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 11th 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