Hot under the collar

By Tanya Bell-Jenje

Visualise a cyclist crashing and you’re bound to picture an outstretched arm trying to cushion the blow. The shock from the impact travels up the arm to the collarbone strut. No wonder then, that fractures to the clavicle or injuries to the acromioclavicular joint (ACJ) and the surrounding ligaments are among the most common traumas seen in cyclists.

Fractures of the clavicle
The majority of fractured or broken collarbones can be diagnosed at the crash site. There is, of course, severe pain, and you will immediately need to support your elbow with the opposite hand. Part of the bone may be jutting out at an odd angle, or even breaking through the skin. You will need an X-ray and, if a fracture has occurred, orthopaedic management will also be required. Fractures that are treated conservatively will require you to wear a sling for four to six weeks.
Certain fractures may require surgical repair. This is to prevent damage to the neurovascular bundle around the fracture site, avoid shortening of the clavicle, which may result in rotator cuff damage later on, or to improve the cosmetic appearance of the structure. Surgical repair can also reduce the risks of non-union, improve pain and speed up recovery as the fracture is stabilised immediately.
After your surgery, indoor cycling should be safe after three weeks and outdoor cycling after six to eight weeks, but whether you meet these milestones will depend on the severity of the fracture and the surgeon’s ability to achieve good fixation. You can build up intensity gradually, starting with base training. Pro cyclists run to different time frames and tend to return to the road much sooner, but they understand and accept the risks involved, plus they have expert supervision and high-level resources at hand.

AC joint injuries
Not all over-the-bar excursions result in fractures. Often crashes cause ligament injuries and subluxation (incomplete or partial dislocation) of the ACJ, or complete dislocation. Treatment depends on the extent of the damage and the degree of joint displacement.
ACJ injuries can be graded from one to six. Usually a small impact causes a mild sprain of the AC ligament and joint capsule – the X-ray appears normal. A greater force causes more joint damage and the X-ray reveals a visible step where the two pieces of bone are no longer aligned as the suspensory support of the arm is lost. As the grade of the injury increases, so does the amount of joint displacement from minimal, to partial to complete displacement of the joint surfaces. The greater the joint displacement and mal-alignment of the structures in the joint, the greater the likelihood for surgical intervention.

You will notice a lump at the ACJ, where the clavicle meets the bony extension (acromion) where the shoulder blade and the collarbone come together. A bigger lump equals a bigger disruption. Symptoms include pain on movement of the shoulder, especially with above-head actions, movement of the arm across the body (horizontally), and placing the hand behind the back. There will be night pain and rolling on your affected side will be especially sore. Cycling will be extremely painful as the forces transmitted through the handlebars to the ACJ injury will jar the damaged ligament and joint. Mountainbiking will put more strain on the ACJ than road riding.

Management of these injuries is a challenge for the cyclist wanting to get back on the bike because they require time to heal and returning to the road too early can result in further damage to the ACJ and long-term rotator-cuff damage.

References
Dr Dinos Kastanos (MB,BCh (Wits), FCS(SA)Orth)
Lauren Bradfield (BSc physio) – research assist
Brukner, P. & Khan, K. Clinical Sports Medicine. Third edition. McGraw-Hill Publishers. 2009. 267 – 271.
Hyde, E. T. & Grengenbach, M.S. Conservative Management of Sport Injuries. Second Edition. Jones and Bartlett Publishers. 2007. 520 – 525.

Tanya is a founding partner of Bell & Rogers Physiotherapy Practice, situated in Bryanston, Sandton and Wilgeheuwel Hospital, Johannesburg (www.physioworx.co.za). She is a respected lecturer and has been medically involved in sport for many years at national and international level. She is also a seriously keen cyclist.