Transcript Shoulder Pain in the Worker’s Compensation Patient

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