt basically like a decent bruise where the bone/muscle met. However, several hours later that evening I was moving my arm around through different movements kind of feeling things out and noticed I would get a pretty pronounced yet painless click/pop every time I raised my arm up in the motion of a lateral raise (about 45 degrees from midline with my hand pronated) which worried me as I didn't remember this ever occuring this consistently before. I started to feel as if something was off with my shoulder, but I wasn't sure if something was really wrong or if I was just amplifying the pre-existing popping in my left shoulder because I was searching for something to be wrong. I do remember my left shoulder would pop on occasion, but not this frequently before the incident except when I would do lateral raises with a rubber band at which time I would get a consistent click on every rep (needless to say I never did these). This may be worth noting because I brought some elastic bands with me on vacation to do basic stretching/shoulder pre-hab work and a few days before my fall I stupidly tried a few sets of band laterals only to find the same clicking/popping present and I remember the front of my shoulder having what I can only describe as a burning/irritated sensation.

Anyways, after the fall my shoulder felt basically back to normal after a few days other than this nagging feeling that something was just off or different about it so I turned to the internet. I began searching for things relating to tendon avulsions as my first thought was that I may have partially avulsed my posterior deltoid or one of the rotator cuff tendons from the bone where I hit and came accross AC joint separations. As soon as I read the injury description I realized this was likely what had happened and looked in the mirror and found to my dismay I had a very small bump at my ac joint and upon palpation it felt as if the AC joint was larger on my left shoulder than my right. I scheduled an appointment at the local bone and joint institute and was set up with a physician's assistant who took axial and AP weight/non-weighted AC joint radiographs and performed what was in my opinion a minimal physical exam of the shoulder with my shirt on. We reviewed the X-rays and her opinion was that the X-rays were normal and I had not separated my AC joint especially considering I had full, pain free range of motion only 7 days after the fall. She said it was possible I may have created small tears in the ligament and to wait 2 weeks before resuming lifting to allow the ligaments a chance to heal up and that anything I do should be fine as long as it's not causing any pain and also that I might be dealing with a chronic problem with the AC joint. I'm not convinced with the diagnosis, but as the week goes on I have two of my friends one being a nurse and the other an MD look at my shoulder and they say it feels normal upon palpation, just inflamed at the ac joint and I start palapating it more thoroughly and begin to agree and really started to feel relieved and think that there was nothing actually wrong with the shoulder.

So at two weeks I begin lifting again and after one or to workouts I'm back to hitting moderately heavy weights in the gym, mostly pain free, except very slight twinges in the AC joint here and there, and the popping with certain movements which I would avoid. But after a few more workouts (including one in which I worked up to 500lb on some deadlifts, foolish in hindsight) my left arm starts feeling what I can only describe as tired or heavy to my trapezius so I stop working out again unsure of what to do. I schedule an appointment with a respected orthopedic surgeon and take my x-rays to him for a visit. He reviews the x-rays and does a more extensive examination of my range of motion etc with my shirt off and says that he agrees with the PA that I don't have a disruptive AC joint separation and I have a class I AC joint sprain and that I should be fine doing any training that doesn't cause a lot of pain and that some soreness is to be expected at this stage and to give it a few weeks and things should be back to normal and the popping should stop. He gives me a theraband to do rotator cuff exercises. So at this point I stop lifting weights entirely for about 2 more weeks and stick strictly to the theraband exercises for the shoulder. At this point it really starts messing with my head as I still feel like the offset between my clavicle and acromion process on my left shoulder is larger than my right and that I never had the bump prior to the fall, which to me would indicate at least the AC ligament is torn.

So I get in contact with the orthopedist again and schedule an MRI, but at a different facility than where my orthopedic surgeon is located. Finally, after some heckling I get the MRI and radiologist report released which reads that there is minimal alteration of signal intensity at the AC joint which could indicate a minimal AC joint injury/sprain and everything else was normal. I have my follow up with the orthopedic surgeon who reviews the MRI and report and says that the AC joint is pretty inflamed but there's no ligament tears or anything else going on inside of the shoulder which is good. He also remains adamant that this should all clear up, and that by the end of October my shoulder should feel as good as before, or at least very close to it and the clicking and popping should subside with as the inflamation does. I then asked him about the bump, and if this was permanent, and he said yes and no and that any of the bump caused by inflammation will go down. So I leave feeling pretty good, until I get home and start feeling the joint and again and looking at it and it doesn't seem as if the bump has gone down any. I've started tentatively lifting weights again but I have a few questions and concerns still.

Does this sound typical of a Class I AC joint separation in which the AC ligament is not torn? I feel like for the bone ends to feel out of place like this the AC ligament would have to be torn which would be more consistent with a class II.

What should I watch out for? Any specific movements I should avoid which will cause this to become more severe?

Is it normal for there to be slight variations in size between AC joints? I've gone back through old pictures and unfortunately the resolution in the shoulder area isn't very good, but there doesn't seem to be much evidence of a bump existing before the fall (I do have one on the right side but it's slightly smaller).

Is it possible that there is still inflammation in the joint this long after the trauma creating this bump? If not is there anything that can be done to reduce the visual deformity?

Thank you for your help!</SPAN>

Anyone? I'm confused how I have a small visible bump over the AC joint which from what I read is consistent with a class II separation yet my X-Ray shows no displacement and I had no localized AC joint pain, loss of strength, or loss of range of motion at the time of trauma. Does anyone have any input?

Bump, does anyone have some input? Please?

You can consider taking a second opinion from another orthopedic surgeon.