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Ironman: Going the Distance After a Shoulder Separation

Last May, 50-year-old John Foley of Bayport, Long Island, completed a Half Ironman Triathlon, an athletic feat most people half his age would have trouble achieving. He entered the race just nine months after he was sidelined by a serious shoulder injury. At the time, he wondered if he'd ever compete again.

In the Half Ironman in Saint Croix, Mr. Foley completed a 1.2-mile swim, a 56-mile bicycle course and a 13.1-mile run. He finished just two minutes shy of his prior year's time. The race was even more meaningful because it came less than a year after surgery and rehabilitation to repair his shoulder injury.

Mr. Foley fell off a mountain bike in August 2007. While most people have heard of a dislocated shoulder, Mr. Foley had suffered a shoulder separation. Less common than a dislocation, it can be equally debilitating. "It was painful. My arm looked like it was hanging four or five inches lower than my other arm, and my collarbone was pushing upward."

Mr. Foley went to see Dr. Frank Cordasco, an orthopedic surgeon specializing in sports medicine knee and shoulder injuries at Hospital for Special Surgery. Mr. Foley had gotten a referral from a friend who was very pleased with the care he received at HSS. Mr. Foley was not disappointed. "Dr. Cordasco took the time to explain my injury and my options, and he was totally correct in his recommendations."

To understand a shoulder separation, it helps to have some basic knowledge of anatomy. The shoulder joint has three main bones: the upper arm bone (humerus), the collarbone (clavicle), and the shoulder blade (scapula). The scapula is a flat, triangular bone that connects the arm bone and the collar bone. Muscles, tendons, and ligaments support and stabilize the joint.

"The shoulder is a complex joint that has a greater range of motion than any other joint in the body," explains Dr. Cordasco, surgical director of the HSS Ambulatory Surgery Center. "Because of this mobility, a shoulder injury is likely to cause problems with function and sport-related activities."

A shoulder separation occurs most often during athletic activity, frequently resulting from a fall or a sharp blow to the top of the shoulder. Common causes include bicycle and equestrian accidents; collision sports, such as hockey and football; and falls that result in the person landing on the shoulder, which is what happened to Mr. Foley.

The collarbone and the shoulder blade are connected by a joint called the acromioclavicular, or AC, joint, and they are held together primarily by two ligaments. A shoulder separation describes a condition in which these ligaments are partially or completely torn. The "separation" occurs when a sharp blow or a fall causes the collarbone to move away from the upper portion of the shoulder blade.

A shoulder separation can range from mild to severe. A mild injury is a sprain or partial tear of ligaments that will heal on its own with rest and good care. A severe injury is a complete tear of one or both of the major ligaments supporting the joint.

Mr. Foley had a severe injury, and in light of his desire to continue swimming and biking, and even participate in triathlons, his best option to restore function was surgery to reconstruct the torn ligaments.

The repair of a torn ligament requires a graft. "Completely torn ligaments will not heal on their own," Dr. Cordasco explains. "The goal of surgery is to restore the anatomy by reconstructing the ligaments. Doing so gives you the optimum outcome."

Dr. Cordasco performed the procedure using an arthroscopic approach he and a colleague developed at HSS. The technique entails a small one-inch incision and several tiny "keyhole" or portal incisions, instead of the standard five- to seven-inch incision of the traditional operation. "In arthroscopic surgery, the orthopedic surgeon is able to repair the injury using miniaturized instruments inserted in the shoulder through small incisions. A small camera inserted through another incision helps guide the procedure," he explains.

The long-term results of arthroscopic procedures are comparable to those of traditional open surgery when performed by an experienced, highly-trained orthopedic surgeon, according to Dr. Cordasco. But the much smaller incisions made possible by arthroscopy are more beneficial to the patient. "In the short-term, arthroscopic treatment is more comfortable for the patient and has a shorter recovery period associated with it," Dr. Cordasco says.

Surgery to repair a shoulder separation has a high success rate, and patients like Mr. Foley are usually able to return to their previous activity level.

"Without Dr. Cordasco, I never would have completed another triathlon," Mr. Foley says. He has already started training for his next one. He's planning to return to Saint Croix in May 2009.

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