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
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