INDUSTRIAL MEDICAL COUNCIL - California
(Adopted by May 15, 1997)
Shoulder problems are common among workers. The overall goals of the management of shoulder problems in workers is to identify and correct both environmental and personal factors that may be causing or aggravating the problem, while providing appropriate management of disability so that it leads to a return to productive work.
Scope of the Guideline
This guideline deals with the assessment and treatment of work-related shoulder problems, including tendinitis, bursitis, impingement syndrome, rotator cuff deficits, muscle injuries affecting the shoulder girdle, shoulder instability (including labral damage and acromioclavicular (AC) separation) and pectoral girdle nerve syndrome. Initial assessment to rule out serious shoulder problems is discussed, but definite diagnosis and treatment of serious disorders is beyond the scope of this guideline. This guideline does not deal with issues of legal causation or work-relatedness. Treatment guidelines are designed to assist providers by providing an analytical framework for the evaluation and treatment of the more common problems of injured workers. These guidelines are educational and descriptive of generally accepted parameters for the assessment and treatment of shoulder injuries. The guidelines are intended to assure appropriate and necessary care for injured workers diagnosed with these types of industrial conditions. Due to the many factors which must be considered when providing quality care, health providers shall not be expected to always provide care within the stated guidelines. Treatment authorization, or payment for treatment, shall not be denied based solely on a health care provider's failure to adhere to the IMC guideline. The guidelines are not intended to be the basis for the imposition of civil liability or professional sanctions. They are not intended to either replace a treating provider's clinical judgment or to establish a protocol for all injured workers with a particular condition. It is understood that some injured workers will not fit the clinical conditions contemplated by a guideline.
Symptom duration is defined as acute (< one month), subacute (one - three months) and chronic (> three months).
For the purpose of this document, a provider is defined as any health care provider acting within the scope of his/her practice, including those to whom an injured worker has been referred or whose treatment has been prescribed by a treating physician.
All health care providers acting within the scope of their practice, including those to whom an injured worker has been referred or whose treatment has been prescribed by a treating physician, shall be allowed to bill and be reimbursed in accordance with usual practices.
A provider may vary from these guidelines, if in his or her judgment, variance is warranted to meet the health care needs of the injured worker and that variance remains within the standards of practice generally accepted by the health care community, and the provider documents the need for the variance in the evaluation report or the medical treatment record in the manner that is generally accepted by the health care community.
Not every medical situation can be addressed in these regulations and medical standards change constantly. The documentation required of the provider is necessary to monitor and explain the use of variances.
In all cases, the provider shall document no later than 6 months from the date of injury, whether further treatment is warranted and whether the injured worker has significant subjective and objective evidence of the condition not having plateaued.
1.0 Initial Assessment (First Month)
The purpose of the initial assessment is to differentiate occupational shoulder disorders secondary to chronic fatigue of neck and shoulder muscles from the specific overuse phenomena, such as tendinitis. It should also be noted that pain complaints in the neck, chest, cardiovascular system, liver, gallbladder or upper thoracic spine are frequently referred to the shoulder.
Conditions considered in this guideline include, but are not limited to, the following examples:
Sudden overload of a muscle tendon unit can create ruptures of various muscles about the shoulder. This is a relatively uncommon problem but disabling for varying periods when it occurs. The injury is usually defined within the first several days, largely based on physical examination.
Instability of the shoulder may be associated with weakness and limited function. Specific definition of the problem, with early decision as to whether surgical reconstruction or specific rehabilitation is necessary, will hasten the return to normal function.
The phrase "impingement syndrome" at times may replace less specific diagnoses such as bursitis or tendinitis.
1.2 Appropriate assessment methods
1.2.1 History and Exam
The history focuses on the nature of the injury, and the duration of the shoulder complaint. The work history may include awkward postures and/or a prolonged duration of similar work postures. Ask about a history of previous or contralateral shoulder problems.
With pain complaint on the part of an individual claiming work injury, clear definition of the source of the injury should be made. Shoulder problems related to impingement syndrome, tendinitis and rotator cuff tears are usually the result of chronic overload over a long period of time yet they may occur on the basis of a single event.
People with impingement syndrome will often complain of pain while sleeping on the affected side and inability to complete simple tasks.
Visual inspection, range of motion, comparing the contralateral side, a manual test for shoulder strength, and palpation for joint tenderness or a possible defect should be performed on all injured workers.
Musculotendinous injuries may be suspected by a history of weakness, joint tenderness and a palpable defect.
Shoulder instability is often quite difficult to diagnose. Posterior subluxation of up to 50% and anterior subluxation of up to 33% may be a normal finding under general anesthesia. The tests to define instability include:
provocative tests such as the Sulcus sign, which is elicited by pulling downward the arm held at the side and noting the subacromial skin indentation.
The impingement syndrome can be diagnosed by physical examination. Examination will often demonstrate an area of tenderness. This is especially noted when the arm is in 10 degrees of extension and internal rotation. This particular location allows the tuberosities to be palpable. Range of motion may be limited particularly in internal rotation and cross-body adduction. Passive motion through a 60 to 90 degree arc of flexion may be associated with crepitus as well as pain. Active elevation of the arm is usually more uncomfortable than passive elevation.
Neutral Position and 90/90 Strength
Arm drop- cuff
Yergason biceps lift thumb out
abduction compression- AC
Neer - thumb down lift
Hawkins - 90 abduction/internal rotation
suppression test- anterior instability
X-rays may be done on the initial medical evaluation if there is a specific history of injury, and/or the examining physician determines that x-rays are clinically necessary. (Mail Survey=4) (Consensus Panel=) [ 4 ]
X-rays may suggest a history of instability. Plain x-rays may document an impression fracture in the posterior superior aspect of the humeral head (Hill-Sachs lesion). Stress x-rays may be useful to document occult instability.
In individuals with impingement syndrome, plain x-rays which focus at the anterior acromion may note sclerosis and, in specific views such as the anterior scapula view, an increased "hooking" of the acromion.
Bonsell S, Pearsall AW 4th, Heitman RJ, Helms CA, Major NM, Speer KP.The relationship of age, gender, and degenerative changes observed on radiographs of the shoulder in asymptomatic individuals. J Bone Joint Surg Br 2000 Nov;82(8):1135-9
Tasu JP, Miquel A, Rocher L, Molina V, Gagey O, Blery M. MR evaluation of factors predicting the development of rotator cuff tears. J Comput Assist Tomogr 2001 Mar-Apr;25(2):159-63
Cuomo F, Kummer FJ, Zuckerman JD, Lyon T, Blair B, Olsen T. The influence of acromioclavicular joint morphology on rotator cuff tears. J Shoulder Elbow Surg 1998 Nov-Dec;7(6):555-9
Nicholson GP, Goodman DA, Flatow EL, Bigliani LU.The acromion: morphologic condition and age-related changes. A study of 420 scapulas. J Shoulder Elbow Surg 1996 Jan-Feb;5(1):1-11
1.2.3 Injections with local anesthetic to clarify or differentiate the diagnosis.(M=3) (C=4) [ 3 ]
1.3 Inappropriate initial assessment methods
Plain arthrography for the evaluation of shoulder instability is inappropriate. CT/arthrography can be considered. [ 1 ]
Plain arthrography may be appropriate for the evaluation of acute rotator cuff tears when the patient cannot undergo MRI. (M=1) (C=) [ 1 ]
Arthroscopy is not routinely necessary for the detection of instability or rotator cuff status. (M=1)(C=)[1 ]
1.3.3 Specialized imaging tests
Routine use of specialized imaging tests is not indicated. (M=1) (C=) [ 1 ]
Chronic degenerative changes occur in the older age group in high frequency. Findings of degenerative changes on an imaging study may be incidental and not the reason for the injured worker's complaints.
2.0 Initial Treatment
The purpose of the initial treatment is to allow the injured worker to resume activities as soon as possible while not aggravating the shoulder symptoms.
2.2 Appropriate initial treatment methods
Appropriate education includes shoulder anatomy and the role of muscle weakness and fatigue in pain complaints. (M=4) (C=) [4 ]
2.2.2 Activity and environmental modifications
Ergonomic modifications and changes of position are appropriate if possible and practical. (M=4)(C=)[4 ]
Various EMG studies have documented a reduced muscle activity with ergonomic modification. Job modifications to avoid work activities such as overhead manual labor should be considered, especially for workers with repetitive-type injuries
Primary shoulder dislocations, once relocated, should be treated immediately with immobilization for up to three to four weeks. (M=4) (C=4) [ 4 ]
22.214.171.124 For occupational shoulder disorders, a strengthening and/or stretching program may be appropriate.
126.96.36.199 For individuals with shoulder instability, exercise programs to strengthen the muscles should be undertaken. (M=4) (C=) [ 4 ]
Efficacy of various strengthening programs has not been documented by comparative studies except for cases of traumatic and non-traumatic subluxation.
188.8.131.52 For individuals with impingement syndrome, initial treatment should be in the form of isometric and/or resistive exercises (if tolerated by the injured worker), as well as mobilization exercises to the involved shoulder, focusing upon those muscles controlling the rotator cuff. (M=4) [4 ]
2.2.5 Medications (M=4) (C=) 
Anti-inflammatory and pain medication may be indicated for shoulder injuries.
Opioids may be necessary if the pain is refractory to treatment with non-opioid analgesics.(M=3)(C=4)
2.2.6 Physical treatments
Appropriate manual therapies include manipulation,or joint and soft tissue mobilization, supplemented by physical modalities and exercise. (M=4) (C=) [ 4 ]
2.2.7 Use of thermal modalities in conjunction with physical treatment may be useful.
For impingement syndrome, bursitis and tendinitis specific local steroid injections (M=4) (C=4) [ 4 ]
2.2.9 Acupuncture (M=4) (C=2) [ 2 ]
Ruptures of major tendons should have surgical consideration for primary as should a significant tear of the rotator cuff or AC dislocation. (M=4) (C=) [ 4 ]
2.2.11 Shoulder girdle trigger point injections for specific indications may be useful, and, if so, should be for a trial of up to 3 sessions. (M=)(C=)
2.3 Inappropriate initial treatments
2.3.1 Surgical treatments for tendinitis, bursitis, acromial clavicular subluxation (M=1) (C=) [ 1 ]
2.3.2 Proximal biceps ruptures often need not be repaired surgically. Function is often just as good with or without repair.M=1)(C=)
2.3.3 Total immobilization after 1 week is inappropriate for most shoulder injuries. (M=1) (C=) [ 1 ]
2.3.4 Steroids for shoulder instability (M=1) (C=) [ 1 ]
2.3.5 Arthroscopic stabilization of the shoulder has not been confirmed to give greater stability than open shoulder stabilization surgery.(M=1)(C=)
2.3.6 Trigger point injections unless a specific rationale can be presented. (M=1) (C=) [ 1 ]
2.4 Case management
Management during the first 4 weeks of treatment will be determined by the clinician's evaluation of the injured worker's response to therapy. Generally, re-evaluation of the problem, determination of treatment effectiveness and work status should be performed every 1-2 weeks until return to modified or full work is achieved. At each visit, the initial diagnosis should be confirmed or modified and the treatment plan adjusted if necessary. If symptoms continue to increase despite adequate conservative therapy, or if there is significant disability due to pain, referral to a provider trained and experienced in the evaluation and treatment of occupational disorders is warranted in the initial treatment phase. Once the acute pain is controlled, the treatment should focus on progressive rehabilitative exercises to increase strength and endurance, and activity modification. This approach minimizes the chance of recurrence once normal occupational duties are resumed.
3.0 Secondary Assessment (after first month)
The purpose of reassessment is to determine the reason for delayed recovery in injured workers who have not experienced functional improvement after appropriate initial treatment.
3.2 Appropriate secondary assessment methods (for clinical indications as noted)
3.2.1 Objective testing (strength and range of motion) of status of rehabilitation may be indicated for individuals with findings of impingement syndrome. (M=4) (C=) [ 4]
3.2.2 Injections with local anesthetic to clarify pain issues (M=4) (C=) [ 4 ]
3.2.3 Specialized imaging tests
A shoulder arthrogram may be useful when an MRI is inconclusive or contraindicated. (M=4) (C=) [ 3 ]
3.2.4 If an arthrogram is contraindicated, an MRI may be appropriate. (M=4) (C=) [ 4]
3.2.5 Ergonomic evaluation may be indicated if findings suggest that physical work factors may be contributing to delayed recovery or frequent exacerbation of the patient's condition. (M=4) (C=) [ 4]
3.3 Inappropriate secondary assessment methods
3.3.1 Psychological evaluation (M=1) (C=) [ 1]
4.0 Secondary Treatment
The purpose of secondary treatment is to cure or relieve the effects of the injury of the worker who remains refractory to primary treatment efforts.
4.2 Appropriate secondary treatment methods (for the specific clinical indications as noted)
4.2.1 Progressive active strengthening and stretching programs with documentation of functional progress. (M=4) (C=) [ 4 ]
4.2.2 Up to a maximum of three steroid injections into the subacromial space for individuals with the diagnosis of impingement. (M=4) (C=) [ 4]
4.2.3 Manual medicine techniques
Manipulation/mobilization and myofascial release may be appropriate if subjective and objective evidence of improvement can be documented on a monthly basis. (M=4) (C=) [ 4]
4.2.4 Surgical treatment methods
184.108.40.206 For individuals with objective findings of impingement syndrome on physical examination, subacromial injection, steroid injection, and imaging studies and who have failed conservative treatment including steroid injections and an exercise program, surgery may be appropriate after 3 to 6 months. (M=4) (C=) [ 4]
220.127.116.11 Recurrent subluxation or dislocation on a traumatic basis is best treated by surgical reconstruction.(M=4)(C=)
4.2.5 Shoulder girdle trigger point injections for specific indications may be useful for a trial of up to 3 sessions (or 6 sessions, if not done in the initial treatment phase). (M=) (C=) [ 3]
4.3 Inappropriate secondary treatments
4.3.1 Frequent steroid injections (> 2 ) (M=1) (C=) [ 1]
4.3.2 Surgery for tendinitis (M=1) (C=) [ 1]
4.3.3 Biofeedback (M=1) (C=) [ 1]
4.3.4 Pain clinic (M=1) (C=) [ 1]
4.3.5 Prolonged time off work (M=) (C=1) [ 1]
4.4 Case management
If the injured worker has not resumed near normal work duties after 8 weeks of full conservative therapy including adherence to a graded exercise program, a referral to a physician trained and experienced in the evaluation and treatment of occupational disorders or an orthopedic surgeon is recommended. Consultation should include a complete evaluation and recommendations for treatment and return to appropriate work. If psychosocial issues are judged to contribute to delayed recovery or heightened disability, it may be appropriate to have a psychiatric evaluation. If the condition becomes chronic or disabling despite full conservative treatment including appropriate medical, rehabilitative, and ergonomic interventions (and surgery if indicated), the injured worker should be evaluated for permanent disability.
The purpose of prevention is to avoid reoccurrence of shoulder pain complaints.
5.2 Appropriate preventive measures
5.2.1 Exercises to maintain/improve strength, range, and endurance. (M=4) (C=) [ 4]
5.2.2 Ergonomic modifications (M=) (C=) [ 4]
6.0 Primary References
1. Bannister GC, Wallace WA, Stabbleforth PG, et al.: The management of acute acromioclavicular dislocation. J Bone Jt Surg 1989;71B(5):848-50.
2. Brox JI, Staff PH, Ljunggren AE, et al.: Arthroscopic surgery compared with supervised exercises in patients with rotator cuff disease. Br Med J 1993;307:899-903.
3. Bunker TD, Wallace WA: Assessment of the shoulder in Shoulder Arthroscopy, Eds. TD Bunker, WA Wallace. Mosby-Year Book, Inc., St. Louis, 1991; 25-39.
4. Burkhead WZ, Rockwood CA: Treatment of instability of the shoulder with an exercise program. J Bone Jt Surg 1992;74A:890-6.
5. Caughey MA, Welsh P: Muscle ruptures about the shoulder in Surgery of the Shoulder, Eds. M Post, et al. Mosby-Year Book, Inc., St. Louis, 1990; 317-20.
6. Caughey MA, Welsh P: Muscle ruptures affecting the shoulder girdle in The Shoulder, Eds. CA Rockwood, FA Matsen. W.B. Saunders Co., Philadelphia, 1990; 863-73.
7. Ellman H, Gartsman GM, Hengst TC: Nonoperative and postoperative rehabilitation of shoulder instability in Arthroscopic Shoulder Surgery and Related Procedures, Ed. DB Cooke, et al. Lea and Febiger, Malvern PA, 1993; 447-52.
8. Frymoyer JW, Mooney V: Current concepts review: occupational orthopaedics. J Bone Jt Surg 1986;68A(3):469-74.
9. Gartsman GM: Arthroscopic acromioplasty for lesions of the rotator cuff. J Bone Jt Surg 1990;72A(2):169-80.
10. Gazielly DF: Preoperative management and rehabilitation of rotator cuff tears in Surgery of the Shoulder, Ed. M Post, et al. Mosby-Year Book, Inc., St. Louis, 1990; 234-7.
11. Gross ML, Seeger LL, Smith JB, et al.: Magnetic resonance imaging of the glenoid labrum. Am J Sports Med 1990;18(3):229-34.
12. Gschwend N, Rubeli M, Pidermann M: Rotator cuff tears: relationship between clinical picture, operative findings, and results in Surgery of the Shoulder, Eds. M Post, et al. Mosby-Year Book, Inc., St. Louis, 1990; 238-42.
13. Hawkins RJ, Bokor DJ: Clinical evaluation of shoulder problems in The Shoulder, Eds. CA Rockwood, FA Matsen. W.B. Saunders Co., Philadelphia, 1990; 149-77.
14. Heckman JD, Levine MI: Traumatic closed transection of the biceps brachii in the military parachutist. J Bone Jt Surg 1978;60A(3):369-72.
15. Herberts P, Kadefors R, Hogfors C, et al.: Shoulder pain and heavy manual labor. Clin Orthop Rel Res 1984;191:166-78.
16. Leahy, MP; Mock LE: Myofascial Release Technique and Mechanical Compromise of Peripheral Nerves of the Upper Extremity. Chiropractic Sports Medicine Vol. 6 No. 4, 1992 pp. 139 - 150.
17. Luck JV, Andersson GB: Occupational shoulder disorders in The Shoulder, Eds. CA Rockwood, FA Matsen. W.B. Saunders Co., Philadelphia, 1990; 1088-108.
18. Neer CS: Anterior acromioplasty for the chronic impingement syndrome in the shoulder. J Bone Jt Surg 1972;54A(1):41-50.
19. Paulos LE, Franklin JL: Arthroscopic shoulder decompression development and application. Am J Sports Med 1990;18(3):235-44.
20. Rockwood CA, Lyons FR: Shoulder impingement syndrome: diagnosis, radiographic evaluation, and treatment with a modified Neer acromioplasty. J Bone Jt Surg 1993;75A(3):409-24.
21. Schneider G: Restricted shoulder movement: capsular contracture or cervical referral- a clinical study. Aust J Physio 1989;35(2):97-100.
Description of IMC Appropriateness Levels
Good Research Based Evidence
Consensus Of The Health Care Community
Clinical Utility Of Appropriateness Level For Common Shoulder Problems
Appropriate and recommended
Acceptable or appropriate in most cases
Appropriate in uncommon individual cases. Document the case-specific clinical factors or circumstances which make this procedure reasonable and necessary for this injured worker.
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