The AC joint—where your collarbone meets your shoulder blade—is stabilized by ligaments that can stretch, partially tear, or completely rupture depending on the force of impact. The severity of injury (Grades I-VI) determines whether conservative treatment or surgery is needed, with most BJJ athletes experiencing Grade I-III injuries that heal well without surgery.

This guide covers everything you need to know:

• AC joint anatomy and function

• How separations occur on the mats

• Grading system (I-VI) and what each grade means

• Conservative vs. surgical treatment

• Evidence-based rehabilitation protocols

• Return-to-training timelines

• Prevention strategies for grapplers

Understanding AC Joint Anatomy

What Is the AC Joint?

Anatomy:

• AC = Acromioclavicular joint

• Connection between clavicle (collarbone) and acromion (shoulder blade)

• Small joint with limited movement

• Located at the "point" of your shoulder (most prominent part)

Function:

• Allows scapula (shoulder blade) to rotate during arm elevation

• Transmits forces from arm to axial skeleton

• Provides suspension for upper limb

• Relatively small joint bearing significant loads

Ligaments That Stabilize the AC Joint

AC Ligaments (Primary Horizontal Stability):

• Superior AC ligament (top)

• Inferior AC ligament (bottom)

• Control anterior-posterior (front-back) translation

• First to be injured in AC separation

Coracoclavicular (CC) Ligaments (Primary Vertical Stability):

• Conoid ligament (medial, cone-shaped)

• Trapezoid ligament (lateral, trapezoid-shaped)

• Attach clavicle to coracoid process (part of scapula)

• Prevent clavicle from moving upward

• Critical for stability—when torn = higher grade injury

The Key Concept:

• Grade I-II: AC ligaments damaged, CC ligaments intact

• Grade III+: CC ligaments torn → clavicle displaces upward → visible "bump"

How AC Joint Separations Occur in BJJ

Primary Mechanism: Direct Impact to Shoulder

1. Falling Directly on Shoulder (Most Common)

• Landing on the "point" of shoulder during takedown

• Thrown and land on shoulder

• Trip/sweep where you can't breakfall properly

• Force drives acromion downward while clavicle stays in place

• Creates shearing force on AC joint

2. Falling on Outstretched Arm (FOOSH)

• Hand impacts mat first

• Force transmits up arm to shoulder

• Drives humeral head into acromion

• Can separate AC joint (less common than direct impact)

3. Direct Blow During Scrambles

• Knee or elbow strikes shoulder during scramble

• Collision with training partner

• Usually lower-grade injuries

4. Chronic Overuse (Rare)

• Repetitive stress to AC joint

• Heavy bench pressing + BJJ training

• Degenerative changes over time

• Usually older athletes (40+)

Common BJJ Scenarios

Takedowns:

• Failed shot → land on shoulder

• Being thrown (sacrifice throw, hip throw)

• Double leg defense gone wrong

Scrambles:

• Granby roll mistimed

• Awkward tumble during transition

• Collision with training partner

Competition:

• Higher intensity = higher risk

• Explosive movements

• Less controlled falls

AC Joint Separation Grading System

The Rockwood Classification (Standard System)

Understanding your grade is critical for treatment decisions.

Grade I: AC Ligament Sprain

Injury:

• AC ligaments stretched/partially torn

• CC ligaments intact

• No displacement of clavicle

Physical Exam:

• Tenderness over AC joint

• No visible deformity

• Minimal swelling

• Pain with cross-body adduction (arm across chest)

X-Ray:

• Normal appearance

• No upward displacement of clavicle

Treatment: Conservative (always)

Prognosis: Excellent

• 2-4 weeks to return to training

• Full recovery expected

• No long-term complications

Grade II: AC Ligament Tear + CC Ligament Sprain

Injury:

• Complete tear of AC ligaments

• Partial tear/stretch of CC ligaments

• Mild clavicle displacement (<25% overlap loss)

Physical Exam:

• Moderate tenderness over AC joint

• Slight "step-off" (bump) palpable

• May not be visible with clothing

• More swelling than Grade I

• Significant pain with movement

X-Ray:

• Slight widening of AC joint

• <25% increase in CC distance

• Clavicle slightly elevated (subtle)

Treatment: Conservative (usually)

Prognosis: Good

• 4-6 weeks to return to training

• May have minor cosmetic deformity

• Occasional long-term AC joint arthritis

• 90%+ good outcomes with conservative treatment

Grade III: Complete AC and CC Ligament Tears

Injury:

• Complete tear of AC ligaments

• Complete tear of CC ligaments

• Clavicle displaced upward 25-100%

Physical Exam:

• Obvious "bump" at shoulder (clavicle sticking up)

• Visible deformity

• "Piano key sign" (can push clavicle down, pops back up)

• Significant tenderness

• Limited ROM due to pain

X-Ray:

• 25-100% increase in CC distance compared to other side

• Clavicle clearly elevated

• May need stress views (holding weight) to confirm

Treatment: CONTROVERSIAL—Conservative vs. Surgical

Decision Factors:

• Age and activity level

• Arm dominance (dominant arm more likely surgery)

• Occupation/sport demands

• Cosmetic concerns

• Patient preference

Prognosis:

• Conservative: 6-12 weeks return, possible persistent bump, 80-85% satisfaction

• Surgical: 4-6 months return, better cosmesis, 85-90% satisfaction, surgical risks

The Debate:

• Studies show similar functional outcomes at 2+ years

• Surgery restores anatomy better (cosmetic benefit)

• Some athletes report persistent weakness with conservative treatment

• Overhead athletes may benefit more from surgery

Grade IV: Posterior Displacement of Clavicle

Injury:

• Complete AC and CC ligament tears

• Clavicle displaced posteriorly (backward into trapezius)

• Rare injury pattern

Treatment: Surgical (usually recommended)

Reason: Risk of neurovascular compromise, cosmetic deformity

Timeline: 4-6 months return to sport

Grade V: Severe Superior Displacement

Injury:

• Complete AC and CC ligament tears

• Clavicle displaced >100% superiorly

• Detachment of deltoid/trapezius muscles from clavicle

Physical Exam:

• Dramatic "bump" (very obvious)

• Clavicle tenting skin

• Severe pain and dysfunction

Treatment: Surgical (strong recommendation)

Reason: Significant functional impairment, cosmetic deformity

Timeline: 4-6 months return to sport

Grade VI: Inferior Displacement of Clavicle

Injury:

• Complete AC and CC ligament tears

• Clavicle displaced inferiorly (below acromion or coracoid)

• Extremely rare, high-energy trauma

Treatment: Surgical (emergency)

Reason: Risk of neurovascular injury, thoracic outlet syndrome

Timeline: 6-9 months return to sport

Summary: Treatment by Grade

Symptoms: Do You Have an AC Joint Separation?

Immediate Post-Injury Symptoms

At Moment of Injury:

• Immediate sharp pain at top of shoulder

• May hear/feel "pop" or "crunch"

• Immediate difficulty moving arm

• Visible deformity (Grade III+)

Within Minutes to Hours:

• Swelling over AC joint

• Bruising develops (may extend down arm)

• Pain with any arm movement

• Difficulty lifting arm

• Holding arm close to body for comfort

Physical Examination Findings

Inspection:

• Visible "bump" at end of clavicle (Grade III+)

• Swelling and bruising

• Asymmetry compared to other shoulder

Palpation:

• Point tenderness directly over AC joint

• Pain with pressing on clavicle

• "Piano key sign" (Grade III+): Can push clavicle down, springs back up

Range of Motion:

• Painful with any movement, especially:

  • Reaching across body (cross-body adduction)

  • Reaching overhead

  • Lifting arm to side

• May be unable to elevate arm >90° due to pain

Strength Testing:

• Difficult to assess initially (too painful)

• Usually normal strength (no muscle/tendon damage)

• Weakness is pain-related, not structural

Self-Assessment Tests

Cross-Body Adduction Test

How to Perform:

1. Bring affected arm across chest

2. Use other arm to pull at elbow

3. Bring arm as far across body as possible

Positive Test:

• Sharp pain at AC joint

• Pain worse at end-range

• Most sensitive test for AC joint pathology

Palpation Test (Most Reliable)

How to Perform:

1. Locate AC joint (end of clavicle, "point" of shoulder)

2. Press firmly directly on joint

Positive Test:

• Very specific, focal tenderness

• Pain significantly greater than other shoulder

• Patient winces or pulls away

Piano Key Sign (Grade III+)

How to Perform:

1. Press down on distal clavicle

2. Release pressure

Positive Test:

• Clavicle depresses with pressure

• Springs back up when released

• Like pressing piano key

• Indicates Grade III or higher

X-Ray (Definitive Diagnosis)

Standard Views:

• AP view (front)

• Zanca view (15° cephalic tilt, focuses on AC joint)

• Bilateral comparison (both shoulders)

Stress Views (For Grade III):

• Hold 10-15 lb weight in each hand

• Increases CC distance if ligaments torn

• Helps differentiate Grade II from III

Conservative Treatment Protocol

Applies to: Grade I, II, and most Grade III injuries

Phase 1: Acute Pain Management (Days 0-7)

Goals: Control pain and swelling, protect joint, prevent stiffness

Immediate Management (First 48-72 Hours):

• RICE Protocol:

  • Rest: Sling for comfort (remove several times daily)

  • Ice: 15-20 min every 2-3 hours

  • Compression: Shoulder wrap or elastic bandage

  • Elevation: Sleep with pillows under arm

• NSAIDs: Ibuprofen or naproxen (if tolerated)

• Avoid: Reaching overhead, lifting, lying on affected side

Sling Use:

• Wear for comfort (usually 3-7 days)

• Remove multiple times daily for gentle ROM

• Don't use >1-2 weeks (stiffness risk)

Gentle Pendulum Exercises (Day 2-3):

• Lean forward, let arm hang

• Small circular motions

• 2-3 minutes, 3-4x daily

• Pain-free only

Sleep Position:

• Semi-reclined (recliner chair ideal)

• Pillow under affected arm

• Avoid lying flat initially

Phase 2: Restore Range of Motion (Weeks 1-3)

Goals: Full pain-free ROM, reduce swelling, begin gentle strengthening

ROM Exercises (Pain-Free Only):

1. Supine Flexion (Lying Down Arm Raises)

• Lie on back

• Use other arm to assist

• Lift arm overhead

• 3 sets x 10 reps, 2x daily

2. Wall Walks

• Face wall, "walk" fingers up wall

• Progress height daily

• 3 sets x 10 reps, 2x daily

3. Supine External Rotation

• Lie on back, elbow at side bent 90°

• Rotate arm outward

• 3 sets x 10 reps, 2x daily

4. Table Slides

• Stand facing table

• Slide arm forward on table surface

• 3 sets x 10 reps, 2x daily

Gentle Isometrics (Week 2):

• Internal/external rotation against wall

• Hold 5-10 sec, no movement

• 3 sets x 10 reps daily

Goals Met When:

• Pain <3/10 with daily activities

• Can reach overhead

• No longer using sling

• Minimal swelling

Phase 3: Strengthening (Weeks 3-6)

Goals: Restore strength, build dynamic stability, prepare for training

Progressive Resistance Exercises:

Rotator Cuff (Week 3-4):

• External rotation with band: 3 sets x 15

• Internal rotation with band: 3 sets x 15

• Scaption (thumbs up): 3 sets x 12

• Prone horizontal abduction: 3 sets x 12

• Frequency: Daily initially, then 3-4x per week

Scapular Strengthening (Week 3-6):

• Rows (band or cable): 3 sets x 12

• Scapular push-ups: 3 sets x 10

• Y-T-W-L raises: 3 sets x 10 each

• Face pulls: 3 sets x 15

Deltoid/Upper Trap (Week 4-6):

• Lateral raises (light weight): 3 sets x 12

• Front raises: 3 sets x 12

• Shrugs: 3 sets x 15

Functional Strengthening (Week 5-6):

• Push-ups (incline progressing to floor): 3 sets x 10

• Plank variations: 3 sets x 30 sec

• Quadruped arm raises: 3 sets x 10 each

Progress Criteria:

• Full pain-free ROM

• Strength improving weekly

• Can perform push-ups without pain

• No swelling after exercise

Phase 4: Return to Training (Weeks 6-12)

Goals: Sport-specific conditioning, build confidence, safe return

Weeks 6-8: Drilling Only

• Technical work, no resistance

• Avoid direct pressure on shoulder

• Focus on positions that don't load AC joint

• No live sparring

Weeks 8-10: Light Positional Sparring

• Bottom positions initially (less AC joint stress)

• 50-60% intensity

• Communicate with training partners

• No takedowns yet

Weeks 10-12: Progressive Return

• Moderate intensity rolling (70-80%)

• Gradual reintroduction of takedowns

• All positions allowed

• Monitor next-day soreness

Return-to-Training Criteria:

• Full pain-free ROM

• Strength >90% of uninjured side

• No tenderness with palpation

• Can perform push-ups, pull-ups without pain

• Confident with contact

• No swelling after training

Long-Term Management:

• May have persistent "bump" (cosmetic, not functional)

• Continue shoulder strengthening 2x per week

• Monitor for AC joint arthritis (future concern)

Grade III: Conservative vs. Surgical Decision

Conservative Treatment Success:

• 80-85% satisfaction rate

• Most return to full activity

• Cosmetic deformity may persist

• Occasional complaints of "weakness" (usually functional, not structural)

Consider Surgery If:

• High-level competitive athlete

• Overhead athlete (less applicable to BJJ)

• Dominant arm affected

• Failed 3+ months conservative treatment

• Significant cosmetic concern

• Chronic pain/dysfunction

The Evidence:

• Meta-analyses show similar functional outcomes at 2 years

• Surgery better for cosmesis

• Conservative treatment: faster initial return (6-12 weeks vs. 4-6 months)

• Surgery: lower risk of long-term AC joint arthritis

Recommendation for BJJ Athletes:

• Most can try conservative treatment first (3 months)

• If persistent symptoms → discuss surgery

• Grade III is truly a patient preference decision

Surgical Treatment Options

Used for: Grade III (selective), Grade IV-VI

Surgical Techniques

1. Modified Weaver-Dunn Procedure

• Transfer coracoacromial ligament to replace torn CC ligaments

• Historical technique (less common now)

2. Anatomic CC Ligament Reconstruction

• Synthetic graft or allograft

• Recreates conoid and trapezoid ligaments

• Gold standard currently

3. Hook Plate Fixation

• Plate with hook under acromion

• Holds clavicle in place while ligaments heal

• Requires second surgery to remove (6-12 weeks)

4. TightRope/FiberTape Technique

• Pass strong suture/tape through bone tunnels

• Suspends clavicle to coracoid

• No implant removal needed

• Increasingly popular

5. Hybrid Techniques

• Combination of above

• Surgeon preference

Post-Surgical Rehabilitation Timeline

Phase 1: Protection (Weeks 0-6)

Immobilization:

• Sling for 4-6 weeks

• Remove for exercises only

• Sleep in sling

Goals: Protect repair, prevent stiffness

Allowed:

• Elbow/wrist ROM

• Pendulum exercises (gentle)

• Scapular squeezes

• No active shoulder movement

Phase 2: Early Motion (Weeks 6-10)

Goals: Restore passive ROM, prevent stiffness

Activities:

• Progress to full passive ROM

• Active-assisted exercises

• No resisted exercises yet

• No weight bearing on arm

Phase 3: Strengthening (Weeks 10-16)

Goals: Build strength, restore function

Activities:

• Begin rotator cuff strengthening

• Scapular exercises

• Progressive loading

• No overhead lifting >10 lbs

Phase 4: Advanced Strengthening (Weeks 16-20)

Goals: Return to normal activities

Activities:

• Full strengthening protocol

• Sport-specific drills

• Plyometric exercises (carefully)

• Progressive overhead loading

Phase 5: Return to Sport (Months 4-6)

Clearance Criteria:

• Full pain-free ROM

• Strength >90% other side

• X-ray shows maintained reduction

• Surgeon clearance

Mat Progression:

• Month 4-5: Drilling only

• Month 5: Light positional sparring

• Month 6: Progressive intensity

• Full training: 6+ months

Long-Term Considerations

Post-Traumatic AC Joint Arthritis

Reality:

• 30-50% develop AC joint arthritis within 5-10 years

• Higher risk with Grade II-III injuries

• More common with conservative treatment vs. surgery

Symptoms:

• Pain with cross-body movements

• Pain with overhead reaching

• Clicking or grinding

• Usually manageable with conservative treatment

Treatment If Symptomatic:

• Physical therapy

• NSAIDs

• Corticosteroid injection

• Distal clavicle excision (surgical, last resort)

Cosmetic Concerns

Persistent "Bump":

• Common with Grade III conservative treatment

• May improve over 6-12 months as scar tissue forms

• Usually doesn't correlate with function

• Some athletes bothered cosmetically

• Surgical option if significant concern

Functional Outcomes

Most Athletes (80-90%):

• Return to full BJJ training

• No significant functional limitations

• May avoid direct impact to shoulder

• Some report "awareness" of injury

Occasional Complaints:

• Difficulty with heavy bench pressing

• Fatigue with overhead activities

• Aching with weather changes

• Usually manageable with strengthening

Prevention Strategies

Can You Prevent AC Joint Separations?

Partially—Reduce Risk:

1. Improve Breakfall Technique (Ukemi)

• Don't land on "point" of shoulder

• Tuck chin, round back

• Distribute impact across larger surface area

• Practice regularly

2. Strengthen Surrounding Muscles

• Strong deltoids and upper traps

• May provide some protection

• 2-3x per week shoulder work

3. Avoid High-Risk Situations

• Controlled takedown practice

• Avoid explosive/uncontrolled throws

• Mat awareness during scrambles

4. Protective Equipment (Limited)

• AC joint pads exist (limited evidence)

• May reduce Grade I-II risk

• Won't prevent high-energy Grade III+

5. If Previous AC Joint Injury:

• Complete full rehab before returning

• Continue strengthening indefinitely

• May be at higher risk for arthritis

• Monitor for symptoms

When to See a Healthcare Provider

Seek Immediate Evaluation:

⚠️ Urgent (Within 24 Hours):

• Suspected AC joint separation (direct shoulder trauma + pain)

• Visible deformity

• Inability to move arm

• Significant swelling/bruising

📅 Schedule Appointment (Within Days):

• Persistent shoulder pain after impact

• Uncertain about injury severity

• Want imaging/diagnosis

• Discuss treatment options

What to Expect

Initial Visit:

• History of injury mechanism

• Physical examination (palpation, ROM, strength)

• Neurovascular exam

Imaging:

• X-rays (standard views + stress views if Grade III suspected)

• Bilateral comparison

• Grading determination

Treatment Discussion:

• Grade I-II: Conservative protocol

• Grade III: Discuss options (conservative vs. surgical)

• Grade IV-VI: Surgical referral

FAQ: AC Joint Separations

Q: How do I know if I need surgery? A: Surgery usually recommended for:

• Grade IV-VI injuries

• Grade III: Patient preference (consider activity level, arm dominance, cosmetic concerns)

• Grade I-II: Conservative always Discuss with orthopedic surgeon.

Q: How long until I can train? A: Timeline by grade:

• Grade I: 2-4 weeks

• Grade II: 4-6 weeks

• Grade III (conservative): 6-12 weeks

• Grade III-V (surgical): 4-6 months Individualized based on healing, symptoms, strength recovery.

Q: Will the bump go away? A: Depends:

• Grade I-II: Usually no visible bump

• Grade III (conservative): Bump may persist (cosmetic, not functional)

• Grade III+ (surgical): Bump usually corrected

• Some improvement over 6-12 months as scar tissue forms

Q: Can I train with an AC joint separation? A: During acute phase (first 2-6 weeks): No After initial healing: Gradual return with modifications Avoid direct impact to shoulder initially.

Q: Will I get arthritis in my AC joint? A: 30-50% develop AC joint arthritis within 5-10 years

• More common with Grade II-III

• Usually manageable with conservative treatment

• Rarely requires surgery (distal clavicle excision)

Q: What if I chose conservative treatment for Grade III and still have problems? A: Options:

• Continue PT (some improve up to 6-12 months)

• Surgical reconstruction (can be done later, though optimal within 3-6 months of injury)

• Most athletes satisfied with conservative treatment long-term

Q: Should I tape my shoulder? A: During return-to-training:

• AC joint taping may provide comfort/proprioception

• Won't prevent re-injury

• Can use during first few weeks back

Q: Is my AC joint separation the same as a "separated shoulder"? A: Yes, same injury. Common terms:

• AC joint separation

• Separated shoulder

• Shoulder separation All refer to AC joint injury (different from shoulder dislocation, which involves glenohumeral joint).

Key Takeaways

✅ AC joint separations are common in BJJ:

• Direct impact to shoulder during takedowns/falls

• Straightforward to diagnose

• Treatment depends on grade (I-VI)

✅ Grading determines treatment:

• Grade I-II: Conservative always (2-6 weeks return)

• Grade III: Controversial (conservative vs. surgery)

• Grade IV-VI: Surgery usually recommended

✅ Conservative treatment works for most:

• Grade I-II: Excellent outcomes

• Grade III: 80-85% satisfaction, cosmetic bump may persist

• Faster initial return than surgery (6-12 weeks vs. 4-6 months)

✅ Surgery considered for:

• Grade IV-VI

• Grade III with high activity demands, dominant arm, cosmetic concerns, or failed conservative treatment

• Similar functional outcomes at 2 years vs. conservative (Grade III)

✅ Long-term considerations:

• 30-50% risk of AC joint arthritis (5-10 years)

• Usually manageable conservatively

• Most return to full training

✅ Prevention focuses on ukemi:

• Proper breakfall technique

• Avoid landing on "point" of shoulder

• Shoulder strengthening provides some protection

Need Help With Your AC Joint Separation?

At Grapplers PerformX, we specialize in helping BJJ athletes navigate AC joint separations—whether conservative or post-surgical rehabilitation.

Our grappling-specific physical therapists will:

• Accurately assess injury grade

• Create individualized rehabilitation plan

• Guide you through evidence-based protocols

• Help you decide conservative vs. surgical (Grade III)

• Get you back to training safely

Free AC Joint Resources:

• Download our Shoulder Injury Rehab Guide →

• Watch: AC Joint Self-Assessment →

• Book a Free 15-Min Consultation →

Related Articles:

• BJJ Shoulder Injuries: Complete Hub →

• BJJ Rotator Cuff & Impingement →

• BJJ Labral Tears & Instability →

• Shoulder Strength for BJJ →