The following guideline covers a wide array of shoulder conditions seen in the workers’ compensation, as well as the nonworkers’ compensation, population. The guideline is intended to help establish work relatedness and aid in making the diagnosis of shoulder injuries and degenerative conditions. It also provides a nonoperative and operative guideline for the treatment of several shoulder conditions, not limited to rotator cuff tears, subacromial impingement syndrome, acromioclavicular arthritis and dislocations, as well as glenohumeral arthritis.
Key points
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Degenerative conditions of the shoulder and rotator cuff have a high prevalence with aging.
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Acute traumatic rotator cuff tears likely benefit from surgical intervention.
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The routine use of a distal claviculectomy during rotator cuff repair is discouraged.
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The use of allografts and xenografts in rotator cuff tear repair is not encouraged.
Introduction
This guideline is intended as an educational resource for health care providers who treat shoulder conditions, particularly injured workers. The emphasis is on accurate diagnosis and treatment that is curative or rehabilitative. The goal is to provide standards that ensure a uniform high quality of care based on the best available clinical and scientific evidence from a systematic review of the literature and on a consensus of expert opinion when scientific evidence was insufficient.
Degenerative conditions and injuries are common in both the workers’ compensation and general populations. Accurate assessment and treatment are critical to ascertaining work-relatedness and facilitating the worker’s return to health and productivity.
Establishing work-relatedness
Shoulder conditions are a common cause of pain and disability among adults, with a prevalence of 7% to 10% . A shoulder condition may arise from acute trauma or, in some circumstances, from nontraumatic industrial activities.
Risk factors associated with shoulder conditions include trauma, overuse, inflammation, age-related tissue degeneration, and smoking. A careful history is needed both for elucidating the mechanism of injury and for establishing causation.
Shoulder Conditions as Industrial Injuries
A shoulder condition may be induced acutely (eg, a patient falls on an outstretched hand and experiences concomitant trauma). To establish a diagnosis of a shoulder condition as a work-related injury, the provider must give a clear description of the traumatic event leading to the injury ( Table 1 ).
| Exposure | Examples of Types of Jobs | Risk | Type of Shoulder Claim |
|---|---|---|---|
| Sudden trauma or fall on an outstretched arm | Construction workers, logging, painters | High | Injury |
| Chronic overuse with high force and repetitive overhead motion | Shipyard welders and plate workers, fish processing workers, machine operators, ground workers (eg, pushing a lawn mower), and carpenters | Medium | Injury or occupational disease |
| Moderate lifting | Grocery checkers | Low | Injury or occupational disease |
Shoulder Conditions as Occupational Diseases
Work-related activities may cause or contribute to the development of shoulder conditions caused by chronic exposures. Conditions that support work-relatedness are
- 1.
Carrying/lifting heavy loads on or above the shoulders or carrying with hands
- 2.
Pushing/pulling heavy loads
- 3.
Working with arms above the shoulder for more than 15 minutes at intervals
- 4.
Repetitive arm/wrist movements combined with force for long periods
To establish a diagnosis of an occupational disease, all of the following are required :
- 1.
Exposure: Workplace activities that contribute to or cause shoulder conditions
- 2.
Outcome: A diagnosis of a shoulder condition that meets the diagnostic criteria in this guideline
- 3.
Relationship: Generally accepted scientific evidence, which establishes on a more-probable-than-not basis (greater than 50%) that the workplace activities (exposure) in an individual case contributed to the development or worsening of the condition relative to the risks in everyday life; translates to an odds ratio of 2 or greater in epidemiologic studies
In order for a shoulder condition to be allowed as an occupational disease, the provider must document that the work exposures created a risk of contracting or worsening the condition relative to the risks in everyday life, on a more-probable-than-not basis ( Dennis v Department of Labor and Industries , 109WN.2d 467 (Washington 1987)).
Introduction
This guideline is intended as an educational resource for health care providers who treat shoulder conditions, particularly injured workers. The emphasis is on accurate diagnosis and treatment that is curative or rehabilitative. The goal is to provide standards that ensure a uniform high quality of care based on the best available clinical and scientific evidence from a systematic review of the literature and on a consensus of expert opinion when scientific evidence was insufficient.
Degenerative conditions and injuries are common in both the workers’ compensation and general populations. Accurate assessment and treatment are critical to ascertaining work-relatedness and facilitating the worker’s return to health and productivity.
Establishing work-relatedness
Shoulder conditions are a common cause of pain and disability among adults, with a prevalence of 7% to 10% . A shoulder condition may arise from acute trauma or, in some circumstances, from nontraumatic industrial activities.
Risk factors associated with shoulder conditions include trauma, overuse, inflammation, age-related tissue degeneration, and smoking. A careful history is needed both for elucidating the mechanism of injury and for establishing causation.
Shoulder Conditions as Industrial Injuries
A shoulder condition may be induced acutely (eg, a patient falls on an outstretched hand and experiences concomitant trauma). To establish a diagnosis of a shoulder condition as a work-related injury, the provider must give a clear description of the traumatic event leading to the injury ( Table 1 ).
| Exposure | Examples of Types of Jobs | Risk | Type of Shoulder Claim |
|---|---|---|---|
| Sudden trauma or fall on an outstretched arm | Construction workers, logging, painters | High | Injury |
| Chronic overuse with high force and repetitive overhead motion | Shipyard welders and plate workers, fish processing workers, machine operators, ground workers (eg, pushing a lawn mower), and carpenters | Medium | Injury or occupational disease |
| Moderate lifting | Grocery checkers | Low | Injury or occupational disease |
Shoulder Conditions as Occupational Diseases
Work-related activities may cause or contribute to the development of shoulder conditions caused by chronic exposures. Conditions that support work-relatedness are
- 1.
Carrying/lifting heavy loads on or above the shoulders or carrying with hands
- 2.
Pushing/pulling heavy loads
- 3.
Working with arms above the shoulder for more than 15 minutes at intervals
- 4.
Repetitive arm/wrist movements combined with force for long periods
To establish a diagnosis of an occupational disease, all of the following are required :
- 1.
Exposure: Workplace activities that contribute to or cause shoulder conditions
- 2.
Outcome: A diagnosis of a shoulder condition that meets the diagnostic criteria in this guideline
- 3.
Relationship: Generally accepted scientific evidence, which establishes on a more-probable-than-not basis (greater than 50%) that the workplace activities (exposure) in an individual case contributed to the development or worsening of the condition relative to the risks in everyday life; translates to an odds ratio of 2 or greater in epidemiologic studies
In order for a shoulder condition to be allowed as an occupational disease, the provider must document that the work exposures created a risk of contracting or worsening the condition relative to the risks in everyday life, on a more-probable-than-not basis ( Dennis v Department of Labor and Industries , 109WN.2d 467 (Washington 1987)).
Making the diagnosis
A case definition for a shoulder condition includes appropriate symptoms, objective physical findings, and abnormal imaging. A presumptive diagnosis may be based on symptoms and objective findings, but the diagnosis usually requires confirmation by clinical imaging before proceeding to surgery.
History and Clinical Examination
A thorough occupational history is essential for determining whether a shoulder condition is work related and whether it is caused by an acute or chronic exposure. The provider should take extra care in documenting the reasons for diagnosing an occupational disease, as multiple employers might share liability. Providers should document the exposure and submit a complete work history as soon as a diagnosis of occupational disease is made (see Establishing work-relatedness).
The most typical symptom that patients with shoulder pathology describe is pain in and around the shoulder. The pain can be localized to a specific area of the shoulder, such as the anterior acromion, acromioclavicular (AC) joint, biceps groove, posterior joint line, lateral acromion, or over the middle of the deltoid several centimeters distal to the acromion. The pain can also radiate down the arm to the elbow or up the trapezius muscle to the base of the neck. Patients can also complain of intermittent tingling down the arm to the fingers. Some patients can complain of popping and grinding in the shoulder during movement. Movement of the shoulder usually makes the pain worse, and rest alleviates the pain. Some patients may have a constant ache in the shoulder that does not go away or worsens when they try to sleep at night.
Patients usually complain of decreased shoulder function because they are unable to do simple activities of daily living, such as sleeping, combing their hair, getting dressed, putting on a coat, reaching out a car window, or emptying the dishwasher. Other patients may complain of weakness in the shoulder, loss of shoulder motion, or inability to play their usual sport or hobby. For patients with work-related injuries, the most common complaint is the inability to perform their regular job duties, such as lifting overhead, pushing heavy objects, or performing repetitive activities with the arm.
Physical examination should consist of accepted test and examination techniques that should help the clinician narrow down the differential diagnosis that was made after taking the patients’ history. The examination should include the neck and the elbow because the joint above or below the affected area can sometimes be the primary cause of patients’ shoulder pain. The clinician should measure active range of motion; if it is not normal, then passive range of motion should also be performed. The clinician should palpate the shoulder for areas of tenderness over the acromion; AC joint; biceps groove; greater tuberosity; anterior, lateral, and posterior deltoid; posterior joint line; trapezius; and scapula. An inspection of the shoulder should be done to find any muscle atrophy, bone deformity, prior surgical scars, skin abnormalities, and dyskinesias during active shoulder movement. Specific clinical examination tests should also be done, such as the Neer impingement sign, lag sign, and so forth. More detailed descriptions of these tests can be found in Appendix .
Diagnostic Imaging
Conventional radiograph, MRI, and ultrasound are the best imaging tools to corroborate the diagnosis of a shoulder condition. MRI has been considered the gold standard; however, research has demonstrated the efficacy of ultrasound, done by a skilled provider or technician, to diagnose rotator cuff tears. A systematic review found ultrasound to have a pooled sensitivity of 0.95 and specificity of 0.96 in detecting full-thickness rotator cuff tears. Ultrasound was nearly as effective as MRI in diagnosing partial tears; therefore, ultrasound may be recommended to diagnose full- and partial-thickness tears.
Contrast MRI is not necessary to diagnose rotator cuff tears but may be considered when there is suspicion of an superior labral anterior-posterior (SLAP) lesion/tear.
Treatment
Conservative Treatment
Shoulder injuries may be complex, often involving more than a single tissue or anatomic element. Different shoulder problems can present with similar findings, such as limited, painful motion and tenderness. It is important to consider which components of the shoulder girdle may be affected and tailor a conservative treatment plan accordingly. Published reports have reported utility for a variety of conservative interventions to reduce pain and improve function for several shoulder conditions. However, well-designed research studies on conservative care for musculoskeletal injuries are limited in both quantity and quality.
The following is an example of a conservative intervention treatment algorithm:
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Nonsteroidal antiinflammatory drugs (NSAIDs) and acetaminophen may be considered to treat pain.
- •
Include brief rest and immobilization (less than 4 days) in the early stage; however, early unloaded movement and manual interventions, such as mobilization and manipulation, have been reported to reduce symptoms and facilitate greater shoulder motion, especially with AC injuries.
- •
Immobilization carries the risk of a frozen shoulder and is, therefore, not recommended, with the exception of fractures or glenohumeral dislocations.
- •
Use therapeutic exercise and mobilization to improve shoulder range of motion and strength and decrease pain in soft tissue injuries, such as shoulder sprain, rotator cuff tendonitis or tears, and glenohumeral dislocations.
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Incorporate strengthening exercise once range of motion is increased and pain is reduced.
- •
Corticosteroid injections, typically within the subacromial space, have been reported to provide short-term relief for adhesive capsulitis, rotator cuff tendinopathy, impingement syndrome, tendon disorders, and SLAP disorders. Care must be exercised when giving a corticosteroid injection to a partial rotator cuff tear, as this may lead to tear extension. Because corticosteroid use is associated with side effects, such as weakening of connective tissue, no more than 3 injections are recommended under one claim for the shoulder, 4 injections per lifetime.
- •
Ergonomic interventions, such as workstation and/or work flow modification, seem to be helpful in sustaining return to work.
Any worker who does not gain meaningful functional improvement (30%–50%) within 4 to 6 weeks of conservative treatment should be considered for a specialist consultation. Meaningful functional improvement may best be determined using validated shoulder/arm function instruments, such as the Simple Shoulder Test (SST), the Shoulder Pain and Disability Index (SPADI), the Disabilities of the Arm, Shoulder, and Hand Score (DASH) or Quick DASH, or the American Shoulder and Elbow Surgeons Assessment (ASES) form.
Specific conditions
Rotator Cuff Tears
Rotator cuff tears can be acute or chronic in onset and will vary in tendon tear size, tendon retraction, muscle atrophy, and tendon loss.
As industrial injury
A worker presenting with acute pain suspicious for a rotator cuff tear should be able to report a precipitating traumatic event, such as a severe fall on an outstretched arm, an episode of heavy lifting, or forceful use of the arm.
As occupational disease
Chronic exposure risk factors for rotator cuff tears include heavy repetitive overhead work, such as in the examples in Table 1 . However, many rotator cuff tears are caused by non–work-related conditions, such as age-related degeneration. The likelihood of having a rotator cuff tear increases with age. Studies show that more than half of individuals aged 60 years and older have partial or complete tears, yet are asymptomatic and have no history of trauma. Smoking has also been associated with rotator cuff tears.
Diagnosis and treatment
A careful occupational history and good clinical examination are most important in making a diagnosis of a rotator cuff tear and relating it to work exposures. Nonspecific symptoms reported with rotator cuff tears are pain with movement and pain at night. Objective clinical findings include weakness on testing forward elevation or external rotation. Patients with a positive drop arm sign, positive painful arc, and weakness with external rotation have a 91% chance of having a rotator cuff tear based on one study.
Ultrasound and conventional MRI are the best imaging tools for diagnosing rotator cuff tears. MRI remains the gold standard in the radiographic assessment of rotator cuff tears. Radiograph or computed tomography arthrogram is appropriate if there is a contraindication to an MRI. Contrast MRI is not necessary for making the diagnosis of a rotator cuff tear. Arthroscopy for the purpose of diagnosing rotator cuff tears is not appropriate.
Acute, symptomatic, full-thickness rotator cuff tears, especially in a young worker, should be surgically repaired as soon as possible because of an increased risk of tear progression, retraction of the tendon, and irreversible fatty infiltration of the rotator cuff muscles. For a rotator cuff tear that was previously treated conservatively, worsening pain usually indicates tear progression or migration of the humeral head and could warrant operative care. Tears that are found incidentally and are asymptomatic are generally not work related and can get better with conservative care.
Partial tears and chronic full-thickness tears in individuals greater than 65 years old should be treated conservatively before surgery is considered. Many workers, regardless of age, can recover function without surgery.
Injured workers with full- or partial-thickness tears may continue to work with restricted use of the involved extremity, if work accommodation is allowed.
Rotator cuff repairs are increasingly done arthroscopically. Evidence does not support a difference in outcomes according to surgical technique, whether it is arthroscopic, mini-open, or single- or double-row techniques. Acromioplasty is not usually necessary during a rotator cuff repair; acromioplasty does not change functional outcome after arthroscopic repair of the rotator cuff.
Tissue grafts (ie, acellular human dermal matrix)
The use of xenografts and allografts is currently not covered, given clinical concerns about localized reactions and a lack of studies demonstrating superiority to conventional techniques. There is an increased risk of infection and rejection reported with the use of xenografts, and there is no difference in outcome when they are used.
Distal clavicle resection as a routine part of acute rotator cuff tear repair is not recommended.
Revision rotator cuff repairs
Nicotine has been associated with delayed tendon-to-bone healing after rotator cuff tear repair surgery. It is strongly recommended that revision surgery not be performed in current nicotine users. Revision rotator cuff surgery should not be done if a patient has a massive rotator cuff tear (ie, tears >3 cm or with severe fatty infiltration). The outcome of revision surgery for symptomatic failed primary repairs is inferior to a successful primary repair.
A second revision surgery or subsequent surgeries will only be considered if compelling evidence exists that the injured worker had returned to a state of clinically meaningful functional improvement (at least 30%) after the last revision surgery, followed by an ongoing significant decline in function. Measures of functional improvement should be documented on a validated instrument (eg, DASH, SST, SPADI, and ASES) for a second revision surgery to be allowed.
Subacromial Impingement Syndrome Without a Rotator Cuff Tear
Subacromial impingement syndrome (SIS) results when the soft tissues of the shoulder between the coracoacromial arch and the humeral tuberosity are compressed, disturbing the normal sliding mechanism of the shoulder when the arm is elevated. Inflammation of the subacromial bursa, tendinopathy of the rotator cuff tendons, and acromial morphology can all contribute to the development of SIS. SIS can be an occupational disease; it has been associated with heavy overhead work, high force, and repetition of shoulder movement.
Diagnosis and treatment
Workers may report generalized shoulder pain. An objective clinical finding is pain over the anterior or lateral shoulder during active elevation as well as a positive Neer or Hawkins impingement sign. To confirm the diagnosis of SIS, a radiograph should reveal abnormal acromion morphology with narrowing of the subacromial space or an MRI should reveal evidence of tendinopathy/tendinitis of the rotator cuff tendon or fluid or inflammation in the subacromial bursa.
Nonoperative treatments of SIS have been shown to be as effective as subacromial decompression. For decompression to be allowed for SIS, the diagnosis must be verified by pain relief from a subacromial injection of local anesthetic and the worker must have failed to improve function and decrease pain after 12 weeks of conservative care.
Subacromial decompression is also a reasonable treatment option for massive, irreparable rotator cuff tears that are not amenable to repair and have not improved with a course of physical therapy.
Calcific Tendonitis
The exact cause of calcific tendonitis is still unknown. It does, however, affect up to 10% to 20% of the population between 30 and 50 years of age.
Diagnosis and treatment
The diagnosis of calcific tendonitis is typically made with conventional plain films alone. Calcific tendonitis is not always symptomatic. When calcific tendonitis is symptomatic, nonoperative treatment of the condition is typically successful. If symptoms continue after 12 weeks of conservative management, then debridement of the calcified tendon is reasonable.
Acromioclavicular Dislocation
Acute AC injury is typically referred to as shoulder separation. The degree of clavicular displacement depends on the severity of the injury. The injury is classified using the Rockwood classification ( Table 2 ).
| Rockwood Classification | |
|---|---|
| Type I | There is sprain of the AC or coracoclavicular ligament. |
| Type II | Subluxation of the AC joint is associated with a tear of the AC ligament; coracoclavicular ligament is intact. |
| Type III | There is dislocation of the AC joint with injury to both AC and coracoclavicular ligaments. |
| Type IV | Clavicle is displaced posteriorly through the trapezius muscle. |
| Type V | There is gross disparity between the acromion and clavicle, which displaces superiorly. |
| Type VI | Dislocated lateral end of the clavicle lies inferior to the coracoid. |
Diagnosis and treatment
AC dislocations (types III-VI) show marked deformity and are accompanied by pain and tenderness over the AC joint. Conventional radiograph is the best imaging tool to use when AC dislocation is suspected.
Surgery is not covered for type I and II injuries, whereas surgery is usually indicated for types IV, V, and VI. Management of type III injuries is more controversial but most patients with type III AC joint dislocations are best treated conservatively. Surgery should be considered only when at least 3 months of conservative care fails. For patients with a type III dislocation and high physical demands on the shoulder, early orthopedic surgical consultation and/or surgery may be indicated.
Labral Tears, Including Superior Labral Anterior-Posterior Tears
Labral lesions constitute a wide range of pathology. The most common labral lesions are SLAP tears ( Table 3 ), which are superior labral tears that extend anteriorly and posteriorly. Some SLAP tears result from acute trauma and others are degenerative in nature. There are several types of SLAP tears; type II SLAP tears are the most common and constitute more than 50% of all tears.
| Tear Type | Description |
|---|---|
| I | There is fraying of the labrum without detachment from the glenoid. |
| II |
|
| III | Bucket handle tear: The torn labrum hangs into the joint and causes symptoms of “locking, popping.” |
| IV | Labral tear extends into the long head of the biceps tendon. |
Related posts:
Evidence-Based Guidelines in Workers’ Compensation
Evidence-based Guidelines in Workers’ Compensation
Guideline Development Process in a Public Workers’ Compensation System
Diagnosis and Treatment of Work-Related Ulnar Neuropathy at the Elbow
Work-Related Carpal Tunnel Syndrome
Diagnosis and Treatment of Work-Related Proximal Median and Radial Nerve Entrapment
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