1. Shoulder Pain in the Worker’s Compensation Patient
William F Bennett MD PA

2. 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!

3. 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”

4. Pathology Can be varied. Biceps tendon rupture.
Dislocation subluxation.
Rotator cuff tear.
Slap lesion.
Exacerbation of arthritis.
Impingement syndrome.

5. 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

6. Clinical Exams

7. 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.

8. 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.

9. 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.

10. 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.

11. 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.

12. Arthroscopic Photo

13. 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.

14. Impingement Syndrome Anatomy
Acromion
Bursae
Rotator Cuff
Humeral Head

15. Acromion

16. Shoulder Anatomy
Acromion
Bursae

17. Bursae

19. Humeral Head

21. Shoulder Pain in the Worker’s Compensation Patient
William F Bennett MD PA

22. 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!

23. 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”

24. Pathology Can be varied. Biceps tendon rupture.
Dislocation subluxation.
Rotator cuff tear.
Slap lesion.
Exacerbation of arthritis.
Impingement syndrome.

25. 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

26. Clinical Exams

27. 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.

28. 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.

29. 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.

30. 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.

31. 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.

32. Arthroscopic Photo

33. 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.

34. Impingement Syndrome Anatomy
Acromion
Bursae
Rotator Cuff
Humeral Head

35. Acromion

36. Shoulder Anatomy
Acromion
Bursae

37. Bursae

38. Shoulder Anatomy
Acromion
Bursae

39. Humeral Head

40. Shoulder Anatomy
Acromion
Bursae

41. 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.

42. Shoulder Anatomy
Acromion
Bursae

43. 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.

44. Treatment Only Surgical
Dislocations.
Slap Lesions.
Bicep tendon ruptures at the elbow.
Occasionally Bicep Lesions at the shoulder.

45. 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.

46. 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.

47. Physical Therapy Two parts.
First-stop the inflammation *Stretching *Modalities I.E… Ultrasound/Electrical Stimulation
Second-Re-strengthen the shoulder Humeral Head depressors.

48. 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.

49. 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.

50. 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 months.

51. 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 months worth.
Less medications.

52. 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?

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

54. 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.

55. 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 months at $450/wk.

56. 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 months.
Also, cost to the employer.

57. 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