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-2323 - Specific Diagnosis, Testing and Treatment

Universal Citation: LA Admin Code I-2323

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

A. Acromioclavicular joint sprains/dislocations. An acute acromioclavicular (AC) joint injury is frequently referred to as a shoulder separation. There are six classifications of AC joint separation, which are based upon the extent of ligament damage and bony displacement:

1. Description/Definition:

a. Type I - Sprain of the AC ligament and capsule; x-ray usually normal.

b. Type II - Sprains consisting of a ruptured AC ligament and capsule with incomplete injury to the coracoclavicular (CC) ligament, resulting in mild AC joint subluxation. X-ray shows clavicle slightly elevated.

c. Type III - Dislocation of the clavicle above the acromion with complete tear of the AC ligament and/or CC ligaments; abnormal stress x-rays.

d. Type IV. - Dislocation consisting of a displaced clavicle that penetrates posteriorly through or into the trapezius muscle. The sterno-clavicular joint may also be dislocated.

e. Type V - Dislocation consisting of complete separation of the AC and CC ligaments and dislocation of the acromioclavicular joint with a large coracoclavicular interval.

f. Type VI - Dislocation consisting of a displaced clavicle that penetrates inferior to the coracoid.

2. Type I-III are common, while Types IV-VI are not, and when found require surgical consultation. For AC joint degeneration from repetitive motion that is found to be work-related, refer to Impingement Syndrome.

3. Occupational Relationship: Generally, workers sustain an AC joint injury when they fall landing on the point of the shoulder, driving the acromion downward; or fall on an outstretched hand or elbow with an adducted arm, creating a backward and outward force on the shoulder. It is important to rule out other sources of shoulder pain from the acute injury, including rotator cuff tear, fracture, and nerve injury.

4. Specific Physical Exam Findings may include the following:

a. At times, tenderness at the AC joint with contusions and/or abrasions at the joint area; and/or prominence/asymmetry of the shoulder can be seen;

b. The patient usually demonstrates decreased shoulder motion, and with palpation, the distal end of the clavicle is painful. There may be increased clavicular translation and cross-body adduction that causes exquisite pain at the AC joint. Cross-body adduction with the arm elevated to 90 degrees can also cause posterior pain with a tight posterior capsule, or lateral pain with impingement. Injection of local anesthetic in the AC joint should relieve pain when performing this maneuver.

5. Diagnostic Testing Procedures: Plain x-rays may include:

a. AP view;

b. AP radiograph of the shoulder with the beam angled 10 degrees cephalad (Zanca view) and a beam strength that is under-penetrating;

c. Axillary lateral views; and

d. Stress view; side-to-side comparison with 10 to 15 lb. of weight in each hand.

6. Non-operative Treatment Procedures may include:

a. Procedures outlined in Section F. Immobilization in some cases (up to 6 weeks for Type I-III AC joint separations). Treatments for Type III injuries are controversial and may range from a sling to surgery.

b. Medication, such as non-steroidal anti-inflammatories and analgesics would be indicated. Narcotics are not normally indicated. Lidocaine patches may be used for pain relief. In chronic acromioclavicular joint pain, a series of injections with or without cortisone may be performed up to three times per year. Benefits may be achieved through therapeutic rehabilitation. It should emphasize a progressive increase in range-of-motion (ROM) without exacerbation of the AC joint injury. Full recovery of AC joint dislocation may require up to twelve weeks. With increasing motion and pain control, a strengthening program should be instituted. Refer to Therapeutic Procedures, Non-operative.

c. Return to appropriate modified duty should begin within the first week. Refer to Return to Work. With restoration of full-motion, return to full-duty should be anticipated within three months.

d. Other therapies in Therapeutic Procedures, Non-operative, may be employed in individual cases.

7. Surgical Indications: Patients who have Type III AC joint dislocations will usually recover well without surgical intervention. Surgical intervention may be considered when functional deficits interfere with activities of daily living and/or job duties after three to four months of active patient participation in non-operative therapy. For patients with particularly high physical demands on their shoulder, immediate orthopaedic consultation with surgical intervention as early as two weeks from the date of injury may be considered. Prior to surgical intervention, the patient and treating physician should identify functional operative goals and the likelihood of achieving improved ability to perform activities of daily living or work activities. The patient should also agree to comply with the pre- and post-operative treatment plan and home exercise requirements and understand the length of partial and full-disability expected post-operatively. With a Type IV-VI AC joint injury, an orthopedic surgical consultation is recommended.

8. Operative Procedures:

a. AC joint stabilization with or without distal clavicle resection. Distal clavicle resection may prevent painful arthritis but can compromise post-operative AC joint stabilization.

9. Post-operative Treatment:

a. An individualized rehabilitation program based upon communication between the surgeon and the therapist using the treatments found in Therapeutic Procedures, Non-operative.

b. Early therapeutic rehabilitation interventions are recommended to maintain ROM with progressive strengthening.

i. Frequency: Three to five times per week for the first two weeks, three times per week for the following two weeks, then one to two times per week.

ii. Optimum Duration: Six to eight weeks with progression to home exercise and/or pool therapy.

iii. Maximum Duration: 12 weeks. Occasional follow-up visits may be justified to reinforce exercise patterns or to reach final functional goals if the therapy to date has demonstrated objective functional gains.

c. Return to work and restrictions after surgery may be made by an experienced primary occupational medicine physician in consultation with the surgeon or by the surgeon.

10. Adhesive Capsulitis/Frozen Shoulder Disorder

a. Description/Definition: Adhesive capsulitis of the shoulder, also known as frozen shoulder disorder, is a soft tissue lesion of the glenohumeral joint resulting in global restrictions of passive and active ROM. Lack of passive ROM can persist even with therapy, for an average of 30 months. The disorder progresses through stages, specifically:

i. Stage 1 - Consists of acute pain with some limitation in range-of-motion; generally lasting two to nine months.

ii. Stage 2 - Characterized by progressive stiffness, loss of passive range-of-motion, muscular atrophy, and decreased pain; generally lasting an additional 3 to 12 months beyond Stage 1.

iii. Stage 3 - Characterized by partial or complete resolution of symptoms and restoration of ROM and strength; it usually takes an additional 5 to 26 months beyond Stage 2.

iv. Patients will usually complain of pain in the sub-deltoid region, but occasionally over the long head of the biceps or radiating down the lateral aspect of the arm to the forearm. Pain is often worse at night, with difficulty sleeping on the involved side. Motion is restricted and painful.

v. In Stages 2 and 3, patients may also experience peri-scapular and neck pain from compensatory scapular thoracic motion.

vi. Idiopathic adhesive capsulitis usually occurs spontaneously without any specific inciting injury. This occurs most frequently in diabetic, middle aged patients. This type of adhesive capsulitis is likely to remit over time and is usually not work related.

vii. Capsulitis or stiffness may occur secondary to trauma or surgery from another condition. Therapy and additional treatment recommendations for other specific diagnoses should be strictly followed to decrease the occurrence of secondary restricted ROM.

b. Specific Physical Exam Findings may include: Restricted active and passive glenohumeral ROM in multiple planes is the primary physical finding. It may be useful for the examiner to inject the subacromial space with lidocaine and then repeat ROM testing to rule out stiffness secondary to rotator cuff or bursal pathology. Lack of improvement of ROM usually confirms the diagnosis. Postural changes and secondary trigger points along with atrophy of the deltoid and supraspinatus muscles may be seen.

c. Diagnostic Testing Procedures:

i. Plain x-rays should be done to rule out concomitant pathology such as subluxation or tumor.

ii. Other diagnostic testing may be indicated to rule out associated pathology. Refer to Follow-up Diagnostic Procedures and to Specific Diagnosis, Testing, and Treatment. Dynamic sonography may be useful to specifically identify the movements most affected and rule out other pathology.

iii. Laboratory tests should be considered to rule out systemic diseases.

d. Non-operative Treatment Procedures: Address the goal to restore and maintain function and may include the following:

i. Therapeutic interventions are the mainstay of treatment. They should include ROM, active therapies, and a home exercise program. Passive as well as active therapies may be used for control of pain and swelling. Therapy should progress to strengthening and instruction in a home exercise program targeted to further improve ROM and strength of the shoulder girdle musculature. There is some evidence that a home exercise program will have similar results to fully-supervised physical therapy in non-workers compensation populations; however, to facilitate return to work, supervised therapy is generally recommended for at least several sessions to assure proper performance of home exercise and to evaluate continued progress. These sessions are in addition to any sessions already performed for the original primary related diagnosis. Refer to Therapeutic Procedures, Non-operative for all other therapies as well as a description of active and passive therapies.

(a). Time to Produce Effect: Four sessions.

(b). Frequency: Two times per week for the first two weeks and one time or less thereafter.

(c). Optimum Duration: 8 to 12 sessions.

(d). Maximum Duration: 20 sessions per year. Additional follow-up visits may be justified to reinforce exercise patterns or to reach final functional goals if therapy to date has demonstrated objective functional gains.

ii. Return to work duties with increased ROM as tolerated are also helpful to increase function. Refer to Return to Work.

iii. Medications, such as NSAIDS and analgesics, may be helpful. Narcotics are indicated for postmanipulation or post-operative cases. Judicious use of pain medications to optimize function may be indicated. Refer to Medications.

iv. Subacromial bursal and/or glenohumeral steroid injections can decrease inflammation and allow the therapist to progress with functional exercise and ROM. There is strong evidence that intra-articular injection of a corticosteroid produces pain relief and increases ROM in the short-term for individuals with restriction of both active and passive ROM in more than one direction. There is good evidence that the addition of a physical therapy or home exercise program is more effective than steroid injections alone. Injections under significant pressure should be avoided as the needle may be penetrating the tendon and injection into the tendon can cause possible tendon breakdown, tendon degeneration, or rupture. Injections should be minimized for patients under 30 years of age. Steroid injections should be used cautiously in diabetic patients. Diabetic patients should be reminded to check their blood glucose level at least daily for 2 weeks after injections.

(a). Time to Produce Effect: One injection.

(b). Maximum Duration: Three injections in one year at least four to eight weeks apart, when functional benefits are demonstrated with each injection.

v. There is no clear long-term benefit for suprascapular nerve blocks, however, blocks may be appropriate for patients when pain is not well-controlled and injections improve function.

(a). Time to Produce Effect: One block should demonstrate increased ability to perform exercises and/or range-of-motion.

(b). Maximum Duration: Three per year.

vi. In cases that are refractory to conservative therapy lasting at least three to six months, and in whom ROM remains significantly restricted (abduction usually less than 90 degrees), the following treatment may be considered:

(a). Distension arthrography or "brisement" in which saline, an anesthetic and usually a steroid are forcefully injected into the shoulder joint causing disruption of the capsule. There is good evidence that distension arthrogram with steroid and saline improves function in patients with decreased passive ROM after three months of treatment. Early therapy to maintain ROM, and restore strength and function should follow distension arthrography. Return to work with restrictions should be expected within one week of the procedure; return to full-duty is expected within four to six weeks.

(b). Dynamic splinting may be appropriate for rare cases when a functional ROM has not been achieved with the treatment listed above.

vii. There is no evidence that hyaluronate injections are superior to physical therapy in this condition and are not recommended.

viii. Other therapies in Therapeutic Procedures, Non-operative, may be employed in individual cases.

e. Surgical Indications: Surgery may be considered when functional deficits interfere with activities of daily living and/or job duties after three to six months of active patient participation in non-operative therapy. For most individuals this constitutes limitations in the range of 130 degrees elevation and 120 degrees abduction; with significant functional limitations; however, individuals who must perform overhead work and lifting may require a greater ROM. Prior to surgical intervention, the patient and treating physician should identify functional operative goals and the likelihood of achieving improved ability to perform activities of daily living or work activities. The patient should also agree to comply with the pre- and post-operative treatment plan and home exercise requirements. The patient should understand the length of partial and full disability expected post-operatively.

f. Operative Procedures: Manipulation under anesthesia which may be done in combination with steroid injection, distension arthrography, or arthroscopy. Contraindications to closed manipulation under anesthesia include anti-coagulation or bleeding diatheses, significant osteopenia, or recent surgical repair of shoulder soft tissue, fracture or neurological lesion. Complications may include humeral fracture, dislocation, cuff injuries, labral tears or brachial plexus injury. Arthroscopic capsular release or open surgical release may be appropriate in rare cases with failure of previous methods and when the patient has demonstrated ability to follow through with required physical and occupational therapy. Other disorders, such as impingement syndrome, may also be treated at the same time. Radiofrequency is not recommended due to reported complications from chondrolyis.

g. Post-Operative Treatment. An individualized rehabilitation program based upon communication between the surgeon and the therapist using the treatments found in Therapeutic Procedures, Non-operative. Therapy may include the following:

i. Early therapeutic rehabilitation interventions are recommended to maintain ROM and should progress to strengthening exercises.

ii. Frequency: Suggested frequency pattern is three to five times per week for the first two weeks, three times per week for the following two weeks, then one to two times per week. The exact frequency per week will depend on the severity.

iii. Optimum Duration: Six to eight weeks with progression to home exercise and/or pool therapy.

iv. Maximum Duration: Up to 12 weeks. Additional follow-up visits may be justified to reinforce exercise patterns or to reach final functional goals if the therapy to date has demonstrated objective functional gains.

v. Return to work and restrictions after surgery may be made by an experienced primary occupational medicine physician in consultation with the surgeon or by the surgeon.

vi. Patient should be approaching MMI within 8 to 12 weeks post-operatively; however, co-existence of other pathology should be taken into consideration.

B. Bicipital Tendon Disorders

1. Description/Definition:

a. Disorders may include: primary bicipital tendonopathy, which is exceedingly rare; secondary bicipital tendonopathy, which is generally associated with rotator cuff tendonitis or impingement syndrome (see appropriate diagnosis subsections); subluxation of the biceps tendon, which occurs with dysfunction of the transverse inter-tubercular ligament and rotator cuff tears; and acute disruption of the tendon, which can result from an acute distractive force or transection of the tendon from direct trauma.

b. Symptoms may include aching, burning and/or stabbing pain in the shoulder, usually involving the anterior medial portion of the shoulder girdle. The symptoms are exacerbated with above-the-shoulder activities and those specifically engaging the biceps (flexion at the shoulder, flexion at the elbow and supination of the forearm). Relief occurs with rest. Patients may report nocturnal symptoms which interfere with sleep during the acute stages of inflammation; pain and weakness in shoulder during activities; repeated snapping phenomenon with a subluxing tendon; immediate sharp pain and tenderness along the course of the long head of the biceps following a sudden trauma which would raise suspicions of acute disruption of the tendon; and/or with predominant pain at the shoulder accompanied by referral patterns which may extend pain into the cervical or distal structures, including the arm, elbow, forearm, and wrist.

2. Occupational Relationship.

a. Bicipital tendon disorders may include symptoms of pain and/or achiness that occur after repetitive use of the shoulder and/or blunt trauma to the shoulder. Secondary bicipital tendonitis may be associated with prolonged above-the-shoulder activities, and/or repeated shoulder flexion, external rotation and abduction. Acute trauma to the biceps tendon of the shoulder girdle may also give rise to occupational injury of the biceps tendon.

b. Occupational disorders of the biceps tendon may accompany scapulothoracic dyskinesis, rotator cuff injury, AC joint separation, sub deltoid bursitis, shoulder instability or other shoulder pathology. Symptoms should be exacerbated or provoked by work that activated the biceps muscle. Symptoms may be exacerbated by other activities that are not necessarily work related and the physician should explore and report these areas.

3. Specific Physical Exam Findings may include the following:

a. If continuity of the tendon has been lost (biceps tendon rupture), inspection of the shoulder would reveal deformity (biceps bunching/Popeye deformity). It is important to differentiate between distal and proximal tendon rupture, as distal biceps ruptures often require urgent intervention.

b. Palpation demonstrates tenderness along the course of the bicipital tendon.

c. Pain at end range of flexion and abduction as well as with biceps tendon activation.

d. Provocative testing may include the following (a detailed description of the signs and tests is located in initial diagnostic procedures):

i. Yergeson's sign.

ii. Speed's Test.

iii. Ludington's Test.

iv. Diagnostic Testing Procedures:

(a). Plain x-rays include:

(i). Anterior/Posterior (AP) view. Elevation of the humeral head is indicative of a rotator cuff tear;

(ii). Lateral view in the plane of the scapula or an axillary view determines an anterior or posterior dislocation or the presence of a defect in the humeral head (a Hill-Sachs lesion);

(iii). Axillary view is also useful to demonstrate arthritis and spurs on the anterior inferior acromion; and

(iv). Outlet view determines if there is a downwardly tipped acromion.

(b). Adjunctive testing, such as sonography, or MRI should be considered when shoulder pain is refractory to four to six weeks of non-operative conservative treatment and the diagnosis is not readily identified by standard radiographic and clinical techniques.

4. Non-Operative Treatment Procedures:

a. Benefit may be achieved through procedures outlined in Non-operative Treatment Procedures, such as appropriate modalities, limited acute immobilization, exercise and evaluation of occupational workstation. Therapy should emphasize progressive increase in ROM. With increasing motion and pain control, a strengthening program should be instituted.

i. Time to Produce Effect: Four sessions.

ii. Frequency: Two times per week for the first two weeks and one time or less thereafter.

iii. Optimum Duration: 8 to 12 sessions.

iv. Maximum Duration: 20 sessions per year.

b. Medication, such as nonsteroidal anti-inflammatory and analgesics would be indicated. Narcotics are not normally indicated.

c. Biceps tendon sheath or subacromial steroid injections may be therapeutic. Injections under significant pressure should be avoided as the needle may be penetrating the tendon. Injection into the tendon can cause tendon degeneration, tendon breakdown, or rupture. Caution should be used in patients with a clinical suspicion of a partial tear. Injections should be minimized for patients under 30 years of age.

d. Steroid injections should be used cautiously in diabetic patients. Diabetic patients should be reminded to check their blood glucose level at least daily for two weeks after injections.

i. Time to Produce Effect: One injection should provide demonstratable functional benefit.

ii. Maximum Duration: Three injections per year at the same site when functional benefits are demonstrated with each injection.

e. Return to work with appropriate restrictions should be considered early in the course of treatment. Refer to Return to Work. By 8 to 11 weeks, with restoration of full-motion, return to full-duty should be anticipated.

f. Other therapies in Therapeutic Procedures, Non-operative, may be employed in individual cases.

5. Surgical Indications:

a. Acute Distal Biceps Tendon Rupture: normally requires urgent surgical repair.

b. Acute Proximal Long Head Biceps Tendon Rupture: active patient participation in non-operative treatment is often successful; however, operative intervention may be indicated for young patients, manual laborers or others who require forceful supination regularly for their work.

c. Bicipital Tendonitis: Conservative care prior to potential surgery must address flexibility and strength imbalances. Surgery may be considered when functional deficits interfere with activities of daily living and/or job duties after 12 weeks of active patient participation in non-operative therapy.

d. Subluxing Bicipital Tendon: Most patients with this condition also have a subscapularis tear. Surgical stabilization of the bicipital tendon is not commonly indicated. Good outcome may be achieved through successful rehabilitation procedures. Surgery may be considered when functional deficits interfere with activities of daily living and/or job duties after 12 weeks of active patient participation in non-operative therapy.

e. Prior to surgical intervention, the patient and treating physician should identify functional operative goals and the likelihood of achieving improved ability to perform activities of daily living or work activities and the patient should agree to comply with the pre- and post-operative treatment plan and home exercise requirements. The patient should understand the length of partial and full disability expected post-operatively.

6. Operative Procedures:

a. Distal Biceps tendon repair.

b. Repair of rotator cuff pulley lesion.

c. Proximal tenodesis or tenotomy: Impingement of the biceps tendon can cause continued irritation, and pain preventing shoulder elevation. Tenodesis or tenotomy has been used for decreased elevation after therapy in conjunction with a sub scapular repair or irreparable rotator cuff tear.

7. Post-operative Treatment:

a. An individualized rehabilitation program based upon communication between the surgeon and the therapist using the treatments found in Therapeutic Procedures, Non-operative. Therapy may include the following:

b. It is reasonable to restrict ROM for two months for tenodesis or distal biceps tendon repair. Early loading of the tendon should be avoided. Surgical patients may not recover sufficiently to perform full activity for 3 to 12 months. Rehabilitation, lasting at least 6 to 12 weeks, is necessary to facilitate Maximum Medical Improvement (MMI).

i. Frequency: Three to five times per week for the first two weeks, three times per week for the following two weeks, then one to two times per week.

ii. Optimum Duration: Six to eight weeks with progression to home exercise and/or pool therapy.

c. Return to work and restrictions after surgery may be made by an experienced primary occupational medicine physician in consultation with the surgeon or by the surgeon.

C. Brachial Plexus and Shoulder Peripheral Nerve Injuries. Injuries to the brachial plexus and nerves of the shoulder girdle region may result in loss of motor and sensory function, pain, and instability of the shoulder. Signs and symptoms vary with the degree and mechanism of injury. The two modes of injury are: acute direct or indirect traumatic injuries to the shoulder region, and repetitive motion or overuse. Transient compression, stretch or traction (neurapraxia) causes sensory and motor signs lasting days to weeks. Damage to the axon (axonotmesis) without disruption of the nerve framework may cause similar symptoms. The recovery time is delayed and depends upon axon re-growth distally from the site of injury. Laceration or disruption of the entire nerve with complete loss of framework (neurotmesis) is the most severe form of nerve injury and will invariably require surgical intervention. Return of function is dependent upon re-growth of the nerve distal to the injury site. Full return of motor function is variable and may take up to 18 months or longer. Electromyography (EMG) is the most commonly used diagnostic modality to analyze nerve injuries. Electrophysiologic studies, such as electromyography and nerve conduction studies are generally accepted, well-established and widely used for localizing the source of neurological symptoms. These studies should be utilized as an extension of the history and clinical examination and to assess or monitor nerve recovery. Studies should be performed three to four weeks following injury or description of symptoms. Studies performed early may be falsely negative and usually require repeat testing three to four weeks after the original injury. Thus, early testing is not generally recommended. If the symptoms have been present for longer than three to four weeks, studies may be performed immediately after the initial evaluation. Serial studies may be indicated if initial studies are negative and may also be useful for gauging prognosis. Limb temperature should be controlled at 30 to 40 degrees centigrade. A description of six common nerve injuries to the shoulder girdle and their treatment follow.

1. Brachial Plexus Injuries:

a. Description/Definition:

i. The Brachial Plexus is formed by the nerve roots of C5-C8 and T1. These nerve roots exit the cervical spine and pass through the scalene musculature. After leaving the scalene musculature, at the level of the clavicle, they form trunks, division and chords which ultimately form the peripheral nerves of the arm.

b. Occupational Relationship: Direct injury to brachial plexus results in widespread sensory and motor loss. Direct trauma, subluxation to shoulder, clavicular fractures, shoulder depression, or head deviation away from the arm may result in variable brachial plexus lesions. Weight-lifting and carrying heavy back packs have also been associated with plexus injuries. Most injuries involve the upper and/or lower trunks. Upper trunk plexopathies may accompany full-thickness rotator cuff tears. Isolated middle trunk involvement is rare. Infraclavicular brachial plexus injuries have been reported due to hematoma formation secondary to an axillary block. If this occurs, emergency evacuation of the hematoma may be indicated. Symptoms may appear hours-to-days after the Procedure. Severe motor and sensory axonal loss is frequently seen on electrodiagnostic studies. It is important to differentiate injuries to the brachial plexus from the acquired (non work-related) Parsonage-Turner Syndrome or neuralgic amyotrophy occurring without a history of trauma. This idiopathic syndrome begins with severe pain in the shoulder girdle and is accompanied by resistance to passive motion. As the pain decreases, severe, near total weakness of one or more shoulder girdle muscles occurs. Almost total recovery can be expected but occurs over two to three years.

c. Specific Physical Exam Findings may include:

i. Evidence of trauma or deformity;

ii. Identification of sensory loss and demonstration of weakness which relates to the severity and anatomy of the injury to the brachial plexus; and/or

iii. Pain with recreation of the motions related to the mechanism of injury.

iv. Diagnostic Testing Procedures:

(a). EMG may show acute or chronic denervation of specific nerves. Nerve Conduction Studies demonstrating a loss of amplitude of 50 percent compared to the normal side are considered abnormal. NCVs/EMGs will be repeated at appropriate intervals to assess reinnervation.

(b). If studies do not localize and give sufficient information, then additional information may be obtained from MRI and/or myelography. These studies are employed to differentiate root avulsion from severe brachial plexus injuries. Occasionally MRI may reveal the presence of an unexpected mass lesion consistent with a tumor.

v. Non-operative Treatment Procedures:

(a). In closed injuries, observation is favored. Repeat electrophysiologic studies may be helpful to assess or monitor recovery.

(b). Rehabilitation is based on procedures set forth Non-operative Treatment Procedures. However, utilization of ultrasound, and cold and heat should be discussed with the primary care physician, since these modalities may aggravate nerve injury.

(c). Medications such as analgesics, nonsteroidal anti-inflammatories, anti-depressants and anti-convulsants are indicated and narcotics may be indicated acutely. All medications should be prescribed as found in Thoracic Outlet Syndrome Guidelines.

(d). Return to work with appropriate restrictions should be considered early in the course of treatment. Refer to Return to Work.

vi. Surgical Indications:

(a). In open injuries, acute exploration may be indicated if nerve discontinuity is visualized. Surgery may be considered post-injury when functional deficits interfere with activities of daily living and/or job duties after active participation in non-operative therapy.

(b). In closed injuries, if functional deficits continue to be documented after three to four months of active patient participation in non-operative therapy, then exploration may be warranted and a surgical consultation should be considered. Patients with progressive weakness or a loss of function post-injury should be referred for surgical consultation immediately.

vii. Operative Procedures.

(a). Exploration and Repair.

viii. Post-operative Treatment.

(a). An individualized rehabilitation program based upon communication between the surgeon and the therapist. Treatment may include the following:

(b). Early therapeutic rehabilitation interventions are recommended to maintain range-of-motion (ROM) and progressive strengthening.

2. Frequency: Suggested frequency pattern is three to five times per week for the first two weeks. Three times per week for the following two weeks, then one to two times per week. The exact frequency per week will depend on the severity and level of the nerve injury.

3. Optimum Duration: Six to eight weeks with progression to home exercise and/or pool therapy.

4. Maximum Duration: Up to 24 sessions. Additional follow-up visits may be justified to reinforce exercise patterns or to reach final functional goals if the therapy to date has demonstrated objective functional gains.

a. Return to work and restrictions after surgery may be made by an experienced primary occupational medicine physician in consultation with the surgeon or by the surgeon.

b. Axillary Nerve:

i. Description/Definition: This nerve is derived from the fifth and sixth cervical roots and passes around the shoulder, supplying motor branches to the teres minor and the three heads of the deltoid. The axillary nerve provides sensation to the top of the shoulder at the level of the deltoid.

5. Occupational Relationship: Direct injury and penetrating wounds to the shoulder and upward pressure on the axilla can cause injury to the axillary nerve. Blunt trauma to the anterolateral shoulder has also been reported. Abnormalities of the nerve can be seen with fractures of the surgical neck of the humerus and dislocation of the shoulder. Axillary nerve injury may also occur from shoulder surgery. Patients complain of reduced abduction of overhead strength and/or numbness in the lateral arm. The quadrilateral space syndrome may cause pain in the axillary nerve region with abduction, external rotation, and extension. The axillary nerve and the posterior circumflex artery are in the space bound by the long head of the triceps, the teres minor, subscapularis, and latissimus dorsi when the arm is abducted. This syndrome is most commonly reported in young males 20 to 40 years of age and has been associated with overhead sports.

6. Specific Physical Exam Findings may include:

a. weakness and atrophy of the deltoid muscle and teres minor;

b. strength is lost in abduction, flexion and extension of the shoulder; and/or

c. sensory loss is reported over the upper arm.

7. Diagnostic Testing Procedures.

a. Plain x-rays.

b. EMG and Nerve Conduction Studies three weeks after the injury and repeated at appropriate intervals to assess for reinnervation. Comparison of EMG and NCV findings with the opposite side is usually necessary to diagnose the degree of injury.

c. MRI may be done to rule out other pathology.

d. To confirm quadrilateral space syndrome, an MRI angiogram may be done to visualize the posterior circumflex artery occlusion in abduction. However, occlusion is present in 80 percent of normals also. This study should only be done after conservative therapy and if surgery is being contemplated.

8. Non-Operative Treatment Procedures:

a. Rehabilitation is based on procedures set forth in Non-operative Treatment Procedures. However, utilization of ultrasound, and cold and heat should be discussed with the primary care physician since these modalities may aggravate the nerve injury. Shoulder range-of-motion should be emphasized. For quadrilateral space syndrome, stretching of the posterior shoulder and teres minor is recommended.

b. Medications such as analgesics, nonsteroidal anti-inflammatory, anti-depressants and anti-convulsants are indicated. Narcotics may be indicated acutely. All medications should be prescribed as described in Thoracic Outlet Syndrome Guidelines.

c. Return to work with appropriate restrictions should be considered early in the course of treatment. Refer to Return to Work.

9. Surgical Indications: Surgical procedures are usually not necessary, since most injuries to the axillary nerve are due to stretch and/or traction and recover within three to six months. Even when deltoid weakness persists, return to full activity can be expected. One may consider surgery when functional deficits interfere with activities of daily living and/or job duties after three to four months of active patient participation in non-operative therapy and with EMG/NCV documentation of ongoing denervation and loss of function. Lesions secondary to direct penetrating trauma or previous surgery may require more immediate intervention. Surgery for quadrilateral space syndrome is not usually necessary as at least 70 percent of patients recover with conservative treatment. Indications may include six months of conservative treatment with persisting functional deficits, a positive arteriogram, and point tenderness at the posterior quadrilateral space. Overall outcomes of surgery cannot be predicted, as only a small case series have been reported.

10. Operative Procedures:

a. Exploration and Repair.

11. Post-Operative Treatment: An individualized rehabilitation program based upon communication between the surgeon and the therapist. Treatment may include the following: Early therapeutic rehabilitation interventions are recommended to maintain range-of-motion ROM) and progressive strengthening.

a. Frequency: Suggested frequency pattern is three to five times per week for the first two weeks. Three times per week for the following two weeks, then one to two times per week. The exact frequency per week will depend on the severity and level of the nerve injury.

b. Optimum Duration: Six to eight weeks with progression to home exercise and/or pool therapy.

c. Maximum Duration: Up to 24 sessions. Additional follow-up visits may be justified to reinforce exercise patterns or to reach final functional goals if the therapy to date has demonstrated objective functional gains.

d. Return to work and restrictions after surgery may be made by an experienced primary occupational medicine physician in consultation with the surgeon or by the surgeon.

e. Long Thoracic Nerve.

12. Description/Definition:

a. The long thoracic nerve is formed by the cervical fifth, sixth, and seventh roots; it crosses the border of the first rib and descends along the posterior surface of the thoracic wall to the serratus anterior.

13. Occupational Relationship:

a. Injury can occur by direct trauma to the posterior triangle of the neck or trauma may be the result of chronically repeated or forceful shoulder depression. Repeated forward, overhead motion of the arms with the head tilted or rotated to the unaffected side, as well as, stretch or compression of the nerve with the arms abducted, can lead to long thoracic nerve dysfunction. Occasionally, severe traction with the shoulder compressed and the head tilted may be associated with long thoracic nerve pathology.

14. Specific Physical Exam Findings may include:

a. dull ache in the region of the shoulder exacerbated by tilting the head away from the effected side and without sensory loss;

b. scapular deformity and/or winging may be described by patient or family; and/or

c. serratus anterior wasting; and

d. scapular winging at the inferior border that may be demonstrated by asking the patient to forward elevate and lean on his arms, such as against a wall and/or the examiner resisting protraction. (Spinal accessory nerve pathology also causes winging when the patient is abducting.)

15. Diagnostic Testing Procedures.

a. Plain x-rays.

c. MRIs or CTs if there is a need to rule out other pathology.

16. Non-Operative Treatment Procedures.

a. Rehabilitation is based on procedures set forth in Non-operative Treatment Procedures. Utilization of ultrasound, cold, and heat should be discussed with the Primary Care Physician since these modalities can aggravate nerve injury. Strengthening of the scapular stabilizers should be stressed.

b. Orthotics may be used to stabilize the scapula but long-term benefit is not established.

c. Medications such as analgesics, nonsteroidal anti-inflammatory, anti-depressants and anti-convulsants are indicated and narcotics may be indicated acutely. All medications should be prescribed as seen in Thoracic Outlet Syndrome Guidelines.

d. Return to work with appropriate restrictions should be considered early in the course of treatment (Refer to Return to Work). Heavy lifting and other activities that might stress the nerve should be avoided.

17. Surgical Indications. Laceration of the nerve and progressive loss of function are indications for prompt surgical intervention. Surgery may be considered when functional deficits interfere with activities of daily living and/or job duties after four to six months of active participation in non-operative therapy. Surgical consultation should occur at three to four months post-injury for these patients. In most cases, function will recover with conservative therapy in 6 to 12 months.

18. Operative Procedures:

a. exploration and repair;

b. muscle transfer;

c. scapular fixation.

19. Post-Operative Treatment: An individualized rehabilitation program based upon communication between the surgeon and the therapist. Treatment may include the following: Early therapeutic rehabilitation interventions are recommended to maintain ROM with progressive strengthening focusing on the scapular stabilizers.

b. Optimum Duration: Six to eight weeks with progression to home exercise and/or pool therapy.

d. Return to work and restrictions after surgery may be made by an experienced primary occupational medicine physician in consultation with the surgeon or by the surgeon.

e. Musculocutaneous Nerve.

D. Description/Definition:The nerve is derived from the fifth and sixth cervical roots. It innervates the coracobrachialis, biceps and brachioradialis muscles and also provides sensation to the lateral aspect of the forearm.

E. Occupational Relationship:Trauma (including surgery) or penetrating wound to the brachial plexus, coracobrachialis, and shoulder often can cause nerve injury. Most commonly, a stretch/traction injury with the arm in abduction and external rotation induces nerve dysfunction. Cases have been reported to be associated with backpack use, pitching, heavy weight-lifting, mal-position during sleep or surgery, and sudden, forceful extension of the elbow. Complaints may include pain from the axilla into the forearm, biceps weakness, or sensation changes to the lateral forearm from the lateral antebrachial cutaneous nerve.

1. Specific Physical Exam Findings may include:

a. weakness and atrophy in the biceps and brachialis; and/or

b. sensory loss over the lateral aspect of the forearm; however, this is not always seen.

2. Diagnostic Testing Procedures.

a. EMG and Nerve Conduction Studies three weeks after the injury and repeated at appropriate intervals to assess for reinnervation. Comparison of EMG and NCV findings with the opposite side is usually necessary to diagnose the degree of injury.

3. Non-operative Treatment Procedures.

a. Rehabilitation is based on procedures set forth in Non-operative Treatment Procedures. Utilization of ultrasound, cold and heat should be discussed with the primary care physician, since these modalities can aggravate nerve injury.

b. Medications such as analgesics, nonsteroidal anti-inflammatory, anti-depressants and anti-convulsants are indicated and narcotics may be indicated acutely. All medications should be prescribed as seen in Thoracic Outlet Syndrome Guidelines.

c. Return to work with appropriate restrictions should be considered early in the course of treatment. Refer to Return to Work.

4. Surgical Indications: Laceration of the nerve and progressive loss of function are indications for prompt surgical intervention. Surgery may be considered when functional deficits interfere with activities of daily living and/or job duties after four to six months of active patient participation in non-operative therapy. Surgical consultation should occur at three to four months post-injury for these patients. In most cases, function will recover with conservative therapy in 6 to 12 months.

5. Operative Procedures.

a. Exploration and Repair.

6. Post-operative Treatment: An individualized rehabilitation program based upon communication between the surgeon and the therapist. Treatment may include the following: Early therapeutic rehabilitation interventions are recommended to maintain ROM with progressive strengthening.

b. Optimum Duration: Six to eight weeks with progression to home exercise and/or pool therapy.

d. Return to work and restrictions after surgery may be made by an experienced primary occupational medicine physician in consultation with the surgeon or by the surgeon.

e. Spinal Accessory Nerve:

i. Description/Definition: Spinal Accessory Nerve is the eleventh cranial nerve innervating the ipsilateral sternocleidomastoid and trapezius muscles which are extremely important for scapular control and ultimately shoulder function.

ii. Occupational Relationship: Direct trauma to the posterior neck, forceful compression of the shoulder downward, and/or deviation of the head away from the traumatized shoulder can lead to injury to this nerve such as from a fall or motor vehicle accident. Surgical resection of the posterior neck can disrupt the nerve. Patients complain of inability to fully elevate or abduct above horizontal.

7. Specific Physical Exam Findings may include:

a. pain in the shoulder;

b. asymmetrical neckline;

c. scapular winging with the arms out to the side, abduction, or with external rotation;

d. weakness or paralysis of the trapezius with weakness in forward flexion or abduction above 90 degrees; and/or

e. drooping of the shoulder.

8. diagnostic Testing Procedures:

b. Radiographic procedures may be necessary to exclude lesions at the base of the brain or upper cervical spine.

9. Non-operative Treatment Procedures.

a. Rehabilitation is based on procedures set forth in Non-Operative Treatment Procedures. Utilization of ultrasound, cold and heat should be discussed with the Primary Care Physician, since these modalities can aggravate nerve injury. Resistance exercises to strengthen muscles. Braces may be used but probably have no long-term value.

b. Occupational work station will usually need significant modification due to inability to work above 90 degrees flexion or abduction. Return to work with appropriate restrictions should be considered early in the course of treatment. Refer to Return to Work.

10. Surgical Indications: Laceration of the nerve and progressive loss of function are indications for prompt surgical intervention. Surgery may be considered when functional deficits interfere with activities of daily living and/or job duties after four to six months of active participation in non-operative therapy. Surgical consultation should occur at three to four months post-injury for these patients. In most cases, function will recover with conservative therapy in 6 to 12 months.

11 Operative Procedures.

a. exploration and repair;

b. tendon transfer - trapezius, levator scapular, rhomboids;

c. scapular fixation for cases with heavy work demands and failed previous procedures.

12. Post-operative Treatment: An individualized rehabilitation program based upon communication between the surgeon and the therapist. Treatment may include the following:

a. Early therapeutic rehabilitation interventions are recommended to maintain ROM with progressive strengthening focusing on scapula stabilizers.

i. Frequency: Suggested frequency pattern is three to five times per week for the first two weeks. Three times per week for the following two weeks, then one to two times per week. The exact frequency per week will depend on the severity and level of the nerve injury.

ii. Optimum Duration: Six to eight weeks with progression to home exercise and/or pool therapy.

iii. Maximum Duration: Up to 24 sessions. Additional follow-up visits may be justified to reinforce exercise patterns or to reach final functional goals if the therapy to date has demonstrated objective functional gains.

iv. Return to work and restrictions after surgery may be made by an experienced primary occupational medicine physician in consultation with the surgeon or by the surgeon.

vi. Suprascapular Nerve.

(a). Description/Definition. This nerve is derived from the fifth and sixth cervical root, superior trunk of the brachial plexus and it innervates the supraspinatus and infraspinatus muscles of the rotator cuff.

(b). Occupational Relationship. Supraclavicular trauma, stretch, and friction through the suprascapular notch or against the transverse ligament at the notch, or a fall on an outstretched arms can cause injury to the nerve. Repetitive use of the arm has been shown on occasion to cause traction to the nerve. Damage, may occur secondary to a ganglion cyst which usually causes infraspinatus atrophy. Ganglion cysts may be associated with labral pathology and/or rotator cuff tears. These are most commonly reported in athletes. Up to one third of volley ball players in one study had asymptomatic infraspinatus atrophy secondary to nerve damage. Nerve damage may also occur associated with a full rotator cuff tear. Since the clinical findings are similar for both diagnoses, clinicians should always consider the possibility of nerve damage when atrophy accompanies a rotator cuff tear.

(c). Specific Physical Exam Findings may include:

(i). pain at the shoulder;

(ii). wasting at the supraspinatus and/or infraspinatus muscles with weakness of external rotation and abduction with overhead activity; and/or

(iii). a positive Tinel's eliciting a provocative pain response.

(d). Diagnostic Testing Procedures:

(i). EMG and Nerve Conduction Studies three weeks after the injury and repeated at appropriate intervals to assess for reinnervation. Comparison of EMG and NCV findings with the opposite side is usually necessary to diagnose the degree of injury.

(ii). If one suspects a mass lesion at the suprascapular notch or related labral or cuff pathology then an MRI or sonography may be indicated.

(iii). CT scan with attention to the suprascapular notch may be used to evaluate for boney impingement.

(e). Non-operative Treatment Procedures:

(i). Resolution of symptoms usually occurs within 6 to 12 months of diagnosis with non-operative treatment in the absence of lesions such as a cyst.

(ii). Rehabilitation is based on procedures set forth in Non-operative Treatment Procedures. An emphasis should be placed on posture; maintaining full shoulder motion; strengthening; and stretching the posterior capsule. Utilization of ultrasound, cold and heat should be discussed with the primary care physician, since these modalities can aggravate nerve injury.

(iii). Medications such as analgesics, nonsteroidal anti-inflammatory, anti-depressants, and anti-convulsants are indicated and narcotics may be indicated acutely. All medications should be prescribed as seen in Thoracic Outlet Syndrome Guidelines.

(iv). Return to work with appropriate restrictions should be considered early in the course of treatment (Refer to Return to Work). Heavy lifting or activities that aggravate the condition should be avoided.

13. Surgical Indications: Surgical release is warranted depending upon the presence of a ganglion cyst, results of the electrophysiologic studies, and/or absence of improvement with conservative management. In cases without cysts or other operative diagnoses, non-operative treatment may be tried for three to six months due to the observed recovery rate of cases with no treatment. Difficulty performing functional activities after active patient participation should be the deciding factor. [General Principles]

14. Operative Treatment Procedures.

a. secompression and/or excision of ganglion cyst; and/or labral repair.;

b. surgical release at the suprascapular notch or spinoglenoid region;

15. Post-operative Treatment: An individualized rehabilitation program based upon communication between the surgeon and the therapist using the treatments found in Therapeutic Procedures, Non-operative. Treatment may include the following: Early therapeutic rehabilitation interventions are recommended to maintain ROM with progressive strengthening.

b. Optimum Duration: Six to eight weeks with progression to home exercise and/or pool therapy.

d. Return to work and restrictions after surgery may be made by an experienced primary occupational medicine physician in consultation with the surgeon or by the surgeon.

F. Bursitis/Rotator Cuff Tendonopathy (Alternate Spelling "Tendinopathy") of the Shoulder

1. Description/Definition.

a. Bursitis: Acute or chronic inflammation of the bursa (a potential fluid filled sac) that may be caused by trauma, chronic overuse, inflammatory arthritis, and acute or chronic infection, and generally presents with localized pain and tenderness of the shoulder.

b. Tendonopathy includes the terms tendonitis, an inflammation of the tendon and tendonosis, non-inflammatory degenerative processes.

c. Rotator cuff tendonopathy may involve one or more of the four musculotendonous structures arising from the scapula and inserting on the lesser or greater tuberosity of the humerus may be involved. These structures include one internal rotator (subscapularis), and two external rotators (infraspinatus and teres minor), and the supraspinatus which assists in abduction.

d. History may include nocturnal pain, pain with over-the-shoulder activities, feeling of shoulder weakness and specific limitations of movement. Prior treatment for presenting complaint(s) and pertinent familial history should be obtained.

2. Occupational Relationship: Onset of symptoms, date, mechanism of onset, and occupational history and current job requirements should be correlated with the intensity, character, duration and frequency of associated pain and discomfort. Tendonopathy may include symptoms of pain and/or achiness that occur after blunt trauma or repetitive use of the shoulder. Bursitis is often a sequela of an occupational strain or tendonopathy in the absence of other mitigating factors.

3. Specific Physical Exam Findings may include:

a. Palpation elicits localized tenderness over the particular bursa or inflamed tendon with loss of motion during activity;

b. Painful arc may be seen between 40 and 120 degrees; and/or

c. Bursitis may be associated with other shoulder injury diagnoses such as impingement, rotator cuff instability, tendonitis, etc.; refer to applicable diagnosis subsections for additional guidelines.

4. Diagnostic Testing Procedures:

a. Plain x-rays include:

5. AP view. Elevation of the humeral head indicates rotator cuff tear;

6. Lateral view in the plane of the scapula or an axillary view determines if there is anterior or posterior dislocation, or the presence of a defect in the humeral head (a Hill-Sachs lesion);

7. Axillary view is also useful to demonstrate arthritis and spurs on the anterior inferior acromion;

8. Outlet view determines if there is a downwardly tipped acromion.

a. Lab Tests. Laboratory tests may be used to rule out systemic illness or disease when proper clinical presentation indicates the necessity for such testing. Testing may include sedimentation rate, rheumatoid profile, complete blood count (CBC) with differential, and serum uric acid level. Routine screening for other medical disorders may be necessary, as well as, bursal aspiration with fluid analysis.

b. The subacromial injection has generally been considered the gold standard for differentiating ROM loss from impingement versus rotator cuff tears. Alleviation from pain may help to confirm the diagnosis. Patients with impingement should recover normal strength after the injection, while those with rotator cuff tears usually do not recover normal strength. However, manually tested elevation strength perceived as normal does not always rule out rotator cuff tear and this may contribute to incorrect diagnoses with this technique. There is good evidence that blinded subacromial blocks are not accurate. Up to a third of blinded injections may involve the cuff, and are likely to cause pain. This may lead to an incorrect diagnosis. One study demonstrated that at least half of the positive responders did so up to 40 minutes after the injection; therefore, a negative response should not be diagnosed until 40 minutes post injection. The inaccuracy of the injection and patient response in some cases may contribute to its inability to completely predict the amount of recovery from subacromial decompression.

c. If there is a concern regarding needle placement, sonography or fluoroscopy may be used.

d. Steroid injections should be used cautiously in diabetic patients. Diabetic patients should be reminded to check their blood glucose level at least daily for two weeks after injections.

9. Non-operative Treatment Procedures:

a. Therapeutic interventions are the mainstay of treatment. They should include ROM, active therapies, and a home exercise program. Passive as well as active therapies may be used for control of pain and swelling. Therapy should progress to strengthening and instruction in a home exercise program targeted to further improve ROM and strength of shoulder girdle musculature. Refer to Therapeutic Procedures, Non-operative.

b. May return to work without overhead activities and lifting with involved arm. An evaluation of the occupational work being performed and the work station may be necessary to institute ergonomic changes or accommodations. Return to work with appropriate restrictions should be considered early in the course of treatment. Refer to Return to Work.

c. Medications such as oral nonsteroidal anti-inflammatory, oral steroids and analgesics.

d. Steroid injections may be therapeutic. Injections under significant pressure should be avoided as the needle may be penetrating the tendon and injection into the tendon can cause possible tendon breakdown, tendon degeneration, or rupture. Injections should be minimized for patients under 30 years of age.

i. Time to Produce Effect: One injection.

ii. Maximum: three injections at the same site per year when functional benefits are demonstrated with each injection.

iii. Steroid injections should be used cautiously in diabetic patients. Diabetic patients should be reminded to check their blood glucose level at least daily for two weeks after injections.

e. Other therapies outlined in Therapeutic Procedures, Non-operative, may be employed in individual cases.

10. Operative Procedures: Are not commonly indicated for bursitis or tendonopathy. Refer to other related diagnoses in Specific Diagnosis Testing and Treatment Procedures.

11. Calcifying Tendodnitis

a. Description/Definition:

i. Calcifying tendonitis is characterized by the deposition of hydroxyapatite (calcium phosphate) in any tendon of the rotator cuff. The supraspinatus tendon is affected most frequently. It is a morphologic diagnosis which may be asymptomatic or may produce pain. It may be present in a painful shoulder without being the cause of the pain. Radiographically evident calcifications are present without producing symptoms in some adults (7.5 percent to 20 percent). The calcifying process occurs in two phases: the formative phase, in which calcium deposits coalesce in the tendon matrix, and the resorptive phase, in which the calcium deposits are removed by phagocytic cells. The resorptive phase is thought to be the painful phase of the disorder. The etiology is not known, but trauma is considered unlikely to be causative. Pain may be accompanied by loss of ROM, a painful arc of motion, or by impingement signs. Morphologic classification of calcium deposits is based on the homogeneity and borders of the deposit on plain x-ray. (Gartner and Simons Classifications) Type I is homogenous with well-defined borders. Type II is heterogeneous in structure with sharp outline or homogenous in structure with no defined border. Type III is cloudy and transparent with no well-defined border. Type III frequently resolves without treatment. Generally, they are not associated with rotator cuff tears. The size of the deposit has not been shown to be correlated with severity of symptoms.

b. Occupational Relationship. Symptomatic calcifying tendonitis may occur after repetitive loading of the shoulder with force, such as with shoveling, raking, pushing, pulling, lifting at/or above shoulder level, or after blunt trauma to the shoulder.

c. Specific Physical Exam Findings may include:

i. pain with palpation to the shoulder with active or passive abduction and external rotation of the shoulder (painful arc);

ii. pain with specific activation of the involved muscles; and/or

iii. pain with impingement signs;

iv. severe pain on examination in some cases.

d. Diagnostic Testing Procedures:

i. plain x-ray films including AP lateral, axial, 30 degrees caudally angulated AP, Outlet view.

ii. If shoulder pain is refractory to 4 to 6 weeks of non-operative care and other diagnoses are suspected, adjunctive testing, such as MRI, sonography or arthrography, may be indicated.

e. Non-operative Treatment Procedures

i. Therapeutic rehabilitation interventions are the mainstay of treatment. They should include ROM, active therapies, and a home exercise program. Passive as well as active therapies may be used for pain control, including iontophoresis. Therapy should progress to strengthening and instruction in a home exercise programs targeted to ongoing ROM and strengthening of shoulder girdle musculature. Refer to Therapeutic Procedures, Non-operative for other therapies as well as a description of active and passive therapies.

ii. Medications such as oral nonsteroidal anti-inflammatories, analgesics, and narcotics for significant pain. Refer to Medications.

iii. May return to work without overhead activities and lifting with involved arm. An evaluation of the occupational work station may be necessary to institute ergonomic changes or accommodations. Return to work with appropriate restrictions should be considered early in the course of treatment. Refer to Return to Work.

iv. Therapeutic ultrasound (Refer to Passive Therapy) may be used for tendonitis. There is some evidence that ultrasound alleviates symptoms, improves function, and reduces calcium deposits better than sham ultrasound in the short term. The advantage of ultrasound beyond six weeks is not certain.

v. Ultrasound-guided needle lavage and aspiration requires a physician skilled in sonographic techniques and is still considered investigational due to lack of randomized controlled trials. It is less costly and reportedly less painful than extracorporeal shock wave therapy. It requires prior authorization but may be an appropriate therapy in select patients who fail other conservative treatment.

vi. Extracorporeal shock wave therapy has good evidence for improving pain and function with calcifying tendonitis Type I or II when conservative treatment has not resulted in adequate functional improvement (See ESWT). General anesthesia or conscious sedation is not required for this procedure. Patients should be cautioned regarding the potential of avascular necrosis.

vii. Steroid injections may be therapeutic. Injections under significant pressure should be avoided as the needle may be penetrating the tendon and injection into the tendon can cause tendon degeneration, tendon breakdown, or rupture. Injections should be minimized for patients under 30 years of age.

(a). Steroid injections should be used cautiously in diabetic patients. Diabetic patients should be reminded to check their blood glucose level at least daily for two weeks after injections.

(i). Time to Produce Effect: One injection.

(ii). Maximum: Three injections at the same site per year when functional benefits are demonstrated with each injection.

viii. Other therapies outlined in Therapeutic Procedures, Non-operative, may be employed in individual cases.

f. Surgical Indications. When functional deficits interfere with activities of daily living and/or job duties after three to four months of active patient participation in non-operative therapy. The natural history of calcifications includes resorption over time, with or without therapy. Prior to surgical intervention, the patient and treating physician should identify functional operative goals and the likelihood of achieving improved ability to perform activities of daily living or work activities. The patient should agree to comply with the pre- and post-operative treatment plan and home exercise requirements. The patient should understand the length of partial and full disability expected post-operatively.

g. Operative Procedures: Either an arthroscopic or open procedure may be used. Careful lavage to remove all calcium deposits from the surgical field is important. Full recovery may vary from three to six months.

h. Post-operative Treatment. Individualized rehabilitation programs are based upon communication between the surgeon and the therapist using the treatments found in Therapeutic Procedures, Non-operative. Treatment may include the following:

i. Sling, pillow sling, or abduction splint;

ii. Gentle pendulum exercise, passive glenohumeral range-of-motion and posterior scapular stabilizing training can be instituted;

iii. Patients can judiciously return to activities as tolerated per physician recommendations. If there is a significant tendon repair, progression will be delayed;

iv. Progressive resistive exercise program beginning at two months with gradual returning to full activity at 4 to 6 months; all active non-operative procedures listed in Non-operative Treatment Procedures should be considered.

(a). Frequency: Three to five times per week for the first two weeks, three times per week for the following two weeks, then one to two times per week.

(b). Optimum Duration: Six to eight weeks with progression to home exercise and/or pool therapy.

(c). Maximum Duration: 12 weeks. Occasional follow-up visits may be justified to reinforce exercise patterns or to reach final functional goals if the therapy to date has demonstrated objective functional gains.

v. Return to work and restrictions after surgery may be made by an experienced primary occupational medicine physician in consultation with the surgeon or by the surgeon. Depending upon the patient's functional response and their job requirements, return to work with job modifications may be considered as early as one week post-operatively. The employer must be able to fully accommodate restrictions of overhead activities or heavy lifting. Physician/surgeon should be very specific regarding restrictions for overhead activities and heavy lifting. Work restrictions should be evaluated every four to six weeks during post-operative recovery and rehabilitation, with appropriate written communications to both the patient and the employer. Should progress plateau, the provider should re-evaluate the patient's condition and make appropriate adjustments to the treatment plan.

12. Fractures. There are five common types of shoulder fractures; each type will be addressed separately and in the order of most frequent occurrence.

a. Clavicular Fracture:

i. Occupational Relationship: Can result from direct blows or axial loads applied to the upper limb; commonly associated injuries include rib fractures, long-bone fractures of the ipsilateral limb and scapulothoracic dislocations.

ii. Specific Physical Exam Findings may include:

(a). Pain along the clavicle;

(b). Abrasions on the chest wall, clavicle and shoulder;

(c). Deformities in the above regions; and/or

(d). Pain with palpation and motion at the shoulder joint area.

iii. Diagnostic Testing Procedures: Clavicle x-rays. If they do not reveal sufficient information, then a 20 degree caudal-cranial AP view centered over both clavicles can be done.

iv. Non-operative Treatment Procedures:

(a). Most are adequately managed by closed techniques and do not require surgery. After reduction, the arm is immobilized in a sling or figure-8 bandage. Shoulder rehabilitation is begun with pendulum exercises 10 to 14 days after injury. Subsequently, with pain control, the therapy program can be progressed with therapeutic approaches as indicated in Non-operative Treatment Procedures.

(b). Medication, such as analgesics and nonsteroidal anti-inflammatories, would be indicated; narcotics may be indicated acutely for fractures and should be prescribed as indicated in Medications.

(c). All patients with fractures, especially those over 50, should be encouraged to ingest at least 1200 mg of Calcium and 800 IU of Vitamin D per day. There is some evidence that, for women in the older age group (58 to 88) with low hip bone density, greater callus forms for those who adhere to these recommendations than those who do not. Although the clinical implications of this are not known, there is greater non-union in this age group and thus, coverage for these medications during the fracture healing time period is recommended. At this time there is no evidence that bisphosphonates increase acute fracture healing.

(d). All female patients over 65 should be referred for an osteoporosis evaluation. Patients who have been on prednisone at a dose of 5 to 7.5 mg for more than three months should be evaluated for glucocorticoid induced osteoporosis. An osteoporosis evaluation may be considered for males who: are over 70, are physically inactive, have previous fragility fracture, have a BMI less than 20, or have been hypogonadal for five years. Evaluation may also be considered for patients on medications that can cause bone loss, patients who have suffered a fracture due to a low-impact fall or with minimum to no provocation, and women under 65 with one of the following: menopause before 40, current smoker, or body mass index less than 20. Low body weight appears to be the best predictor of osteoporosis in women younger that 65. In one adequate study, all patients aged 50 to 75 referred to an orthopaedic department for treatment of wrist, vertebral, proximal humerus, or hip fractures received bone mass density testing. 97 percent of patients had either osteoporosis (45 percent) or osteopenia (42 percent). Referral is important to prevent future factures in these groups. Long-term care for osteoporosis is not covered under workers compensation even though it may be discovered due to an injury-related acute fracture.

(e). Smoking may affect fracture healing. Patients should be strongly encouraged to stop smoking and provided with appropriate counseling.

(f). Return to work with appropriate restrictions should be considered early in the course of treatment. Refer to Return to Work.

v. Surgical Indications: Open fractures, vascular or neural injuries requiring repair, bilateral fractures, ipsilateral scapular or glenoid neck fractures, scapulothoracic dislocations, flail chest and non-union (displaced-closed fractures that show no evidence of union after four to six months). A Type II fracture/dislocation at the AC joint where the distal clavicular fragment remains with the acromion and the coracoid, and the large proximal fragment is displaced upwards is another indication for surgery. Completely displaced midclavicular fractures may be an indication for surgical repair. There is some evidence that plate fixation of completely displaced fractures involving the middle third of the clavicle leads to slightly better shoulder function than immobilization without surgical fixation and shorter healing time. Conservatively treated completely displaced fractures heal with mild decreases in strength and good patient satisfaction in 70 percent or more of cases. However, initial surgical repair may be considered for patients who desire excellent shoulder function for sport or job activities and/or those with approximately two cm or greater shortening of the clavicle. Because smokers have a higher risk of non-union and post-operative costs, it is recommended that insurers cover a smoking cessation program peri-operatively.

vi. Operative Procedures: Repair of fracture or associated distal clavicular resection using plates and screws or an intramedullary device.

vii. Post-operative Treatment: An individualized rehabilitation program based upon communication between the surgeon and the therapist. This program would begin with two to three weeks of rest with a shoulder immobilizer while encouraging isometric deltoid strengthening. Pendulum exercises with progression to assisted forward flexion and external rotation would follow. Strengthening exercises should be started at 10 to 12 weeks as indicated in Non-operative Treatment Procedures.

viii. Bone-Growth Stimulators

(a). Electrical: Preclinical and experimental literature has shown a stimulatory effect of externally applied electrical fields on the proliferation and calcification of osteoblasts and periosteal cells. Ensuing clinical literature on electrical stimulation of bone fractures has principally focused on the spine and lower extremity. Several techniques have been developed to deliver an electrical stimulus to a fracture or osteotomy site. Nonsurgical techniques include Capacitive Coupling (CC), which places skin electrodes on opposite sides of the bone being treated. Pulsed Electromagnetic Field (PEMF) uses a current-carrying coil which induces a secondary electrical field in bone. High-quality literature of electrical bone growth stimulation are lacking for shoulder injuries. Literature is conflicting in the use of electrical stimulation in other regions of the body. Due to a lack of supporting scientific evidence, it requires prior authorization and may be only considered when conventional surgical management has failed.

(b). Low-intensity Pulsed Ultrasound: There is some evidence that low-intensity pulsed ultrasound, applied by the patient at home and administered as initial treatment of the fracture, reduces the time required for cortical bridging in certain fractures of bones outside the shoulder joint. Shoulder fractures were not included in this literature. Non-union and delayed unions were not included in these clinical trials. Possible indications for Low-Intensity Pulsed Ultrasound are non-unions or fractures that are expected to require longer healing time. Prior authorization is required.

b. Proximal Humeral Fractures: Fractures of the humeral head have been classically described using Neer criteria; however, literature has shown a low level of observer agreement. These fractures are commonly referred to as one, two, three or four part fractures based on the number of fracture fragments. Displaced fractures of the greater tuberosity and impacted angulated fractures of the humeral head also have specific associated problems.

i. Occupational Relationship: May be caused by a fall onto an abducted arm; high-energy (velocity or crush) trauma with an abducted or non-abducted arm. Associated injuries are common, such as glenohumeral dislocation; stretch injuries to the axillary, musculocutaneous, and radial nerves; and axillary artery injuries with high-energy accident.

ii. Specific Physical Exam Findings may include:

(a). pain in the upper arm;

(b). swelling and bruising in the upper arm, shoulder and chest wall;

(c). abrasions about the shoulder; and/or

(d). pain with any attempted passive or active shoulder motion.

iii. Diagnostic Testing Procedures:

(a). X-ray trauma series (three views) are needed; AP view, axillary view and a lateral view in the plane of the scapula. The latter two views are needed to determine if there is a glenohumeral dislocation. When an axillary view cannot be obtained, a CT should be done to rule out posterior dislocation.

(b). Vascular studies are obtained emergently if the radial and brachial pulses are absent.

(c). Classification can be by the Neer Method, however, agreement between observers using this method is poor. There are four fragments: the humeral shaft, humeral head, greater tuberosity, and the lesser tuberosity. The fragments are not usually considered fragments unless they are separated by 1 cm or are angulated 45 degrees or more.

iv. Non-operative Treatment Procedures

(a). Non-displaced and minimally displaced fractures are generally treated conservatively with broad arm sling or body swath. There is some evidence that simple non-displaced proximal humeral fractures recover normal function more quickly when physical therapy is started one week after the fracture than when it is started three weeks after the fracture. Immobilization without physical therapy for more than one week is not recommended.

(b). Anterior or posterior dislocation associated with minimally displaced fractures can usually be reduced by closed means, but a general anesthetic is needed. These are usually not performed in the emergency room in order to avoid displacement of the fracture.

(c). Medication, such as analgesics and nonsteroidal anti-inflammatories, would be indicated; narcotics may be indicated acutely for fracture and should be prescribed as indicated in Medications.

(d). Immobilization may be provided with a sling, to support the elbow, or with an abduction immobilizer if a non-impacted greater tuberosity fragment is present. Immobilization is usually continued for four to ix weeks; however, the time will vary according to the type of fracture and surgeon's discretion.

(e). Shoulder rehabilitation is begun with pendulum exercises 0 to 14 days after injury. Light, functional exercises may be added at two to four weeks post-injury. Subsequently, with pain control, the therapy program can be progressed with therapeutic approaches as described in Non-operative Treatment Procedures. Home exercises are essential for recovery.

(i). Time to Produce Effect: Six sessions.

(ii). Optimum Duration: Nine sessions.

(iii). Maximum Duration: 12 to 24 sessions.

(f). Use of the injured arm at work is determined by the orthopaedist. The patient may, however, return to work without use of the injured arm soon after the injury. Refer to Return to Work.

(g). Also refer to osteoporosis in this Clavicular Fracture.

(h). Smoking may affect fracture healing. Patients should be strongly encouraged to stop smoking and provided with appropriate counseling.

v. Surgical Indications:

(a). Greater tuberosity fractures with 5mm of displacement usually require surgical fixation. However, rehabilitation may start as early as two to three days post-operatively.

(b). Two-part fractures are repaired according to the surgeon's preference. Internal fixation may be necessary to prevent varus or valgus angulation of the humerus; however, it is unclear whether this technique is more successful than more conservative treatment particularly in patients over 70. Percutaneous techniques and closed reduction have both been used.

(c). Three and four-part fractures frequently require operative treatment. Internal fixation is commonly used. Hemiarthroplasty may be used in the elderly population or for severely comminuted fractures. Use of this technique in the younger active patients frequently leads to the need for revision surgery and/or increased wear of the glenoid cavity. For four-part fractures with a fractured greater tuberosity, reverse arthroplasties have also been described, however; they should rarely be used since the long-term success of this prosthesis is currently unknown. This procedure is described under Section G. Therapeutic Procedures, Operative Shoulder Replacement (arthroplasty).

(i). Because smokers have a higher risk of non-union and post-operative costs, it is recommended that carriers cover a smoking cessation program peri-operatively.

vi. Operative Procedures: Percutaneous or internal fixation of the fracture or arthroplasty.

vii. Post-operative Treatment

(a). An individualized rehabilitation program based upon communication between the surgeon and the therapist using the treatment found in Section F.

(b). Schanz pins will require removal, frequently between Two to six weeks.

(c). One-time Extracorporeal Shock Wave Therapy (ESWT) has been purported to increase healing in non-union fractures of long bones. None have been tested in prospective controlled studies. They are all considered experimental and are not recommended at this time.

(d). Bone-Growth Stimulators. (Refer to Clavicular Fractures.)

(e). Hyperbaric oxygen therapy there is no evidence to support long-term benefit of hyperbaric oxygen therapy for non-union upper extremity fractures. It is not recommended.

(f). Return to work and restrictions after surgery may be made by an experienced primary occupational medicine physician in consultation with the surgeon or by the surgeon.

c. Humeral Shaft Fractures:

i. Occupational Relationship: A direct blow can fracture the humeral shaft at the junction of its middle and distal thirds. Twisting injuries to the arm will cause a spiral humeral shaft fracture. High energy (velocity or crush) will cause a comminuted humeral shaft fracture.

ii. Specific Physical Exam Findings may include:

(a). deformity of the arm;

(b). bruising and swelling; and/or

(c). possible sensory and/or motor dysfunction of the radial nerve.

iii. Diagnostic Testing Procedures:

(a). plain x-rays including AP view and lateral of the entire humeral shaft.

(b). vascular studies if the radial pulse is absent.

(c). compartment pressure measurements if the surrounding muscles are swollen, tense and painful and particularly if the fracture resulted from a crush injury.

iv. Non-operative Treatment Procedures:

(a). Most isolated humeral shaft fractures can be managed non-operatively.

(b). Medication, such as analgesics and nonsteroidal anti-inflammatories, would be indicated. Narcotics may be indicated acutely for fracture and should be prescribed as indicated in Section F.6, Medications.

(c). A coaptation splint may be used.

(d). At two to three weeks after injury, a humeral fracture orthosis may be used to allow for full elbow motion.

(e). Return to work with appropriate restrictions should be considered early in the course of treatment. Refer to Return to Work.

(f). Other therapies outlined in Therapeutic Procedures, Non-operative, may be employed in individual cases.

(g). Refer to comments related to osteoporosis in Clavicular Fracture.

(h). Smoking may affect fracture healing. Patients should be strongly encouraged to stop smoking and provided with appropriate counseling.

v. Surgical Indications:Indications for operative care would include:

(a). open fracture;

(b). associated forearm or elbow fracture (i.e., the floating elbow injury);

(c). burned upper extremity;

(d). associated paraplegia;

(e). multiple injuries (polytrauma);

(f). A radial nerve palsy which presented after closed reduction;

(g). pathologic fracture related to an occupational injury; and/or

(h). inability to perform basic activities of daily living while following conservative care.

(i). because smokers have a higher risk of non-union and post-operative costs, it is recommended that carriers cover a smoking cessation program peri-operatively.

vi. Operative Procedures

(a). Accepted methods of internal fixation of the fracture include:

(i). A broad plate and screws; and/or

(ii). Intramedullary rodding with or without cross-locking screws may be used but is associated with increased shoulder pain;

(b). Human Bone Morphogenetic Protein (RhBMP). Use of this material for surgical repair of shoulder fractures requires prior authorization. Refer to Operative Procedures, for further details.

vii. Post-operative Treatment:An individualized rehabilitation program based upon communication between the surgeon and the therapist using the treatments found in Therapeutic Procedures, Non-operative. Treatment may include the following:

(a). Following rigid internal fixation, therapy may be started to obtain passive and later active shoulder motion using appropriate therapeutic approaches as indicated in Section F, Non-operative Treatment Procedures. Active elbow and wrist motion may be started immediately. Early therapeutic rehabilitation interventions are recommended to maintain range-of-motion (ROM) and progressive strengthening.

(i). Frequency: Three to five times per week for the first two weeks, three times per week for the following two weeks, then to two times per week.

(ii). Optimum Duration: Six to eight weeks with progression to home exercise and/or pool therapy.

(iii). Maximum Duration: 12 weeks. Additional follow-up visits may be justified to reinforce exercise patterns or to reach final functional goals if the therapy to date has demonstrated objective functional gains or if a nerve injury accompanies the fracture.

(b). Return to work and restrictions after surgery may be made by an experienced primary occupational medicine physician in consultation with the surgeon or by the surgeon.

(c). Bone Growth Stimulation. (Refer to Clavicular Fractures.)

d. Scapular Fractures:

i. Occupational Relationship. These are the least common of the fractures about the shoulder and include acromial, glenoid, glenoid neck and scapular body fractures. With the exception of anterior glenoid lip fractures caused by an anterior shoulder dislocation, all other scapular fractures are due to a high-energy injury.

ii. Specific Physical Findings may include:

(a). pain about the shoulder and thorax;

(b). bruising and abrasions;

(c). possibility of associated humeral or rib fractures; and/or

(d). vascular problems (pulse evaluation and Doppler examination).

iii. Diagnostic Testing Procedures:

(a). Trauma x-ray series - AP view, axillary view, and a lateral view in the plane of the scapula.

(b). Arteriography if a vascular injury is suspected.

(c). Electromyographic exam if nerve injuries are noted.

iv. Non-operative Treatment:

(a). Non-displaced acromial, coracoid, glenoid, glenoid neck and scapular body fractures may all be treated with the use of a shoulder immobilizer.

(b). Medication, such as analgesics and nonsteroidal anti-inflammatories, would be indicated. Narcotics may be indicated acutely for fracture and should be prescribed as indicated in Medications.

(c). Pendulum exercises may be started within the first week.

(d). Progress to assisted range-of-motion exercises at three to four weeks using appropriate therapeutic procedures as indicated in Section F, Non-operative Treatment Procedures.

(e). Return to work with appropriate restrictions should be considered early in the course of treatment. Refer to Return to Work.

(f). Refer to comments related to osteoporosis in Clavicular Fracture.

(g). Smoking may affect fracture healing. Patients should be strongly encouraged to stop smoking and provided with appropriate counseling.

v. Surgical Indications

(a). displaced acromial fractures.

(b). displaced glenoid fractures.

(c). displaced scapular body fractures in some circumstances.

(d). displaced fractures of the scapular neck and the ipsilateral clavicle.

(e). because smokers have a higher risk of non-union and post-operative costs, it is recommended that carriers cover a smoking cessation program peri-operatively.

vi. Operative Treatment

(a). displaced acromial fractures are treated with internal fixation.

(b). displaced glenoid fractures greater than 5 mm should be fixed internally. Fractures with less displacement may be treated surgically according to the surgeon's discretion. Two and three dimensional CT scans may be useful in planning the surgical approach.

(c). displaced scapular body fractures require internal fixation if the lateral or medial borders are displaced to such a degree as to interfere with scapulothoracic motion.

(d). displaced fractures of the scapular neck and the ipsilateral clavicle require internal fixation of the clavicle to reduce the scapular neck fracture.

vii. Post-operative Treatment: An individualized rehabilitation program based upon communication between the surgeon and the therapist using the appropriate therapeutic procedures as indicated in Section F, Non-operative Treatment Procedures. Treatment may include the following:

(a). A shoulder immobilizer is utilized. Pendulum exercises initially begin at one week, and deltoid isometric exercises are started early at four to six weeks, active ROM is usually commenced.

(b). Early therapeutic rehabilitation interventions are recommended to maintain ROM with progressive strengthening.

(i). Frequency: Three to five times per week for the first two weeks, three times per week for the following two weeks, then one to two times per week.

(ii). Optimum Duration: 8 to 10 weeks with progression to home exercise and/or pool therapy.

(iii). Maximum Duration: 12 to 14 weeks. Occasional follow-up visits may be justified to reinforce exercise patterns or to reach final functional goals if the therapy to date has demonstrated objective functional gains.

(c). Return to work and restrictions after surgery may be made by an experienced primary occupational medicine physician in consultation with the surgeon or by the surgeon.

e. Sternoclavicular Dislocation/Fracture

i. Occupational Relationship: Sudden trauma to the shoulder/anterior chest wall. Anterior dislocations of the sternoclavicular joint usually do not require active treatment; however, symptomatic posterior dislocations will require reduction.

ii. Specific Physical Findings may include:

(a). Dysphagia and shortness of breath which requires emergency reduction.

(b). Pain at the sternoclavicular area;

(c). Abrasions on the chest wall, clavicle and shoulder;

(d). Deformities in the above regions; and/or

(e). Pain with palpation and motion at the sternoclavicular joint area.

iii. Diagnostic Testing Procedures:

(a). Plain x-rays of the sternoclavicular joint are routinely done. When indicated, comparative views of the contralateral limb may be necessary.

(b). X-rays of other shoulder areas and chest may be done if clinically indicated.

(c). CT scan for classification of pathology.

(d). Vascular studies should be considered if the history and clinical examination indicate extensive injury.

iv. Non-operative Treatment Procedures:

(a). Symptomatic posterior dislocations should be reduced in the operating room under general anesthesia.

(b). Immobilize with a sling for three to four weeks. Subsequently, further rehabilitation may be utilized using procedures set forth in Non-operative Treatment Procedures.

(c). Medications, such as analgesics and nonsteroidal anti-inflammatories, would be indicated. Narcotics may be indicated acutely for fracture and should be prescribed as indicated in Medications.

(d). Return to work with appropriate restrictions should be considered early in the course of treatment. Refer to Return to Work.

(e). Refer to comments related to osteoporosis in Clavicular fracture.

(f). Smoking may affect fracture healing. Patients should be strongly encouraged to stop smoking and provided with appropriate counseling.

v. Surgical Indications:

(a). failure of closed reduction.

(b). because smokers have a higher risk of non-union and post-operative costs, it is recommended that carriers cover a smoking cessation program peri-operatively.

vi. Operative Procedures

(a). reduction with soft tissue reconstruction is preferred;

(b). internal fixation - significant complications can occur with use of pins due to migration into other tissues.

vii. Post-operative Treatment: An individualized rehabilitation program based upon communication between the surgeon and the therapist. This program would begin with four to six weeks of rest with a shoulder immobilizer, followed by therapeutic rehabilitation interventions.

(a). Early therapeutic rehabilitation interventions are recommended to maintain ROM with progressive strengthening.

(i). Frequency: Three to five times per week for the first two weeks, three times per week for the following two weeks, then one to two times per week.

(ii). Optimum Duration: Six to eight weeks with progression to home exercise and/or pool therapy.

(iii). Maximum Duration: 12 weeks. Occasional follow-up visits may be justified to reinforce exercise patterns or to reach final functional goals if the therapy to date has demonstrated objective functional gains.

(b). Return to work and restrictions after surgery may be made by an experienced primary occupational medicine physician in consultation with the surgeon or by the surgeon.

13. Impingement Syndrome

a. Description/Definition: A collection of symptoms, not a pathologic diagnosis. The symptoms result from the encroachment of the acromion, coracoacromial ligament, coracoid process, and/or the AC joint of the rotator cuff mechanism that passes beneath them as the shoulder is moved. The cuff mechanism is intimately related to the coracoacromial arch. Separated only by the thin lubricating surfaces of the bursa, compression and friction can be minimized by several factors, such as:

i. shape of the coracoacromial arch that allows passage of the subjacent rotator cuff;

ii. normal undersurface of the AC joint;

iii. normal bursa;

iv. normal capsular laxity; and

v. coordinated scapulothoracic function.

b. The impingement syndrome may be associated with AC joint arthritis and both partial and full thickness rotator cuff tears, as well as, adhesive capsulitis/frozen shoulder. Normal function of the rotator cuff mechanism and biceps tendon assist to diminish impingement syndrome.

i. History may include

(a). delayed presentation (since the syndrome is usually not an acute problem). Patients will access care if their symptoms have not resolved with rest, time and "trying to work it out";

(b). complaints of functional losses due to pain, stiffness, weakness and catching when the arm is flexed and internally rotated; and

(c). sleep complaints are common and pain is often felt down the lateral aspect of the upper arm near the deltoid insertion or over the anterior proximal humerus.

(d). occupational Relationship: Repetitive overuse of the upper extremity, often seen with constant overhead motion.

c. specific Physical Exam Findings may include: As with most shoulder diagnoses, the examiner should not rely upon one set of physical exam findings alone due to the lack of specificity and sensitivity of most tests and common overlap of diagnoses. Physical examination findings may include the following:

i. Range-of-motion is limited particularly in internal rotation and in cross-body adduction, which may reflect posterior capsular tightness. Forward flexion and elevation may also be limited.

ii. Passive motion through the 60 to 90 degrees arc of flexion may be accompanied by pain and crepitus. This is accentuated as the shoulder is moved in-and-out of internal rotation.

iii. Active elevation of the shoulder is usually more uncomfortable than passive elevation.

iv. Pain on maximum active forward flexion is frequently seen with impingement syndrome, but is not specific for diagnosis.

v. Strength testing may reveal weakness of flexion and external rotation in the scapular plane. This weakness may be the result of disuse, tendon damage, or poor scapulothoracic mechanics.

vi. Pain on resisted abduction or external rotation may also indicate that the integrity of the rotator cuff tendons may be compromised, causing alteration of shoulder mechanics.

vii. Weakness of the posterior scapular stabilizers causing alteration of shoulder mechanics can also contribute to impingement syndrome.

viii. If inspection of the shoulder reveals deltoid and rotator cuff atrophy other diagnoses should be suspected such as cervical radiculopathy, axillary nerve pathology, or massive rotator cuff tears.

(a). Impingement syndromes commonly co-exist with other shoulder abnormalities such as rotator cuff tears, AC joint arthritis, biceps tendon ruptures, calcifying tendonitis, bursitis, labral tears, and in older patients, glenohumeral instability. This combination of pathology further complicates diagnostic decisions based mainly on clinical findings. Physicians use a combination of test results with history and other findings to create a differential diagnosis.

(b). Commonly used clinical tests include the following:

(i). Hawkins;

(ii). Neer;

(iii). Horizontal adduction;

(iv). Drop arm test;

(v). Yergason's;

(vi). Speed test.

(c). Diagnostic Testing Procedures

(i). Plain x-rays include:

[a]. AP view is useful to evaluate for arthritis and elevation of the humeral head which are not typically present in impingement syndrome.

[b]. Lateral view in the plane of the scapula or an axillary view can help to determine aspects of instability which can give symptoms similar to impingement syndrome.

[c]. Axillary view is also useful to demonstrate glenohumeral arthritis and spurs on the anterior inferior acromion.

[d]. Outlet view determines if there is a downward curved acromion. A downward curved acromion does not necessarily establish the diagnosis of impingement syndrome and is not a sole indication for operative treatment.

(ii). Adjunctive testing, sonography or MRI, may be considered when shoulder pain is refractory to four to ix weeks of non-operative conservative treatment and the diagnosis is not readily identified by a good history and clinical examination. (Refer to Follow-up Diagnostic Procedures.)

(iii). The subacromial injection has generally been considered the gold standard for differentiating ROM loss from impingement versus rotator cuff tears. Alleviation from pain may help to confirm the diagnosis. Patients with impingement should recover normal strength after the injection, while those with rotator cuff tears usually do not recover normal strength. However, manually tested elevation strength perceived as normal does not always rule out rotator cuff tear and this may contribute to incorrect diagnoses with this technique. There is good evidence that blinded subacromial blocks are not accurate. Up to a third of blinded injections may involve the cuff, and are likely to cause pain. This may lead to an incorrect diagnosis. One study demonstrated that at least half of the positive responders did so up to 40 minutes after the injection. Therefore, a negative response should not be diagnosed until 40 minutes post injection. The inaccuracy of the injection and patient response in some cases may contribute to its inability to completely predict the amount of recovery from subacromial decompression.

(iv). If there is a concern regarding needle placement, sonography or fluoroscopy may be used.

(v). Steroid injections should be used cautiously in diabetic patients. Diabetic patients should be reminded to check their blood glucose level at least daily for two weeks after injections.

(d). Non-operative Treatment Procedures

(i). An aggressive attempt should be made to define the contributing factors which are driving the syndrome, such as shoulder stiffness, humeral head depressor weakness (rotator cuff fiber failure), posterior capsular tightness and subacromial crowding, AC joint arthritis, muscle imbalance, and postural dysfunction.

(ii). Benefits may be achieved through therapeutic interventions. They should include ROM, active therapies, and a home exercise program. Passive as well as active therapies may be used for control of pain and swelling. Therapy should progress to strengthening and an independent home exercise program targeted to further improve ROM and strength of the shoulder girdle musculature. Refer to Therapeutic Procedures, Non-operative.

(iii). There is some evidence that manual therapy at a frequency of three times per week for four weeks, increases function and decreases pain.

(iv). Patients may return to work without overhead activities and lifting with involved arm. An evaluation of the jobsite may be necessary to institute ergonomic changes or accommodations. Return to work with appropriate restrictions should be considered early in the course of treatment. Refer to Return to Work.

(v). Medications, such as nonsteroidal anti-inflammatories and analgesics, should be prescribed. Refer to Medications.

(vi). Subacromial space injection may be therapeutic. Injections under significant pressure should be avoided as the needle may be penetrating the tendon and injection into the tendon can cause tendon degeneration, tendon breakdown, or rupture. Injections should be minimized for patients under 30 years of age.

[a]. Time to Produce Effect: One Injection.

[b]. Maximum: Three injections at the same site per year when functional benefits are demonstrated with each injection. Steroid injections should be used cautiously in diabetic patients. Diabetic patients should be reminded to check their blood glucose level at least daily for two weeks post injections.

(vii). Other therapies in Therapeutic Procedures, Non-operative may be employed in individual cases.

(e). Surgical Indications

(i). When functional deficits interfere with activities of daily living and/or job duties after three to six months of active patient participation in non-operative therapy, surgery may restore functional anatomy and reduce the potential for repeated impingement. Prior to surgical intervention, the patient and treating physician should identify functional operative goals and the likelihood of achieving improved ability to perform activities of daily living or work activities and the patient should agree to comply with the pre- and post-operative treatment plan including home exercise. The provider should be especially careful to make sure the patient understands the amount of post-operative therapy required and the length of partial and full disability expected post-operatively.

(f). Operative Procedures

(i). Procedures might include partial coracoacromial ligament release, and an acromioplasty, as well as, repair of associated pathology. An acromioplasty is not always necessary as an adjunct to rotator cuff repair. There is some evidence that patients with a full-thickness rotator cuff tear and Type II acromions do not show appreciable benefit from subacromial decompression.

(ii). Coplaning of the clavicle involves the removal of spurs from its inferior surface with the purpose of increasing the space available for movement of the supraspinatus tendon. It is an acceptable procedure. Studies are conflicting regarding possible pain sequelae at the acromioclavicular joint as a consequence of the procedure. In cases with extensive rotator cuff repair, preservation of the coracoacromial ligament is recommended to maintain joint stability.

(g). Post-operative Treatment

(i). An individualized rehabilitation program based upon communication between the surgeon and the therapist using the treatments found in Therapeutic Procedures, Non-operative. Treatment may include the following:

(ii). sling, pillow sling, or abduction splint;

(iii). gentle pendulum exercise, passive glenohumeral range-of-motion, and posterior scapular stabilizing training can be instituted;

(iv). patients can judiciously return to activities as tolerated per physician recommendations. If there is a significant tendon repair, progression will be delayed;

(v). Progressive resistive exercise from six to eight weeks with gradual returning to full activity at four to six months.

(vi). Return to work and restrictions after surgery may be made by an experienced primary occupational medicine physician in consultation with the surgeon or by the surgeon. Depending upon the patient's functional response and their job requirements, return to work with job modifications may be considered as early as one week post-operatively, depending on job requirements. The employer must be able to fully accommodate restrictions of overhead activities or heavy lifting. Work restrictions should be evaluated every four to six weeks during post-operative recovery and rehabilitation with appropriate written communications to both the patient and the employer. Should progress plateau, the provider should re-evaluate the patient's condition and make appropriate adjustments to the treatment plan.

14. Rotator Cuff Tear

a. Description/Definition: Partial or full-thickness tears of the rotator cuff tendons, most often the supraspinatus, can be caused by vascular, traumatic or degenerative factors or a combination. Further tear classification includes: a small tear is less than 1cm; medium tear is 1 to 3cm; large tear is 3 to 5cm; and massive tear is greater than 5cm, usually with retraction. Partial thickness cuff tears usually occur in age groups older than 30. Full-thickness tears can occur in younger age groups. Patient usually complains of pain along anterior, lateral shoulder or posterior glenohumeral joint.

b. Occupational Relationship: May be caused by sudden trauma to the shoulder such as breaking a fall using an overhead railing or an out-stretched arm; or chronic overuse with repetitive overhead motion or heavy lifting; or moderate lifting in de-conditioned workers.

c. Specific Physical Exam Findings may include

i. partial Thickness Tear

(a). There may be pain at the end of range-of-motion (ROM) when full passive ROM for abduction, elevation, external rotation and internal rotation are obtainable;

(b). Occasionally, there is a restriction of passive motion in one or more planes;

(c). Active ROM will be limited and painful for abduction and external rotation, as well as internal rotation and forward flexion;

(d). A painful arc may be present with active elevation;

(e). Pain will be positive for resisted tests (abduction, flexion, external rotation, internal rotation, abduction/internal rotation at 90 degrees, and abduction/external rotation at 45 degrees); and/or

(f). There may be positive impingement signs, refer to Impingement Syndrome.

ii. Full-Thickness Tear

(a). Passive and resisted findings are similar to those for partial thickness tears with greater weakness of abduction and external rotation;

(b). Active elevation may be severely limited with substitution of scapular rotation;

(c). Occasionally strength remains well preserved.

(d). Rotator cuff tears commonly co-exist with other shoulder abnormalities such as impingement, AC joint arthritis, bicep tendon ruptures, calcifying tendonitis, and older patients with glenohumeral instability, bursitis, and labral tears. This combination of pathology further complicates diagnostic decisions based mainly on the clinical findings. Full-thickness tears are usually readily apparent from the drop arm test or weakness with elevation. For other diagnoses, physicians should use a combination of test results with history and other findings to create a differential diagnosis. The following tests may be used:

(i). hawkins;

(ii). drop arm;

(iii). lift off;

(iv). subscapularis strength test;

(v). empty can test;

(vi). external rotation lag test.

(e). Neurological lesions can occur with rotator cuff tears or may be missed as isolated lesions. When muscle atrophy and weakness are present, the physician should consider neurologic lesions in the differential diagnoses.

d. Diagnostic Testing Procedures

i. AP view is useful to evaluate for arthritis and elevation of the humeral head. Superior migration of the humeral head is indicative of an extensive, and possibly irreparable, rotator cuff tear.

ii. Lateral view in the plane of the scapula or an axillary view can help to determine aspects of instability which can give symptoms similar to impingement syndrome.

iii. The axillary view is also useful to demonstrate glenohumeral arthritis and spurs on the anterior inferior acromion.

iv. Outlet view determines if there is a downward curved acromion. A downward curved acromion does not necessarily establish the diagnosis of impingement syndrome and is not a sole indication for operative treatment.

(a). Cases with the presence of significant weakness on elevation or rotation, a palpated defect at the greater tuberosity or a traumatic history should have early MRI. Adjunctive testing such as sonography or MRI should be considered for other shoulder cases refractory to four to six weeks of non-operative conservative treatment. Sonography may be better at detecting partial thickness tears but is operator dependent. The sonogram is very specific for rotator cuff tears but is not sensitive.

(b). Rotator cuff tears, both full-thickness and partial, appear to occur commonly in asymptomatic individuals. Sonographic diagnostic criteria for rotator cuff tear may be met in approximately 39 percent of asymptomatic persons, and MRI criteria for rotator cuff tear may occur in approximately 26 percent of asymptomatic persons. There also appears to be a linear trend with age, such that more than half of asymptomatic individuals over the age of 60 may demonstrate imaging changes consistent with rotator cuff tear, while a small minority of patients younger than 40 demonstrate these changes. Correlation of radiological and clinical findings is an important part of patient management.

e. Non-operative Treatment Procedures

i. Medications, such as nonsteroidal anti-inflammatories and analgesics, would be indicated. Acute rotator cuff tear may indicate the need for limited narcotics use.

ii. Relative rest initially and procedures outlined in Non-Operative Treatment Procedures. Therapeutic rehabilitation interventions may include ROM and use a home exercise program and passive modalities for pain control. Therapy should progress to strengthening and independent home exercise programs targeted to ongoing ROM and strengthening of shoulder girdle musculature.

iii. Return to work with appropriate restrictions should be considered early in the course of treatment. Refer to Return to Work.

iv. Other therapies outlined in Therapeutic Procedures, Non-operative, may be employed in individual cases.

f. Surgical Indications

i. Goals of surgical intervention are to restore functional anatomy by re-establishing continuity of the rotator cuff, addressing associated pathology and reducing the potential for repeated impingement.

ii. Surgery may be indicated when functional deficits interfere with activities of daily living and/or job duties after 6 to 12 weeks of active patient participation in non-operative therapy.

iii. If no increase in function for a partial tear is observed after 6 to 12 weeks, a surgical consultation is indicated. For full-thickness tears it is thought that early surgical intervention produces better surgical outcome due to healthier tissues and often less limitation of movement prior to and after surgery. Patients may need pre-operative therapy to increase ROM.

iv. Full- thickness tears in individuals less than 60 should generally be repaired. Surgery for partial thickness tears has variable results and debridement should be performed early in younger active patients. Many patients with partial tears and good ROM and strength recover well without surgery. In patients over 65 the decision to repair a full rotator cuff tear depends on the length of time since the injury, the amount of muscle or tendon that has retracted, the level of fatty infiltration and the quality of the tendon. Procedures for these patients may include biceps tendon repair and shaving of the humeral tuberosity. For patients with lack of active elevation above 90 degrees, arthroscopic biceps tenotomy and tenodesis may be effective in returning some elevation. Recurrence rate may be up to 50 percent in older patients with multiple tendon full-thickness tears. Pseudo paralysis or severe rotator cuff arthropathy are contraindications to the procedure.

v. Literature suggests that the presence of three of the following factors may decrease the likelihood of a successful repair: decreased passive ROM, superior migration of the humeral head, presence of atrophy, and/or external rotation/abduction weakness strength. Presence of these conditions is not necessarily contraindications to surgery, however, the patient should be made aware that the outcome may be less predictable.

vi. Prior to surgical intervention, the patient and treating physician should identify functional operative goals and the likelihood of achieving improved ability to perform activities of daily living or work activities and the patient should agree to comply with the pre- and post-operative treatment plan and home exercise requirements. The patient should understand the length of partial and full disability expected post-operatively.

vii. Smoking may affect soft tissue healing through tissue hypoxia. Patients should be strongly encouraged to stop smoking and provided with appropriate counseling.

g. Operative Procedures:

i. Options would include arthroscopic or open debridement and/or repair. In some cases, partial coracoacromial ligament release, and/or anterior acromioplasty.

ii. An acromioplasty is not always necessary as an adjunct to rotator cuff repair. There is some evidence that patients with a full-thickness rotator cuff tear and Type II acromions do not show appreciable benefit from subacromial decompression.

iii. Coplaning of the clavicle involves the removal of spurs from its inferior surface with the purpose of increasing the space available for movement of the supraspinatus tendon. It is an acceptable procedure. Studies are conflicting concerning the consequences of the procedure for the stability of the acromioclavicular joint.

iv. Distal clavicular resection is not recommended for patients without AC joint pain.

v. In cases with extensive rotator cuff tear, preservation of the coracoacromial ligament is recommended to prevent instability.

vi. Arthroscopic laser treatment is not recommended due to lack of evidence regarding outcomes.

h. Post-operative Treatment: Individualized rehabilitation program based upon communication between the surgeon and the therapist. Treatment may include the following:

i. Sling, pillow sling, or abduction splint. Sling protection for a period of two to eight weeks is usually recommended after rotator cuff repair;

ii. Gentle pendulum exercise, passive glenohumeral range-of-motion in flexion and external rotation to prevent adhesions and maintain mobilization;

iii. Isometrics and activity of daily living skills usually being six weeks post-operatively.

iv. Active assisted range-of-motion exercises in supine with progression to sitting;

v. Light resistive exercise may begin at 6 to 12 weeks, depending on quality of tissue and surgeon's discretion;

vi. Pool exercise initially under therapists or surgeon's direction then progressed to independent pool program;

vii. Progression to a home exercise program is essential;

viii. Gradual resistive exercise from 3 to 12 months, with gradual return to full activity at 6 to 12 months;

ix. Time frames for therapy (excluding pool therapy).

(a). Optimum: 24 to 36 sessions.

(b). Maximum: 48 sessions. If functional gains are being achieved additional visits may be authorized for the patient to achieve their functional goal.

x. Continuous passive motion is not generally recommended. It may be used if the patient has no home assistance to regularly perform the passive movements required in the first six weeks and/or access to therapy is limited.

xi. Should progress plateau, the provider should re-evaluate the patient's condition and make appropriate adjustments to the treatment plan. Refer to Therapeutic Procedures-Non-Operative for other therapies that may be employed in individual cases.

xii. Return to work and restrictions after surgery may be made by an experienced primary occupational medicine physician in consultation with the surgeon or by the surgeon. Work restrictions should be evaluated every four to six weeks during post-operative recovery and rehabilitation with appropriate written communications to both the patient and employer. Return to full-duty too early in the course of tendon recovery increases the likelihood of recurrent, symptomatic tears. Animal models estimate that the infraspinatus tendon regains only 30 percent of strength at six weeks, 50 percent at three months, and 80 percent at six months. Therefore, return to any significant lifting early in the course of recovery may result in failure of the surgery and/or recurrent tears.

15. Shoulder Instability/Glenohumeral Instability

a. Description/Definition: Subluxation (partial dislocation), or dislocation of the glenohumeral joint in either an anterior, interior, posterior or a combination of positions.

i. History may include:

(a). a slipping sensation in the arm;

(b). severe pain with inability to move the arm;

(c). abduction and external rotation producing a feeling that the shoulder might "come out"; or

(d). feeling of shoulder weakness.

b. Occupational Relationship: Instability may be caused by any of the following:

i. a direct traumatic blow to the shoulder;

ii. a fall on an outstretched arm;

iii. performing repetitive forceful overhead activities similar to pitching baseball;

iv. a significant traction injury to the arm.

v. In cases of subluxation symptoms may be exacerbated or provoked by work and initially alleviated with a period of rest. Symptoms may also be exacerbated by other activities that are not necessarily work related (e.g., driving a car or sports).

c. Specific Physical Exam Findings may include

i. Anterior dislocations may exhibit loss of normal shoulder contour; fullness in the axilla and pain over the shoulder with any motion. The patient may hold the extremity in a static position;

ii. Posterior dislocations usually occur with a direct fall on the shoulder or outstretched arm resulting in posteriorly directed forces to the humeral head. Seizures or electrocution may also cause posterior dislocations. Patients present with inability to externally rotate the shoulder;

iii. Neurologic examination may reveal findings consistent with axillary nerve injuries, musculocutaneous nerve injuries, generalized brachioplexopathies or other entrapment neuropathies;

iv. Abduction and external rotation positioning classically produces apprehension in those who have anterior instability. This finding may be present with other diagnoses. If apprehension is reproduced and then relieved with positive posterior pressure after a positive first maneuver, this is considered a positive relocation test. As with all shoulder diagnoses, a combination of physical findings and history should guide the provider in determining the final diagnoses. Direct posterior stress may produce pain and apprehension in those with posterior instability;

v. The contralateral joint should always be examined. Patients who have laxity in multiple positions, who have contralateral joint laxity or who have increased external rotation (90 degrees or more) with the arm at the side are not likely to be surgical candidates and can be treated conservatively.

vi. Other clinical findings (described in the Initial Diagnostic Procedures Section C):

(a). sulcus sign;

(b). inferior instability;

(c). posterior instability;

(d). apprehension, also known as crank, fulcrum or feagin;

(e). relocation;

(f). load and shift or anterior and posterior drawer.

d. Diagnostic Testing Procedures

i. Plain x-rays to rule out bony deficit on the glenoid, including AP, axillary view, lateral in the plane of the scapula and possibly the West Point view. Axillary view to identify larger Hill-Sachs lesion of humeral head.

ii. More difficult diagnostic cases with subtle history and physical findings suggesting instability, rotator cuff or labral tear, may require a MRI or a CT arthrogram. This imaging may be useful to evaluate for labral detachment and capsular stress injury or laxity after four to eight weeks of active patient involvement in therapy.

iii. Suspected rotator cuff tear cases may require diagnostic arthroscopy.

e. Non-Operative Treatment Procedures: In subacute and/or chronic instabilities, age of onset of instability is an important part of the history. Older patients are less likely to have recurrent dislocations unless they have associated large rotator cuff tears. Therefore, the rotator cuff tear protocol should be followed if there is a suspicion of this pathology. Associated axillary nerve injuries are more common in older patients. Patients less than 30 years of age, especially males actively participating in sports, tend to have a higher recurrence rate, up to 75 percent in some series. Surgery should be considered for these patients after the first dislocation. Avoid any aggressive treatment in patients with history of voluntary subluxation or dislocation. These patients may need a psychiatric evaluation. Patient may not return to work with overhead activity or lifting with involved arm until cleared by physician for heavier activities.

i. First-time dislocation

(a). Immobilization. There is no evidence that immobilization beyond splinting for comfort initially affords any additional treatment advantage thus, it is not routinely required. Literature using MRI has shown that the Bankart lesion is separated from the bone in internal rotation and apposed to the bone in external rotation. There is some evidence that immobilization for three weeks with the shoulder in adduction and approximately 10 degrees of external rotation reduces the risk of recurrent dislocation. Decisions concerning external rotation splinting versus other options will depend on surgeon and patient preferences.

(b). Consider surgical intervention for young patients active in sports, or older patients with significant rotator cuff tears. If additional pathology is present consult appropriate diagnostic categories.

(c). Medications such as analgesics and anti-inflammatories may be helpful. (Refer to medication discussions in Medications.

(d). Other therapeutic procedures may include instruction in therapeutic exercise and proper work techniques, evaluation of occupational work station and passive modalities for pain control. (Refer to Therapeutic Procedures-Non operative, for specific time parameters.)

(e). Additional treatment may include, depending on level of improvement, manual therapy techniques, work conditioning and other treatment found in section F.

(f). Patient may not return to work with overhead activity or lifting with involved arm until cleared by physician for heavier activities. Return to work with appropriate restrictions should be considered early in the course of treatment. Refer to Return to Work.

ii. Acute or chronic dislocations: with a fracture contributing to instability;

(a). Practitioner should immobilize dislocations if in an acceptable position. Consultation should be obtained as surgical repair may be necessary.

(b). Return-to-work will be directly related to the time it takes the fracture to heal.

iii. Subacute and/or chronic instability:

(a). Chronic dislocations should first be treated similarly to acute dislocation. If continuing treatment is unsuccessful, with findings of instability, operative repair should be considered.

f. Surgical Indications

i. Identify causative agent for the instability (i.e., labral detachment, bony lesion, large rotator cuff tear, subscapularis tendon rupture, or multi-directional instability). There is strong evidence that initial operative repair in young active patients results in fewer recurrent dislocations, thus, operative repair should be considered for these patients. Those with Hill Sachs lesions, bony Bankart injuries, or significant glenoid bone loss have a worse prognosis for recurrences.

ii. Fractures not amenable to immobilization may also need operative management after the first dislocation. Even with open repairs some decrease in function should be expected. Loss of external rotation is common. In some cases the loss of motion may have an adverse effect on post-operative function. The desire for surgery should carefully balance the desire to prevent recurrent dislocations and the need for ROM.

iii. Older patients with documented large rotator cuff tears should also be considered for operative repair after first time dislocations. Repair of the rotator cuff tear alone or in combination with stabilization should be considered. Refer to the rotator cuff tear section.

iv. In general, older patients without the above lesions will suffer few recurrences, and therefore, are treated conservatively. Operative repair may be considered only after recurrent dislocations when functional deficits interfere with activities of daily living and/or job duties and active patient participation in non-operative therapy has occurred. Patients with multi-directional laxity and/or laxity in the contralateral shoulder are usually not good candidates for operative repair.

g. Operative Procedures:

i. Bankart lesion repair; or

ii. Capsular tightening. There is no evidence of benefit from thermal capsulorrhaphy and it is not recommended;

iii. Bony block transfer;

h. Post-operative Treatment:

i. An individualized rehabilitation program based upon communication between the surgeon and the therapist. Depending upon the type of surgery, the patient will be immobilized for three to six weeks.

ii. As soon as it is safe to proceed without damaging the repair, begin therapeutic exercise. Pool therapy may be beneficial. Refer to Therapeutic Procedures, Non-operative for other therapies.)

iii. During this period of time, the patient could resume working when the surgeon has cleared the patient for specific activities and appropriate modifications can be made in the workplace. Return to work and restrictions after surgery may be made by an experienced primary occupational medicine physician in consultation with the surgeon or by the surgeon. Full ROM, lifting and pushing are prohibited usually for at least three months. Overhead work may be restricted up to six months.

iv. MMI can be expected three months after non-operative treatment and 6 to 12 months after operative treatment. Further job assessment and adjusted work restrictions may be needed prior to the patients return to full-duty.

16. Superior Labrum Anterior and Posterior (Slap) Lesions

a. Description/Definition: Lesions of the superior aspect of the glenoid labrum that extend anteriorly and posteriorly in relation to the biceps tendon insertion. There are several different types of SLAP lesions described.

i. Type I is a fraying of the superior labral edge without detachment of the labrum from the glenoid rim.

ii. Type II is a detachment of the biceps anchor from the glenoid. Three distinct Type II lesions have been described as anterior only, posterior only, or combined anterior and posterior.

iii. Type III is a bucket handle tear in the superior labrum only with biceps tendon and remainder of the superior labrum having stable attachment.

iv. Type IV is a bucket handle tear as in Type III, but with extension of the tear in to the biceps tendon. Additional types of lesions have been described that include extensions of the above-described lesions or extensions of Bankart lesions.

v. History may include:

(a). Symptoms with overhead throwing motions;

(b). Dislocation, subluxation, or subjective sense of instability;

(c). Poorly localized shoulder pain that is exacerbated by overhead activities;

(d). Catching, locking, popping or snapping;

(e). Subtle instability.

b. Occupational Relationship: Common mechanisms of injury that are thought to contribute to SLAP lesions include: compression injury such as fall on an outstretched arm with the shoulder in forward flexion and abduction or direct blow to the glenohumeral joint; traction injury such as repetitive overhead throwing, attempting to break a fall from a height, and sudden pull when losing hold of a heavy object; driver of an automobile who is rear ended; repetitive overhead motions with force such as pitching; or a fall on adducted arm with upward force directed on elbow. In some cases no mechanism of injury can be identified.

c. Specific Physical Exam Findings: The physical examination is often nonspecific secondary to other associated intra-articular abnormalities. No one test or combination of tests has been shown to have an acceptable sensitivity and specificity or positive predictive values for diagnosing SLAP lesion. Sensitivity and specificity are relatively low for individual tests and combinations. Overall physical examination tests for SLAP lesions may be used to strengthen a diagnosis of SLAP lesion, but the decision to proceed to operative management should not be based on physical examination alone. Refer to Initial Diagnostic Procedures for specific descriptions of these signs and tests.

i. Speed Test.

ii. Yergason's Test.

iii. Active Compression (O'Brien) Test.

iv. Jobe Relocation Test.

v. Crank Test.

vi. Anterior Apprehension Maneuver.

vii. Tenderness at the bicipital groove.

viii. Anterior Slide (Kibler) Test.

ix. Compression Rotation Test.

x. Pain Provocation Test.

xi. Biceps Load Test II.

d. Diagnostic Testing Procedures:

i. Radiographs are usually normal in isolated SLAP lesions. However, they can be useful in identifying other sources of abnormalities.

ii. Magnetic resonance imaging with arthrogram has the highest reported accuracy for both diagnosis and classification of SLAP lesions; however, it may be difficult to differentiate SLAP lesions, especially Type II lesions, from normal anatomic variants and from asymptomatic age related changes.

iii. Arthroscopic evaluation is the most definitive diagnostic test.

e. Non-operative Treatment Procedures: Most SLAP lesions are associated with other pathology such as rotator cuff tears, Bankart lesions, joint instability, biceps tendon tears, and supraspinatus tears. The provider should refer to the treatment protocols for these conditions and follow both the surgical and non surgical recommendations. For suspected isolated SLAP lesions, non invasive care, consider the following.

i. Medications such as analgesics and anti-inflammatories may be helpful. (Refer to medication discussions are in Medications.)

ii. Therapeutic procedures may include instruction in therapeutic exercise and proper work techniques, evaluation of occupational work station.

iii. Benefits may be achieved through therapeutic rehabilitation and rehabilitation interventions. They should include range-of-motion (ROM), active therapies, and a home exercise program. Passive as well as active therapies may be used for control of pain and swelling. Therapy should progress to strengthening and an independent home exercise program targeted to further improve ROM and strength of the shoulder girdle musculature. (Refer to Therapeutic Procedures, Non-operative.)

iv. Subacromial bursal and/or glenohumeral steroid injections may decrease inflammation and allow the therapist to progress with functional exercise and ROM.

(a). Time to Produce Effect: One injection.

(b). Maximum Duration: Three injections in one year at least four to eight weeks apart.

(c). Steroid injections should be used cautiously in diabetic patients. Diabetic patients should be reminded to check their blood glucose levels at least daily for two weeks after injections.

v. Return to work with appropriate restrictions should be considered early in the course of treatment. Refer to Return to Work.

vi. Other therapies in Therapeutic Procedures, Non-operative may be employed in individual cases.

f. Surgical Indications: There is a significant amount of normal anatomic variation of the superior glenoid labrum and origin of the long head of the biceps tendon. Differentiation between normal variation and pathology is imperative.

i. The physician should identify other shoulder pathology if any exists and follow the appropriate surgical indications. If a SLAP lesion is suspected, an arthroscopic exam should be performed in conjunction with the primary surgical procedure and an appropriate repair performed if necessary. See Specific Diagnosis Testing, & Treatment related sections. Or;

ii. When no additional pathology is identified and there is an inadequate response to at least three months of non-operative management with active patient participation as evidenced by continued pain with functional limitations and/or instability significantly affecting activities of daily living or work duties;

iii. Prior to surgical intervention, the patient and treating physician should identify functional operative goals and the likelihood of achieving improved ability to perform activities of daily living or work activities and the patient should agree to comply with the pre- and post-operative treatment plan and home exercise requirements. The patient should understand the length of partial and full disability expected post-operatively. The patient should also understand that non-operative treatment is an acceptable option and that a potential complication of the surgery is shoulder stiffness with pain and possibly decreased function.

g. Operative Procedures: Operative treatment of SLAP lesions depends on the type of lesion present and whether any other intra-articular abnormalities are present. The following are generally accepted protocols for surgical intervention; however, due to current lack of evidence, operative treatment is not limited to these.

i. TypeI: Debridement is reasonable but not required.

ii. TypeII: Repair via suture anchors or biceps tenotomy are reasonable options.

iii. TypeIII: Debridement or excision of the bucket handle component alone or repair via suture anchors or biceps tenotomy/tenodesis are reasonable options.

iv. TypeIV: Debridement and/or biceps tenotomy or tenodesis are reasonable options.

h. Post-Operative Treatment: Post-operative rehabilitation programs should be individualized and dependent upon whether any other intra-articular abnormalities exist and were operatively treated. There is a paucity of information on rehabilitation of isolated SLAP lesions. Common post-operative care involves wearing a sling, without active shoulder motion for 4 to 6 weeks. Elbow, wrist, and hand range-of-motion (ROM) exercises may be used at this time. The sling is removed at 4 to 6 weeks and active ROM is usually begun with restrictions directed by the surgeon. It is reasonable to restrict external rotation and abduction up to six months post-operative. Return to work and restrictions after surgery may be made by an experienced primary occupational medicine physician in consultation with the surgeon or by the surgeon.

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

Disclaimer: These regulations may not be the most recent version. Louisiana may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.

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