Shoulder Pain in the Shoulder Pain in the Worker’sWorker’s

Compensation PatientCompensation Patient

William F Bennett MD PA

InjuriesInjuries

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!

PainPain

Is the result of inflammationInflammation occurs with almost all injuriesInflammation is the bodies’ mechanism of

healingInflammation gives off substances that

interact with nerves and cause pain– I.e., bradykinins and substance “p”

PathologyPathology

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

DiagnosisDiagnosis

More Trainer, quicker to diagnosisMost diagnoses, or close to, can be made

with physical examAncillary testing, I.E., often helps to create

a treatment plan and help elucidate prognosis

Clinical Exams Clinical Exams

Treatment-must have Treatment-must have accurate diagnosis or accurate diagnosis or

extended time and moneyextended time and moneyShoulder pain and cervical pain must be

differentiated.Shoulder training-residency better now than

20 years ago.Fellowships in Shoulder Surgery as well.

Biceps Tendon RuptureBiceps 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/SubluxationsDislocations/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 LesionSlap 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 TearsRotator 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 PhotoArthroscopic Photo

Impingement SyndromeImpingement 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 SyndromeImpingement SyndromeAnatomyAnatomy

AcromionBursae

Rotator CuffHumeral Head

AcromionAcromion

Shoulder AnatomyShoulder AnatomyAcromion

Bursae

BursaeBursae

Humeral HeadHumeral Head

Shoulder Pain in the Shoulder Pain in the Worker’sWorker’s

Compensation PatientCompensation Patient

William F Bennett MD PA

InjuriesInjuries

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!

PainPain

Is the result of inflammationInflammation occurs with almost all injuriesInflammation is the bodies’ mechanism of

healingInflammation gives off substances that

interact with nerves and cause pain– I.e., bradykinins and substance “p”

PathologyPathology

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

DiagnosisDiagnosis

More Trainer, quicker to diagnosisMost diagnoses, or close to, can be made

with physical examAncillary testing, I.E., often helps to create

a treatment plan and help elucidate prognosis

Clinical Exams Clinical Exams

Treatment-must have Treatment-must have accurate diagnosis or accurate diagnosis or

extended time and moneyextended time and moneyShoulder pain and cervical pain must be

differentiated.Shoulder training-residency better now than

20 years ago.Fellowships in Shoulder Surgery as well.

Biceps Tendon RuptureBiceps 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/SubluxationsDislocations/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 LesionSlap 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 TearsRotator 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 PhotoArthroscopic Photo

Impingement SyndromeImpingement 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 SyndromeImpingement SyndromeAnatomyAnatomy

AcromionBursae

Rotator CuffHumeral Head

AcromionAcromion

Shoulder AnatomyShoulder Anatomy

Acromion

Bursae

BursaeBursae

Shoulder AnatomyShoulder AnatomyAcromion

Bursae

Humeral HeadHumeral Head

Shoulder AnatomyShoulder Anatomy

Acromion

Bursae

Rotator CuffRotator Cuff

Confluence of four tendons.Actually just a cableMuscle to bone.Should be called Rotator Hood.Functions to rotate the arm.More importantly functions to depress the

Humeral Head.

Shoulder AnatomyShoulder Anatomy

Acromion

Bursae

Exacerbation Of ArthritisExacerbation 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 SurgicalTreatment Only Surgical

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

Treatment Approach For The Treatment Approach For The OthersOthers

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 How To Stop The InflammationInflammation

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 TherapyPhysical Therapy

Two parts.First-stop the inflammation

*Stretching*Modalities I.E…

Ultrasound/Electrical StimulationSecond-Re-strengthen the shoulder

Humeral Head depressors.

If No Response By Three If No Response By Three WeeksWeeks

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 If Patient Has Not Responded By Six WeeksBy 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-SpecialtyMy 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 Arthroscopic Versus Open RepairRepair

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 Let Us Talk About Cost ComponentsComponents

Office visit. Oral medication. Injections. Physical Therapy. Lost work days

Lost wagesLost work hoursSubstitute workerImpairment rating?

Don’t Forget Cost Of Ancillary Don’t Forget Cost Of Ancillary TestingTesting

MRICat ScanEMG/NCS

Arthroscopic ApproachArthroscopic Approach

More expensive on the day of surgeryLess expensive overall.Surgery-$4,000-$8,000.Hospital-$6,000-$12,000.Physical therapy only 3-4 months worth $3-

$4,000.

Open ApproachOpen 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 ComparisonCost 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 American Shoulder and Elbow SurgeonsSurgeons

1111thth Open meeting Open meetingCost Analysis of Successful Rotator Cuff

Repair Surgery in Worker’s Compensation Patients.

Felix Savoie

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