Shoulder Pain in the Worker’s Compensation Patient

William F Bennett MD PA

Injuries  Typically lifting overhead repetitively..

 Trying to catch or restrain a heavy falling object in various positions.

 Falling on and outstretched arm.

 Direct blow.

 Injury to the neck!

Pain  Is the result of inflammation  Inflammation occurs with almost all injuries  Inflammation is the bodies’ mechanism of healing  Inflammation gives off substances that interact with nerves and cause pain – I.e., bradykinins and substance “p”

Pathology  Can be varied.

 Biceps tendon rupture.

 Dislocation subluxation.

 Rotator cuff tear.

 Slap lesion.  Exacerbation of arthritis.

 Impingement syndrome.

Diagnosis  More Trainer, quicker to diagnosis  Most diagnoses, or close to, can be made with physical exam  Ancillary testing, I.E., often helps to create a treatment plan and help elucidate prognosis

Clinical Exams

Treatment-must have accurate diagnosis or extended time and money  Shoulder pain and cervical pain must be differentiated.

 Shoulder training-residency better now than 20 years ago.

 Fellowships in Shoulder Surgery as well.

Biceps Tendon Rupture  Rare.

 Can be from the shoulder side.

 Or from the elbow side.

 Shoulder sided tears are associated with rotator cuff tears.

 Elbow sided tears should be fixed surgically.

Dislocations/Subluxations   Usually occur in patients less than 40 years of age.

If it’s a traumatic dislocation in a young person should be fixed surgically.

 Recurrence rate as high as 80%.

 Will preclude from working with the arm in certain positions because of a sense of instability if not fixed.

 Subluxations can cause continued pain due to an impingement syndrome-Secondary Impingement.

Slap Lesion  More common in baseball players.

 Can occur with trauma.

 Partial tearing of the biceps tendon in the shoulder.

 Surgery is indicated.

 Can be done arthroscopically.

Rotator Cuff Tears  Overhead Repetitive motion or Trauma can tear the cuff.

 May be able to alleviate the symptoms with physical therapy.

 But functionally may not be able to return to work.

 More likely to have a recurrence of pain with work.

Arthroscopic Photo

Impingement Syndrome  Major culprit in work comp cases.

 Pain with overhead activity.

 Syndrome is a bursitis and a tendonitis.

 If you can not stop the inflammation you can not rehabilitate the shoulder.

Impingement Syndrome Anatomy  Acromion  Bursae  Rotator Cuff  Humeral Head

Acromion

Shoulder Anatomy Acromion Bursae

Bursae

Humeral Head

Shoulder Pain in the Worker’s Compensation Patient

William F Bennett MD PA

Injuries  Typically lifting overhead repetitively..

 Trying to catch or restrain a heavy falling object in various positions.

 Falling on and outstretched arm.

 Direct blow.

 Injury to the neck!

Pain  Is the result of inflammation  Inflammation occurs with almost all injuries  Inflammation is the bodies’ mechanism of healing  Inflammation gives off substances that interact with nerves and cause pain – I.e., bradykinins and substance “p”

Pathology  Can be varied.

 Biceps tendon rupture.

 Dislocation subluxation.

 Rotator cuff tear.

 Slap lesion.  Exacerbation of arthritis.

 Impingement syndrome.

Diagnosis  More Trainer, quicker to diagnosis  Most diagnoses, or close to, can be made with physical exam  Ancillary testing, I.E., often helps to create a treatment plan and help elucidate prognosis

Clinical Exams

Treatment-must have accurate diagnosis or extended time and money  Shoulder pain and cervical pain must be differentiated.

 Shoulder training-residency better now than 20 years ago.

 Fellowships in Shoulder Surgery as well.

Biceps Tendon Rupture  Rare.

 Can be from the shoulder side.

 Or from the elbow side.

 Shoulder sided tears are associated with rotator cuff tears.

 Elbow sided tears should be fixed surgically.

Dislocations/Subluxations   Usually occur in patients less than 40 years of age.

If it’s a traumatic dislocation in a young person should be fixed surgically.

 Recurrence rate as high as 80%.

 Will preclude from working with the arm in certain positions because of a sense of instability if not fixed.

 Subluxations can cause continued pain due to an impingement syndrome-Secondary Impingement.

Slap Lesion  More common in baseball players.

 Can occur with trauma.

 Partial tearing of the biceps tendon in the shoulder.

 Surgery is indicated.

 Can be done arthroscopically.

Rotator Cuff Tears  Overhead Repetitive motion or Trauma can tear the cuff.

 May be able to alleviate the symptoms with physical therapy.

 But functionally may not be able to return to work.

 More likely to have a recurrence of pain with work.

Arthroscopic Photo

Impingement Syndrome  Major culprit in work comp cases.

 Pain with overhead activity.

 Syndrome is a bursitis and a tendonitis.

 If you can not stop the inflammation you can not rehabilitate the shoulder.

Impingement Syndrome Anatomy  Acromion  Bursae  Rotator Cuff  Humeral Head

Acromion

Shoulder Anatomy Acromion Bursae

Bursae

Shoulder Anatomy Acromion Bursae

Humeral Head

Shoulder Anatomy Acromion Bursae

Rotator Cuff  Confluence of four tendons.

 Actually just a cable  Muscle to bone.

 Should be called Rotator Hood.

 Functions to rotate the arm.

 More importantly functions to depress the Humeral Head.

Shoulder Anatomy Acromion Bursae

Exacerbation Of Arthritis  Can be of the Acromioclavicular joint.

 Or of the Glenohumeral joint.

 Usually you think of it as a preexisting condition.

 Can have arthritis and not be symptomatic.

 Traumatic injury can begin a cycle of inflammation that may not be controlled.

Treatment Only Surgical  Dislocations.

 Slap Lesions.

 Bicep tendon ruptures at the elbow.

 Occasionally Bicep Lesions at the shoulder.

Treatment Approach For The Others  Must stop the inflammation.

 Resolution of inflammation stops the pain.

 But you still need to rehab the shoulder.

 With pain the shoulder becomes weak.

 If the depressors of the Humeral Head are not strengthened problem can recur and prevent work.

How To Stop The Inflammation  NSAIDS-Nonsteroidal anti-inflammatory drugs.

 If….Ibuprofen, Naprosyn, Cataflam, Lodine, Daypro, Relafen.

 Can cause an upset stomach/should not be used in patients with ulcers.  Efficacy is strictly individual.

Physical Therapy  Two parts.

 First-stop the inflammation *Stretching *Modalities I.E… Ultrasound/Electrical Stimulation  Second-Re-strengthen the shoulder Humeral Head depressors.

If No Response By Three Weeks  Will give one shot of cortisone.

 Shot must be in the Bursae.

 Attempts to knock out the inflammation.

 If you miss can actually cause the Rotator Cuff to degrade and eventually tear with multiple injections.

If Patient Has Not Responded By Six Weeks  Either no response or has gotten somewhat better but not able to work.

 Recommend and arthroscopic subacromial decompression.

 Allows direct evaluation of Rotator Cuff and creates more space so that the Humeral Head does not hit the Acromion.

My Sub-Specialty  Any problems in the shoulder can be addressed arthroscopically.

 Arthroscopic intervention returns the patient to full activity quicker and with less physical therapy than conventional open treatment.

 3-4 months versus 10-12 months.

Arthroscopic Versus Open Repair  Address problem early.

 Does not detach the Deltoid.

 Object is to have little to no impairment rating.

 Returns worker to full duty quick (4-6 months for manual laborer).

 Less physical therapy.

 3-4 months worth versus 10-12 months worth.

 Less medications.

Let Us Talk About Cost Components  Office visit.

 Oral medication.

 Injections.

 Physical Therapy.

 Lost work days Lost wages Lost work hours Substitute worker Impairment rating?

Don’t Forget Cost Of Ancillary Testing  MRI  Cat Scan  EMG/NCS

Arthroscopic Approach  More expensive on the day of surgery  Less expensive overall.

 Surgery-$4,000-$8,000.

 Hospital-$6,000-$12,000.

 Physical therapy only 3-4 months worth $3 $4,000.

Open Approach  Day of surgery may be less expensive.

 But usually one to two day inpatient at $1,200.

 Surgery $3-5,000.

 Hospital $4-7,000.

 Physical therapy 10-12 months at $450/wk.

Cost Comparison  Arthroscopic $13,000 to $24,000.

 Open $26,200 to $31,200.

 Don’t forget to figure work hours lost and lost wages in a comparison of 3-4 months to 10-12 months.

 Also, cost to the employer.

American Shoulder and Elbow Surgeons 11 th Open meeting  Cost Analysis of Successful Rotator Cuff Repair Surgery in Worker’s Compensation Patients.

Felix Savoie Non-specialist cost $54,000 Specialist immediately- $24,000