Louisiana Administrative Code
Title 40 - LABOR AND EMPLOYMENT
Part I - Workers' Compensation Administration
Subpart 2 - Medical Guidelines
Chapter 23 - Upper and Lower Extremities Medical Treatment Guidelines
Subchapter B - Shoulder Injury Medical Treatment Guidelines
Section I-2319 - Initial Diagnostic Procedures

Universal Citation: LA Admin Code I-2319

Current through Register Vol. 50, No. 9, September 20, 2024

A. The OWCA recommends the following diagnostic procedures be considered, at least initially, the responsibility of the workers' compensation carrier to ensure that an accurate diagnosis and treatment plan can be established. Standard procedures that should be utilized when initially diagnosing a work-related shoulder complaint are listed below.

1. History Taking and Physical Examination (Hx and PE) are generally accepted, well-established and widely used procedures that establish the foundation/basis for and dictates subsequent stages of diagnostic and therapeutic procedures. List of medications patient is taking should be included in every history, including over the counter medicines as well as supplements. When findings of clinical evaluations and those of other diagnostic procedures are not complementing each other, the objective clinical findings should have preference. The medical records should reasonably document the following:
a. History of Present Injury
i. Mechanism of injury. This includes details of symptom onset and progression, and documentation of right or left dominance;

ii. Relationship to work. This includes a statement of the probability that the illness or injury is work-related;

iii. Prior occupational and non-occupational injuries to the same area including specific prior treatment;

iv. History of locking, clicking, weakness, acute or chronic swelling, crepitation, pain while lifting or performing overhead work, dislocation or popping. Pain or catching with overhead motion may indicate a labral tear. Night time pain can be associated with specific shoulder pathology. Anterior joint pain, such as that seen in throwing athletes, may indicate glenohumeral instability. Pain radiating below the elbow, may indicate cervical disc problems or proximal entrapment neuropathy.

v. Ability to perform job duties and activities of daily living; and

vi. Exacerbating and alleviating factors of the reported symptoms. The physician should explore and report on non-work related as well as, work related activities.

b. Past History
i. Past medical history includes previous shoulder conditions, neoplasm, gout, arthritis, diabetes and previous shoulder symptoms;

ii. Review of systems includes symptoms of rheumatologic, neurologic, endocrine, neoplastic, and other systemic diseases;

iii. Smoking history; and

iv. Vocational and recreational pursuits.

c. Physical Examination: Examination should include the elbow and neck. Both shoulders should be examined to compare asymptomatic and symptomatic sides and identify individuals with non-pathological joint laxity or degenerative rotator cuff pathology. Physical examinations should consist of accepted tests and exam techniques applicable to the joint or area being examined, including:
i. visual inspection;

ii. palpation, including the acromio-clavicular (AC) joint, sternoclavicular joint, and the subacromial bursa in the region of the acromiohumeral sulcus;

iii. range-of-motion/quality of motion;

iv. strength, shoulder girdle weakness may indicate musculoskeletal or neurogenic pathology;

v. joint stability;

vi. integrity of distal circulation and limited neurologic exam;

vii. cervical spine evaluation; and

viii. if applicable, full neurological exam including muscle atrophy and gait abnormality.

ix. specific shoulder tests
(a). This section contains a description of common clinical shoulder tests. Generally, more than one test is needed to make a diagnosis. Clinical judgment should be applied when considering which tests to perform, as it is not necessary to perform all of the listed tests on every patient. The physical examination may be non-specific secondary to multi-faceted pathology in many patients, and because some tests may be positive for more than one condition. Given the multitude of tests available, the physician is encouraged to document the specific patient response, rather than report that a test is 'positive.' The tests are listed for informational purposes, and are also referenced in Specific Diagnostic, Testing and Treatment Procedures.
(i). Rotator cuff/Impingement tests/Signs - Most published clinical examination studies assess rotator cuff pathology. There is some evidence that tests are reliable for ruling out diagnoses, but not necessarily defining the pathology accurately. Some studies indicate that the Neer test, Hawkins test, Jobe test, crossed-arm adduction test, impingement sign and arc of pain are approximately 80 percent sensitive for impingement or rotator cuff pathology. The drop arm, Yergason's, Speed, and passive external Rotation Tests are thought to have specificity of 60 percent or higher. (Questions remain about interrater reliability.)
[a]. Weakness with abduction.

[b]. Arc of pain Pain with 60 to 120 degrees of abduction.

[c]. Neer impingement sign Examiner flexes arm anteriorly to reproduce impingement. Positive if pain is reproduced.

[d]. Neer impingement test When the Neer impingement sign is positive, the subacromial bursa is injected with local anesthetic. If, after 40 minutes, the patient has sufficient pain relief so that the examiner can perform the Neer impingement sign without recreating the initial pain, the test suggests impingement.

[e]. Hawkins - arm is abducted to 90 degrees, forward flexed by 90 degrees with elbow flexed. Examiner internally rotates the humerus. Pain suggests impingement.

[f]. Drop arm - Patient slowly lowers arm from full abduction. If the arm drops, or if the patient is unable to maintain slow progress from approximately 90 degrees, the test suggests rotator cuff tear.

[g]. Lift off - patient's hand is placed against back of waist with 90 degrees flexion of elbow. The patient is asked to lift the hand off of his back at waist level. If the hand drops to the initial position against the back, this suggests subscapularis tear or weakness. Some patients may not be able to perform the initial hand placement due to pain or limited range-of-motion.

[h]. Subscapularis strength test - Patient places hand on mid-abdomen, and then applies pressure. If the elbow moves posteriorly or the wrist flexes, the test suggests subscapularis weakness or tear.

[i]. Empty Can test - Patient's arm abducted to 60 to 90 degrees with 30 degrees forward flexion and with forearm pronated. Thumbs are pointing toward the floor. Patient resists examiner's downward pressure on the elbow. Weakness of the affected side, compared to the opposite side, or pain in subacromial area suggests supraspinatus tear, tendonitis or tendonosis.

[j]. External rotation lag test - the patient's arm is abducted to 20 degrees with elbow flexed at 90 degrees, and almost fully externally rotated. If the patient cannot maintain the arm in external rotation, this suggests a supraspinatus and/or infraspinatus tear.

[k]. External rotation weakness Elbows are flexed with arms at side, and patient attempts to externally rotate against resistance. Weakness suggests infraspinatus and teres minor pathology.

[l]. Impingement sign Patient extends shoulder, then abducts and reports any pain

(ii). Acromioclavicular Joint Tests
[a]. Crossed arm adduction Examiner adducts arm across the body as far as possible toward the opposite shoulder. If patient reports pain in the AC joint, this suggests AC joint pathology. Examiner may measure the distance between antecubital fossa and the opposite acromion of the opposite shoulder. If one shoulder demonstrates increased distance compared to the other shoulder, this suggests a tight posterior capsule.

[b]. Paxino's - The examiner's thumb is placed under the posterolateral aspect of the acromion, with the index and long fingers on the superior aspect of middle part of the clavicle. Examiner applies anterior superior pressure to acromion with thumb, and pushes inferiorly on the middle of the clavicle with index and long fingers. If the patient reports increased pain in the AC joint, the test suggests AC joint pathology.

(iii). Labral Tears
[a]. Labral tears which may require treatment usually occur with concurrent bicipital tendon disorders pathology and/or glenohumeral instability. Therefore, tests for labral pathology are included in these sections.

(iv). Bicipital Tendon Disorders
[a]. Yergason's Test - The patient has the elbow flexed to 90 degrees. The examiner faces the patient, grasps the patient's hand with one hand and palpates the bicipital groove with the other. The patient supinates the forearm against resistance. If the patient complains of pain in the biceps tendon with resistance, it suggests a positive finding.

[b]. Ludington's - The patient's hands are placed behind the head, with the shoulders in abduction and external rotation. If biceps contraction recreates pain, the test suggests biceps tendon pathology.

[c]. Speed Test - The patient's shoulder is flexed to 90 degrees and supinated. The examiner provides resistance to forward flexion. If pain is produced with resistance, the test suggests biceps tendon instability or tendonitis.

[d]. Biceps Load Test II - The patient is supine with the arm elevated to 120 degrees, externally rotated to maximum point, with elbow in 90 degrees of flexion and the forearm supinated. The examiner sits adjacent to the patient on the same side, and grasps the patient's wrist and elbow. The patient flexes the elbow, while the examiner resists. If the patient complains of pain with resistance to elbow flexion, or if the pain is increased with resisted elbow flexion, this may suggest a biceps related SLAP lesion in young patients.

(v). Glenohumeral Instability/Labral Tears/SLAP Lesions. Many of the following tests are also used to test for associated labral tears. The majority of the tests/signs should be performed on both shoulders for comparison. Some individuals have increased laxity in all joints, and therefore, tests/signs which might indicate instability in one individual may not be pathologic in individuals whose asymptomatic joint is equally lax.
[a]. Sulcus sign With the patient's arm at the side, the examiner pulls inferiorly and checks for deepening of the sulcus, a large dimple on the lateral side of the shoulder. Deepening of the sulcus suggests instability.

[b]. Inferior instability With patient's arm abducted to 90 degrees, examiner pushes down directly on mid-humerus. Patient may try to drop the arm to the side to avoid dislocation.

[c]. Posterior instability The patient's arm is flexed to 90 degrees anteriorly and examiner applies posterior force to the humerus. The examiner then checks for instability.

[d]. Apprehension Patient's shoulder is in 90 degrees of abduction and in external rotation. Examiner continues to externally rotate and apply axial force to the humerus. If there is pain, or if patient asks to stop, the test suggests anterior instability.

[e]. Relocation Examiner applies posterior force on humerus while externally rotating. This is performed in conjunction with the apprehension test. If symptoms are reduced, the test suggests anterior instability.

[f]. Load and shift or anterior and posterior drawer Patient is supine or seated with arm abducted from shoulder from 20 to 90 degrees and elbow flexed. Humerus is loaded by examiner, then examiner attempts to shift the humeral head anterior, posterior, or inferior. Both shoulders should be tested. Results are graded using:
[i]. Grade 0, little or no movement;

[ii]. Grade 1, humeral head glides beyond the glenoid labrum; and

[iii]. Grades 2 & 3 actual dislocation of the humeral head off the glenoid.

[g]. Anterior slide or Kibler test Patient places hands on hips with thumb directed posteriorly. Examiner applies force superiorly and anteriorly on the humerus, while the patient resists. If a click or deep pain results, test suggests labral tear.

[h]. Active compression (O'Brien) test The patient has the shoulder in 90 degrees flexion and 10 to 15 degrees adduction. The arm is internally rotated so the thumb is pointing downward. The patient elevates the arm while the examiner resists. If the patient experiences deep anterior shoulder pain that is relieved when the same process is repeated with external rotation of the arm, the test suggests labral tear or AC joint pathology.

[i]. Crank test The patient is standing and has arm elevated to 160 degrees in the scapular plane. The examiner loads the glenohumeral joint while the arm is passively rotated internally and externally. The test is repeated in the supine position. Pain, clicking, popping, or other mechanical grinding suggests labral tear and possible instability.

[j]. Compression rotation test The patient is supine with shoulder abducted at 90 degrees. The examiner applies an axial load across the glenohumeral joint while simultaneously passively rotating the patient's arm in internal and external rotation. Pain, clicking, popping, or other mechanical grinding suggests a labral tear and possible instability.

[k]. Pain provocation or Mimori test The patient is seated upright with the shoulder in 90 degrees abduction. The examiner maximally pronates and supinates the forearm while maintaining the shoulder at 90 degrees abduction. A positive test is suggested when pain or pain severity, is greater with the forearm pronated.

(vi). Functional assessment. The provider should assess the patient's functional skills initially and periodically during treatment. The initial exam will form the baseline for the patient's functional abilities post- injury. This assessment will help the physician and patient determine when progress is being made and whether specific therapies are having a beneficial effect. A number of functional scales are available that have been validated in clinical research settings. Many of these scales were developed to evaluate specific diagnoses and will not be useful for all patients with shoulder pain. The following areas are examples of functional activities the provider may assess:
[a]. interference with sleep;

[b]. difficulty getting dressed or combing or washing hair;

[c]. ability to do the household shopping alone;

[d]. ability to shower or bath and dry oneself using both hands;

[e]. ability to carry a tray of food across a room with both hands;

[f]. ability to hang up clothes in the closet;

[g]. ability to reach high shelves with the affected shoulder;

[h]. difficulty with any other activities including sports and work duties;

[i]. concerns about putting on overhead clothing;

[j]. concerns that a specific activity might cause the shoulder to "go out";

[k]. a detailed description of ability to perform job duties.

[l]. any positive historical information should be validated by the provider's physical exam.

2. Radiographic Imaging of the shoulder is a generally accepted, well-established and widely used diagnostic procedure when specific indications based on history and/or physical examination are present. It should not be routinely performed for most non-traumatic diagnoses. The mechanism of injury and specific indications for the radiograph should be listed on the request form to aid the radiologist and x-ray technician. For additional specific clinical indications, Specific Diagnosis, Testing and Treatment Procedures. Indications include:
a. inability to actively move arm through range-of-motion;

b. history of significant trauma, especially blunt trauma or fall from a height;

c. history of dislocation;

d. age over 55 years;

e. unexplained or persistent shoulder pain over two weeks. (Occult fractures, may not be visible on initial x-ray. A follow-up radiograph and/or bone scan may be required to make the diagnosis);

f. history or exam suggestive of intravenous drug abuse or osteomyelitis; and

g. pain with swelling and/or range-of-motion (ROM) limitation localizing to an area of prior fracture, internal fixation, or joint prosthesis.

3. Laboratory tests are generally accepted, well-established and widely used procedures. They are, however, rarely indicated at the time of initial evaluation, unless there is suspicion of systemic illness, infection, neoplasia, connective tissue disorder, or underlying arthritis or rheumatologic disorder based on history and/or physical examination. Laboratory tests can provide useful diagnostic information. The OWCA recommends that lab diagnostic procedures be initially considered the responsibility of the workers' compensation carrier to ensure that an accurate diagnosis and treatment plan can be established. Tests include, but are not limited to:
a. Completed Blood Count (CBC) with differential can detect infection, blood dyscrasias, and medication side effects;

b. Erythrocyte sedimentation rate, rheumatoid factor, antinuclear antigen (ANA), human leukocyte antigen (HLA), and C-reactive protein can be used to detect evidence of a rheumatologic, infection, or connective tissue disorder;

c. Serum calcium, phosphorous, uric acid, alkaline phosphatase, and acid phosphatase can detect metabolic bone disease;

d. Liver and kidney function may be performed for prolonged anti-inflammatory use or other medications requiring monitoring; and

e. Analysis of joint aspiration for bacteria, white cell count, red cell count, fat globules, crystalline birefringence and chemistry to evaluate joint effusion.

7. Other Procedures
a. Joint Aspiration: is a generally accepted, well-established and widely used procedure when specifically indicated and performed by individuals properly trained in these techniques. Especially, when history and/or physical examination are of concern for a septic joint or bursitis. Aspiration of a large effusion can help to decrease pain and speed functional recovery. Persistent or unexplained effusions may be examined for evidence of infection, rheumatologic, or inflammatory processes. The presence of fat globules in the effusion strongly suggests occult fracture.

AUTHORITY NOTE: Promulgated in accordance with R.S. 23:1203.1.

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