Shoulder Pain in the Workers Compensation Patient

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Shoulder Pain in the WorkersCompensation Patient

• William F Bennett MD PA

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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!

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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

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Pathology

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

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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

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Clinical Exams
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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.

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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.

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Dislocations/Subluxations

• Usually occur in patients less than 40 years of
  age.
• If its 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.

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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.

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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.

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Arthroscopic Photo
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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.

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Impingement SyndromeAnatomy

• Acromion
• Bursae
• Rotator Cuff
• Humeral Head

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Acromion
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Shoulder Anatomy
Acromion
Bursae
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Bursae
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Humeral Head
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Shoulder Pain in the WorkersCompensation 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 its 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
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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 SyndromeAnatomy

• Acromion
• Bursae
• Rotator Cuff
• Humeral Head

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Acromion
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Shoulder Anatomy
Acromion
Bursae
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Bursae
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Shoulder Anatomy
Acromion
Bursae
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Humeral Head
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Shoulder Anatomy
Acromion
Bursae
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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.

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Shoulder Anatomy
Acromion
Bursae
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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.

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Treatment Only Surgical

• Dislocations.
• Slap Lesions.
• Bicep tendon ruptures at the elbow.
• Occasionally Bicep Lesions at the shoulder.

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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.

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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.

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Physical Therapy

• Two parts.
• First-stop the inflammation Stretching Modal
  ities I.EUltrasound/Electrical Stimulation
• Second-Re-strengthen the shoulder Humeral Head
  depressors.

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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.

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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.

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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.

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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.

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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?

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Dont Forget Cost Of Ancillary Testing

• MRI
• Cat Scan
• EMG/NCS

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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.

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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.

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Cost Comparison

• Arthroscopic 13,000 to 24,000.
• Open 26,200 to 31,200.
• Dont 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.

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American Shoulder and Elbow Surgeons11th Open
meeting

• Cost Analysis of Successful Rotator Cuff Repair
  Surgery in Workers Compensation Patients.
• Felix Savoie
• Non-specialist cost 54,000
• Specialist immediately- 24,000

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