7 Colo. Code Regs. § 1101-3 R17 Ex 04
SHOULDER INJURY MEDICAL TREATMENT GUIDELINES
This document has been prepared by the Colorado Department of Labor and Employment, Division of Workers' Compensation (Division) and should be interpreted within the context of guidelines for physicians/providers treating individuals qualifying under Colorado's Workers' Compensation Act as injured workers with upper extremity involvement.
Although the primary purpose of this document is advisory and educational, these guidelines are enforceable under the Workers' Compensation Rules of Procedure, 7 CCR 1101-3. The Division recognizes that acceptable medical practice may include deviations from these guidelines, as individual cases dictate. Therefore, these guidelines are not relevant as evidence of a provider's legal standard of professional care.
To properly utilize this document, the reader should not skip nor overlook any sections.
The principles summarized in this section are key to the intended implementation of all Division of Workers' Compensation guidelines and critical to the reader's application of the guidelines in this document.
The practitioner should understand all of the physical demands of the patient's job position before returning the patient to full duty and should request clarification of the patient's job duties. Clarification should be obtained from the employer or, if necessary, including, but not limited to, an occupational health nurse, occupational therapist, vocational rehabilitation specialist, or an industrial hygienist.
When possible, guideline recommendations will note the level of evidence supporting the treatment recommendation. It is generally recognized that early reports of a positive treatment effect are frequently weakened or overturned by subsequent research. When interpreting medical evidence statements in the guideline, the following apply:
* Consensus means the judgment of experienced professionals based on general medical principles. Consensus recommendations are designated in the guideline as "generally well-accepted," "generally accepted," "acceptable/accepted," or "well-established."
* "Some evidence" means the recommendation considered at least one adequate scientific study, which reported that a treatment was effective. The Division recognizes that further research is likely to have an impact on the intervention's effect.
* "Good evidence" means the recommendation considered the availability of multiple adequate scientific studies or at least one relevant high-quality scientific study, which reported that a treatment was effective. The Division recognizes that further research may have an impact on the intervention's effect.
* "Strong evidence" means the recommendation considered the availability of multiple relevant and high-quality scientific studies, which arrived at similar conclusions about the effectiveness of a treatment. The Division recognizes that further research is unlikely to have an important impact on the intervention's effect.
All recommendations in the guideline are considered to represent reasonable care in appropriately selected cases, irrespective of the level of evidence or consensus statement attached to them. Those procedures considered inappropriate, unreasonable, or unnecessary are designated in the guideline as "not recommended."
The remainder of this document should be interpreted within the parameters of these guideline principles that may lead to more optimal medical and functional outcomes for injured workers.
The Division recommends the following diagnostic procedures be considered, at least initially, the responsibility of the workers' compensation carrier to ensure that an accurate diagnosis and treatment plan can be established. Standard procedures that should be utilized when initially diagnosing a work-related shoulder complaint are listed below.
Shoulder pain can be difficult to diagnose for many reasons, such as:
* Bone: constant, localized
* Nerve: hot, burning, radiating
* Capsular/ligamentous: achy
* Muscular: pain aggravated by movement
* Vascular: throbbing
* Cartilaginous: clicking and/or pain with range of motion.
Patient-reported outcomes, whether of pain or function, are susceptible to a phenomenon called response shift. This refers to changes in self-evaluation which may accompany changes in health status. Patient self-reports may not coincide with objective measures of outcome, such as Disability of Arm, Shoulder and Hand (DASH), due to reconceptualization of the impact of pain on daily function and internal recalibration of pain scales. Response shift may obscure treatment effects in clinical trials and clinical practice, and may lead to apparent discrepancies in patient-reported outcomes following treatment interventions. While methods of measuring and accounting for response shift are not yet fully developed, understanding that the phenomenon exists can help clinicians understand what is happening when some measures of patient progress appear inconsistent with other measures of progress.
This section contains a description of common clinical shoulder tests. Generally, more than one test is needed to make a diagnosis. Clinical judgment should be applied when considering which tests to perform, as it is not necessary to perform all of the listed tests on every patient. The physical examination may be non-specific secondary to multi-faceted pathology in many patients. In addition, some tests may be positive for more than one condition. Given the multitude of tests available, the physician is encouraged to document the specific patient response, rather than report that a test is ''positive." The tests are listed for informational purposes, and are also referenced in Section E of this document, Specific Diagnostic, Testing and Treatment Procedures.
Many of the following tests are also used to test for associated labral tears. The majority of the tests/signs should be performed on both shoulders for comparison. Some individuals have increased laxity in all joints, and therefore, tests/signs which might indicate instability in one individual may not be pathologic in individuals whose asymptomatic joint is equally lax.
* Grade 0, little or no movement;
* Grade 1, humeral head glides beyond the glenoid labrum; and
* Grades 2 & 3 actual dislocation of the humeral head off the glenoid.
Labral tears which may require treatment usually occur with concurrent bicipital tendon disorders pathology and/or glenohumeral instability. Therefore, tests for labral pathology are included in these sections. Additional tests for SLAP (superior labral tear from anterior to posterior are found under SLAP Lesions).
Most published clinical examination studies assess rotator cuff pathology. Tests may be reliable for ruling out diagnoses, but not necessarily for defining the pathology accurately.
* Interference with sleep;
* Difficulty getting dressed or combing or washing hair;
* Perform personal hygiene such as ability to wipe perineal area with the affected arm;
* Ability to do the household shopping alone;
* Ability to shower or bathe and dry oneself using both hands;
* Ability to carry a tray of food across a room with both hands;
* Ability to hang up clothes in the closet;
* Ability to reach high shelves with the affected shoulder;
* Ability to enter/exit automobile including operation of steering mechanism, seat belt, and gear selector.
* Difficulty with any other activities including sports and work duties;
* Concerns about putting on overhead clothing;
* Fear of dislocation, or concerns that a specific activity might cause the shoulder to "go out";
A detailed description of ability to perform job duties. A positive historical information should be validated by the provider's physical exam.
Valid functional shoulder tests are valuable for case management. It is suggested that providers follow patients' functional status throughout the claim with tools such as the Constant-Murley, DASH, Simple Shoulder Test, Patient Specific Functional Scale, Shoulder Pain and Disability Index (SPADI).
Principles of Causation of Occupational Shoulder Diagnoses
Causation is a medical/legal analysis in the workers compensation system. The information in the Medical Treatment Guidelines pertaining to causation addresses only the evidence related to the medical analysis of causation. Actual cases may vary from the evidence presented based on specific circumstances of the claim. Work-related conditions may occur from the following:
* a specific incident or injury,
* aggravation of a previous symptomatic condition, or
* a work-related exposure that renders a previously asymptomatic condition symptomatic and subsequently requires treatment.
All of these conditions must be determined based on the specifics of the work related injury or exposure. The clinician determines the need for treatment due to the work related event. Most occupational shoulder cases result from injuries. However there are some studies looking at shoulder diagnoses from a cumulative occupational exposure viewpoint.
The studies reviewed were chosen because they identified shoulder conditions as chronic or causing disability. The complaint of pain alone is generally not compensable in this system. To apply the below standards, the clinician must first make a specific shoulder diagnosis which is substantiated by consistent physical exam findings. The following information was reviewed using evidence-based standards to address the effects on workers of cumulative exposures and should only be considered in that context. The clinician should use this information judiciously.
Cumulative work-related causation for shoulder disorders is difficult to quantify given 1) the variable techniques used to measure work exposures and the paucity of studies which have measured exposures, 2) the lack of verified clinical exams and 3) the lack of prospective studies. Given this difficulty, this section of the guidelines will summarize not only those studies which qualify for at least some evidence given our study criteria but also studies of lower levels which have similar findings in order to assure that the final recommendations are the best reflection of current literature.
Several studies reported on shoulder pain alone based on self-report of both pain and work related activities. They do not meet our criteria for evidence but are interesting to consider in relationship to the evidence studies. One prospective study of 598 workers in repetitive jobs found that men who reported shoulder pain 3 years after the initial questionnaire were more statistically likely to report repetitive use of a tool, while women were statically more likely to report use of a vibrating tool and frequent bending forward and/or arm above shoulder activities. A separate two year prospective study of new onset shoulder pain in newly hired employees found the following related factors in a multi-variate analysis: working with hands above the head >15minutes/day; pushing and pulling >= 70 lbs; and lifting with one or two hands >22 lbs.
These studies could considerably distort the actual work related task limits for the shoulder diagnoses as discussed in this guideline as no physical exams were performed and all work estimates were self-reported. Another study matching self-reported work activities with actual observed activities found that trunk flexion, neck flexion and hand above shoulder activities were significantly overestimated by workers.
A prospective population based Finnish study followed a sample of 1286 workers 20 years after an initial study. 883 workers who had no shoulder disorder at baseline completed a standard clinical exam by physicians blinded to their work status. Work factors were obtained through self-report of current or longest occupational exposure. Four work factors increased the risk for physical exam findings: lifting heavy loads, vibration, repetition, and awkward postures. The actual length of time with exposure to these tasks is unknown but thought to reflect the workers' most common occupation exposures. Multiple exposures appeared to increase the risk. When risk factors were separated by gender, heavy lifting was not a significant risk for males 30-45 years; however, it was a significant risk factor for all women. It was not possible to verify the actual exposures of workers in a manner that would allow translation to clear causative definition.
Several studies using better criteria for diagnosis and work related exposures qualified for a level of "some evidence".
A study related blinded magnetic resonance imaging (MRI) findings of rotator cuff tears, partial and full thickness, to work-related activities that had been created based on actual observed activity among three occupations: house painters, car mechanics and machinists. Car mechanics reported the highest torque associated with their job while force was not an important issue for house painters. Housepainters performed work above 90 degrees for 0.9% of the time and car mechanics for 0.6% of the time or approximately 1 hour per day and 1/2 hour per day respectively (this was based on the cumulative seconds a task required the arm to remain at or above 90 degrees). In this study, approximately 18.5 years above-shoulder duties as a painter and 33 years with similar duties as a car mechanic would predict MRI evidence of rotator cuff tears. Because imaging over-estimates actual symptomatic disease, these results may be overestimates of the actual limits for disease process to occur cumulatively. There is some evidence that jobs like that of a house painter, with arm elevation above 90 degrees for more than 30 minutes per day for five or more years, increased the odds of supraspinatus tendinopathy by 27% for each five years of exposure.
A cross-sectional study in Denmark of the same three occupations as the MRI study above reported on 732 men who had physical exams performed by blinded examiners was also studied for physical exam findings of supraspinatus pathology. The study provides some evidence that upper arm elevation above 90° increases the odds of shoulder pain with disability, shoulder pain without disability, and supraspinatus tendinitis, with a greater than fourfold increase when the upper arm is elevated at that level for more than 6% of working time (about 30 minutes per day).
A final case control study comparing those with shoulder pain and MRI positive for supraspinatus tendon tears found a significantly increased incidence of supraspinatus pathology in employment such as plumbers, mechanics , welders and other metal workers. The time above shoulder work needed to qualify for this was 3,195 lifetime hours or 13.3 years of one hour per week for 48 weeks.
There is some evidence that jobs requiring heavy lifting, heavy carrying, above-shoulder work, and handheld vibration, are likely to be associated with an increased risk of symptomatic supraspinatus tendon lesions, either partial or full thickness tears.
Given all of this information, it is reasonable to consider that there is some evidence for the following causative risk factors for shoulder tendon related pathology:
It is also likely that jobs requiring daily heavy lifting at least 10 times per day over the years may contribute to shoulder disorders. In the study relying on self-report, men over 45 and women of any age were more likely to report heavy lifting (probably 20kg or greater) which was significantly related to shoulder findings. Vibration can also be considered an additional risk factor.
Given the lack of multiple high quality studies it is necessary to consider each case individually when dealing with the likelihood of cumulative trauma contributing to or causing shoulder pathology.
* Inability to actively move arm through range-of-motion;
* History of significant trauma, especially blunt trauma or fall from a height;
* History of dislocation;
* Unexplained or persistent shoulder pain over two weeks. (Occult fractures may not be visible on initial x-ray. A follow-up radiograph and/or bone scan may be required to make the diagnosis);
* History or exam suggestive of intravenous drug abuse or osteomyelitis; and
* Pain with swelling and/or ROM limitation localizing to an area of prior fracture, internal fixation, or joint prosthesis.
* Tests include, but are not limited to:
* Complete Blood Count (CBC) with differential can detect infection, blood dyscrasias, and medication side effects;
* Erythrocyte sedimentation rate (ESR), rheumatoid factor, antinuclear antigen (ANA), human leukocyte antigen (HLA), and C-reactive protein can be used to detect evidence of a rheumatologic, infection, or connective tissue disorder;
* Serum calcium, phosphorous, uric acid, alkaline phosphatase, and acid phosphatase can detect metabolic bone disease;
* Liver and kidney function may be performed for prolonged use of antiinflammatory use or other medications requiring monitoring; and
* Analysis of joint aspiration for bacteria, white cell count, red cell count, fat globules, crystalline birefringence and chemistry to evaluate joint effusion.
One diagnostic imaging procedure may provide the same or distinctive information as does another procedure. Therefore, the prudent choice of a single diagnostic procedure, a complement of procedures or a sequence of procedures will optimize diagnostic accuracy; maximize cost effectiveness (by avoiding redundancy), and minimize potential adverse effects to patients.
All diagnostic imaging procedures have a significant percentage of specificity and sensitivity for various diagnoses. None is specifically characteristic of a certain diagnosis. Clinical information obtained by history taking and physical examination should form the basis for selecting an imaging procedure and interpreting its results.
Practitioners should be aware of the radiation doses associated with various procedures and provide appropriate warnings to patients. Coloradans have a background exposure to radiation, and unnecessary CT scans or X-rays increase the lifetime risk of cancer death.
When a diagnostic procedure, in conjunction with clinical information, can provide sufficient information to establish an accurate diagnosis, the second diagnostic procedure will become a redundant procedure. At the same time, a subsequent diagnostic procedure can be a complementary diagnostic procedure if the first or preceding procedures, in conjunction with clinical information, cannot provide an accurate diagnosis. Usually, preference of a procedure over others depends upon availability, a patient's tolerance, and/or the treating practitioner's familiarity with the procedure.
Diagnostic imaging may be useful in resolving the diagnostic uncertainties that remain after the clinical examination. Even a thorough history and physical examination may not define the shoulder pathology that produces the patient's symptoms. Therefore, additional investigations should be considered as an accepted part of the patient evaluation when surgery is being considered or clarification of diagnosis is necessary to formulate a treatment plan.
In general, the high field, conventional, MRI provides better resolution than a low field scan. A lower field scan may be indicated when a patient cannot fit into a high field scanner or is too claustrophobic despite sedation. Inadequate resolution on the first scan may require a second MRI using a different technique. All questions in this regard should be discussed with the MRI center and/or radiologist.
MRI provides excellent soft tissue detail, but interpretation of the image is problematic and depends on operator skill. There is good evidence that MRI, MRA, and US are all accurate at identifying full thickness rotator cuff tears in patients whose history and physical examination makes them candidates for possible surgery, and that there is no evidence to suggest that any of the three is superior for this purpose. There is inadequate evidence about the comparative accuracy in partial thickness tears (due to the way that clinically very different categories were combined in the analysis, leading to equivocal interpretation of the findings).
Bone scanning is more sensitive but less specific than MRI. It is useful for the investigation of trauma, infection, stress fracture, occult fracture, Complex Regional Pain Syndrome, and suspected neoplastic conditions of the upper extremity.
If there is a concern regarding needle placement, sonography or fluoroscopy may be used. The subacromial injection may also be repeated by a specialist skilled in this procedure to confirm the diagnosis. Please refer to Section F.4.f. Subacromial Injections, for more information.
In general, these diagnostic procedures are complementary to imaging procedures such as CT, MRI, and/or myelography or diagnostic injection procedures. Electrodiagnostic studies may provide useful, correlative neuropathophysiological information that would not be obtainable from standard radiologic studies.
Portable Automated Electrodiagnostic Device (also known as Surface EMG) is not a substitute for conventional EMG/NCS testing in clinical decision-making, and therefore, is not recommended.
Diagnostic testing procedures may be useful for patients with symptoms of depression, delayed recovery, chronic pain, recurrent painful conditions, disability problems, and for pre-operative evaluation as well as a possible predictive value for post-operative response. Psychological testing should provide differentiation between pre-existing depression versus injury-caused depression, as well as post-traumatic stress disorder.
Formal psychological or psychosocial evaluation should be performed on patients not making expected progress within 6 to 12 weeks following injury and whose subjective symptoms do not correlate with objective signs and tests. In addition to the customary initial exam, the evaluation of the injured worker should specifically address the following areas:
This information should provide clinicians with a better understanding of the patient, thus allowing for more effective rehabilitation.
The evaluation will determine the need for further psychosocial interventions, and in those cases, a Diagnostic Statistical Manual (DSM) of Mental Disorders diagnosis should be determined and documented. An individual with a PhD, PsyD, or Psychiatric MD/DO credentials should perform initial evaluations, which are generally completed within one to two hours. A professional fluent in the primary language of the patient is strongly preferred. When such a provider is not available, services of a professional language interpreter must be provided. When issues of chronic pain are identified, the evaluation should be more extensive and follow testing procedures as outlined in the Division's Chronic Pain Disorder Medical Treatment Guidelines.
* Frequency: One time visit for evaluation. If psychometric testing is indicated as a portion of the initial evaluation, time for such testing should not exceed an additional two hours of professional time.
* Frequency: One time for evaluation, one for mid-treatment assessment, and one at final evaluation.
There is some evidence that an FCE fails to predict which injured workers with chronic low back pain will have sustained return to work. Another cohort study concluded that there was a significant relation between FCE information and return to work, but the predictive efficiency was poor. There is some evidence that time off work and gender are important predictors for return to work, and floor-to-waist lifting may also help predict return to work, however, the strength of that relationship has not been determined.
A full review of the literature reveals that there is no evidence to support the use of FCEs to prevent future injuries. There is some evidence in chronic low back pain patients that (1) FCE task performance is weakly related to time on disability and time for claim closure and (2) even claimants who fail on numerous physical performance FCE tasks may be able to return to work.
Full FCEs are rarely necessary. In many cases, a work tolerance screening or return to work performance will identify the ability to perform the necessary job tasks. There is some evidence that a short form FCE reduced to a few tests produces a similar predictive quality compared to the longer 2-day version of the FCE regarding length of disability and recurrence of a claim after return to work.
When an FCE is being used to determine return to a specific jobsite, the provider is responsible for fully understanding the physical demands and the duties of the job the worker is attempting to perform. A jobsite evaluation is usually necessary. A job description should be reviewed by the provider and FCE evaluator prior to having this evaluation performed. FCEs cannot be used in isolation to determine work restrictions. It is expected that the FCE may differ from both self-report of abilities and pure clinical exam findings in chronic pain patients. The length of a return to work evaluation should be based on the judgment of the referring physician and the provider performing the evaluation. Since return to work is a complicated multidimensional issue, multiple factors beyond functional ability and work demands should be considered and measured when attempting determination of readiness or fitness to return to work. FCEs should not be used as the sole criteria to diagnose malingering.
* Frequency: Can be used:
A jobsite evaluation may include observation and instruction of how work is done, what material changes (desk, chair) should be made, and determination of readiness to return to work.
Requests for a jobsite evaluation should describe the expected goals for the evaluation. Goals may include, but are not limited to the following:
* Frequency: One time with additional visits as needed for follow-up visits per jobsite.
The vocational assessment should provide valuable guidance in the determination of future rehabilitation program goals. It should clarify rehabilitation goals, which optimize both patient motivation and utilization of rehabilitation resources. The physician should have identified the expected permanent limitation(s) prior to the assessment. Declaration of MMI should not be delayed solely due to lack of attainment of a vocational assessment.
* Frequency: One time with additional visits as needed for follow-up.
* Frequency: One time for initial screen. May monitor improvements in strength every 3 to 4 weeks up to a total of 6 visits.
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 bone displacement:
Type I Sprain of the AC ligament and capsule; x-ray usually normal.
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.
Type III Dislocation of the clavicle above the acromion with complete tear of the AC ligament and/or CC ligaments; abnormal stress x-rays.
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.
Type V Dislocation consisting of complete separation of the AC and CC
ligaments and dislocation of the acromioclavicular joint with a large coracoclavicular interval.
Type VI Dislocation consisting of a displaced clavicle that penetrates inferior to the coracoid.
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 Section E.9. Impingement Syndrome.
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.
Plain x-rays may include:
Patients who have Type III AC joint dislocations are frequently treated surgically in order achieve better cosmetic and radiologic results; however, they will usually recover well with non-surgical treatment. 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 orthopedic 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.
Informed decision making should be documented for all invasive procedures. This must include a thorough discussion of the pros and cons of the procedure and the possible complications as well as the natural history of the identified diagnosis. Since most patients with the most common conditions will improve significantly over time, without invasive interventions, patients must be able to make well-informed decisions regarding their treatment.
With a Type IV-VI AC joint injury, an orthopedic surgical consultation is recommended.
Smoking may affect soft tissue healing through tissue hypoxia. Patients should be strongly encouraged to stop smoking and be provided with appropriate counseling by the physician. If a treating physician recommends a specific smoking cessation program peri-operatively, this should be covered by the insurer. Physicians may monitor smoking cessation with laboratory tests such as cotinine levels. The surgeon will make the final determination as to whether smoking cessation is required prior to surgery.
AC joint stabilization and ligament reconstruction. When hooks or pins are used, removal may be required at 6-12 weeks.
Continuous interscalene blocks (ISB) are not recommended. For more information, please refer to Section G.7. Interscalene Anesthesia.
An individualized rehabilitation program will be based upon communication between the surgeon and the therapist using the treatments found in Section F. Therapeutic Procedures - Non-operative.
Early therapeutic rehabilitation interventions are recommended to maintain ROM with progressive strengthening.
* Frequency: Suggested frequency pattern is 3 to 5 times per week for the first 2 weeks, 2 - 3 times per week for the following 2 weeks, then 1 to 2 times per week. The exact frequency per week will depend on the severity and the recommendation of the surgeon.
* Optimum Duration: 6 to 8 weeks with progression to home exercise and/or aquatic therapy.
* 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.
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. The injured worker should adhere to the written return to work restrictions not only in the workplace, but at home and for 24 hours a day.
Idiopathic adhesive capsulitis usually occurs spontaneously without any specific inciting injury. This is not normally a work-related condition. The following is limited to a description of the condition, therefore there are no recommendations for treatment. It occurs most frequently in diabetic, middle aged patients. This type of adhesive capsulitis is likely to remit over time. Other risk factors may include thyroid problems, cervical dysfunctions, and other shoulder injuries. It may be useful to order laboratory tests to screen for diabetes.
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:
Stage 1-Freezing - Consists of acute pain with some limitation in range-of-motion; generally lasting 2 to 9 months.
Stage 2-Frozen - Characterized by progressive stiffness, loss of passive range-of-motion, muscular atrophy, and decreased pain; generally lasting an additional 4 to 9 months beyond Stage 1.
Stage 3-Thawing - 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.
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 or at the acromioclavicular joint. Pain is often worse at night, with difficulty sleeping on the involved side particularly in stage 1. Motion, including passive external rotation, is restricted and painful. The common capsular pattern of shoulder range of motion limitation ranges from: external rotation with the highest limitation, followed by abduction, then flexion, internal rotation, with extension presenting with the lowest level of limitation.
In all stages patients may also experience peri-scapular and neck pain from compensatory scapular thoracic motion. It is estimated that 7-15% of patients may have permanent loss of motion, which is usually not functionally disabling.
Disorders may include:
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 the 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. Distal tendon rupture may decrease strength of supination.
Onset of symptoms, date, mechanism of onset, occupational history and current job requirements should be correlated with the intensity, character, duration and frequency of associated pain and discomfort. Occupational disorders of the biceps tendon may accompany scapulothoracic dyskinesis, rotator cuff injury, AC joint separation, subdeltoid bursitis, shoulder instability or other shoulder pathology. Symptoms should be exacerbated or provoked by work that activates 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.
Acute trauma to the long head of the biceps tendon of the shoulder girdle may also give rise to occupational injury of the biceps tendon. Those with distal biceps rupture may report an acute event related to an unexpected extension force applied to a flexed elbow. The injury is more common in those who smoke and in the dominant arm.
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.
* Yergason's sign.
* Speed's test.
* Ludington's test.
Therapeutic Procedures - Non-operative, 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.
* Time to Produce Effect: 4 sessions.
* Frequency: 2 times per week for the first 2 weeks and 1 time per week or less thereafter.
* Optimum Duration: 8 to 12 sessions.
* Maximum Duration: 20 sessions per year.
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.
Informed decision making should be documented for all invasive procedures. This must include a thorough discussion of the pros and cons of the procedure and the possible complications, as well as the natural history of the identified diagnosis. Since most patients with the most common conditions will improve significantly over time, without invasive interventions, patients must be able to make well-informed decisions regarding their treatment.
Smoking may affect soft tissue healing through tissue hypoxia. Patients should be strongly encouraged to stop smoking and be provided with appropriate counseling by the physician. If a treating physician recommends a specific smoking cessation program peri-operatively, this should be covered by the insurer. Physicians may monitor smoking cessation with laboratory tests such as cotinine levels. The surgeon will make the final determination as to whether smoking cessation is required prior to surgery.
Complications depend on the procedure. Distal repairs may injure the lateral antebrachial cutaneous nerve or the posterior interosseous nerve or cause heterotopic ossification. Complications may be higher for chronic repairs. Postoperative fracture, tendon rupture, complex regional pain syndrome, and wound infections have been reported.
There is some evidence that, in the setting of repairable rotator cuff tears with lesions of the long head of the biceps, there is little difference in functional outcome at two years between tenotomy and tenotomy accompanied by tenodesis. Because tenodesis is a more complex procedure and requires more time off work, it is not recommended.
Continuous interscalene blocks (ISB) are not recommended. For more information, please refer to Section G.7. Interscalene Anesthesia.
An individualized rehabilitation program will be based upon communication between the surgeon and the therapist using the treatments found in Section F. Therapeutic Procedures - Non-operative. Therapy may include the following:
* It is reasonable to restrict ROM for 2 months for tenodesis and distal biceps tendon repair. Extension may gradually increase over 6 weeks. Early loading of the tendon should be avoided. Strengthening is usually delayed until 4 to 6 weeks post-op. 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).
* Frequency: Suggested frequency pattern is 3 to 5 times per week for the first 2 weeks, 2 - 3 times per week for the following 2 weeks, then 1 to 2 times per week. The exact frequency per week will depend on the severity and the recommendation of the surgeon.
* Optimum Duration: 6 to 8 weeks with progression to home exercise and/or aquatic therapy.
* 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.
* 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. The injured worker should adhere to the written return to work restrictions not only in the workplace, but at home and for 24 hours a day.
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:
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 6 weeks following injury or description of symptoms. Studies performed early may be falsely negative and usually require repeat testing 3 to 4 weeks after the original injury. Thus, early testing is not generally recommended. If the symptoms have been present for longer than 3 to 4 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. During the nerve study, 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.
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 cords which ultimately form the peripheral nerves of the arm.
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 2 to 3 years.
* Evidence of trauma or deformity;
* Identification of sensory loss and demonstration of weakness which relates to the severity and anatomy of the injury to the brachial plexus;
* Atrophy; and/or
* Pain with recreation of the motions related to the mechanism of injury.
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.
In closed injuries, if functional deficits continue to be documented after 3 to 4 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.
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.
Informed decision making should be documented for all invasive procedures. This must include a thorough discussion of the pros and cons of the procedure and the possible complications as well as the natural history of the identified diagnosis. Since most patients with the most common conditions will improve significantly over time, without invasive interventions, patients must be able to make well-informed decisions regarding their treatment.
Smoking may affect soft tissue healing through tissue hypoxia. Patients should be strongly encouraged to stop smoking and be provided with appropriate counseling by the physician. If a treating physician recommends a specific smoking cessation program peri-operatively, this should be covered by the insurer. Physicians may monitor smoking cessation with laboratory tests such as cotinine levels. The surgeon will make the final determination as to whether smoking cessation is required prior to surgery.
* Exploration and repair.
Continuous interscalene blocks (ISB) are not recommended. For more information, please refer to Section G.7. Interscalene Anesthesia.
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 and progressive strengthening.
* Frequency: Suggested frequency pattern is 3 to 5 times per week for the first 2 weeks, 2 - 3 times per week for the following 2 weeks, then 1 to 2 times per week. The exact frequency per week will depend on the severity and the recommendation of the surgeon.
* Optimum Duration: 6 to 8 weeks with progression to home exercise and/or aquatic therapy.
* 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.
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. The injured worker should adhere to the written return to work restrictions not only in the workplace, but at home and for 24 hours a day.
This nerve is derived from the 5th and 6th 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.
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 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. Quadrilateral space syndrome may cause pain in the axillary nerve region with abduction, external rotation, and forward flexion in the scapular plane. This syndrome is most commonly reported in young males and has been associated with overhead sports.
Surgical procedures are usually not necessary, since most injuries to the axillary nerve are due to stretch and/or traction and recover within 3 to 6 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 3 to 4 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% of patients recover with conservative treatment. Indications may include a space occupying lesion or 3-6 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.
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.
Informed decision making should be documented for all invasive procedures. This must include a thorough discussion of the pros and cons of the procedure and the possible complications as well as the natural history of the identified diagnosis. Since most patients with the most common conditions will improve significantly over time, without invasive interventions, patients must be able to make well-informed decisions regarding their treatment.
Smoking may affect soft tissue healing through tissue hypoxia. Patients should be strongly encouraged to stop smoking and be provided with appropriate counseling by the physician. If a treating physician recommends a specific smoking cessation program peri-operatively, this should be covered by the insurer. Physicians may monitor smoking cessation with laboratory tests such as cotinine levels. The surgeon will make the final determination as to whether smoking cessation is required prior to surgery.
* Exploration and repair.
Continuous interscalene blocks (ISB) are not recommended. For more information, please refer to Section G.7. Interscalene Anesthesia.
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 and progressive strengthening.
* Frequency: Suggested frequency pattern is 3 to 5 times per week for the first 2 weeks, 2 - 3 times per week for the following 2 weeks, then 1 to 2 times per week. The exact frequency per week will depend on the severity and the recommendation of the surgeon.
* Optimum Duration: 6 to 8 weeks with progression to home exercise and/or aquatic therapy.
* 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.
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. The injured worker should adhere to the written return to work restrictions not only in the workplace, but at home and for 24 hours a day.
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.
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.
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 4 to 6 months of active participation in non-operative therapy. Surgical consultation should occur at 3 to 4 months post-injury for these patients. In most cases, function will recover with conservative therapy in 6 to 12 months.
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 postoperatively.
Informed decision making should be documented for all invasive procedures. This must include a thorough discussion of the pros and cons of the procedure and the possible complications as well as the natural history of the identified diagnosis. Since most patients with the most common conditions will improve significantly over time, without invasive interventions, patients must be able to make well-informed decisions regarding their treatment.
Smoking may affect soft tissue healing through tissue hypoxia. Patients should be strongly encouraged to stop smoking and be provided with appropriate counseling by the physician. If a treating physician recommends a specific smoking cessation program peri-operatively, this should be covered by the insurer. Physicians may monitor smoking cessation with laboratory tests such as cotinine levels. The surgeon will make the final determination as to whether smoking cessation is required prior to surgery.
* Exploration and repair.
* Muscle transfer.
* Scapular fixation is rarely done and requires a second orthopedic opinion.
Continuous interscalene blocks (ISB) are not recommended. For more information, please refer to Section G.7. Interscalene Anesthesia.
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.
* Frequency: Suggested frequency pattern is 3 to 5 times per week for the first 2 weeks, 2 - 3 times per week for the following 2 weeks, then 1 to 2 times per week. The exact frequency per week will depend on the severity and the recommendation of the surgeon.
* Optimum Duration: 6 to 8 weeks with progression to home exercise and/or aquatic therapy.
* 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.
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. The injured worker should adhere to the written return to work restrictions not only in the workplace, but at home and for 24 hours a day.
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.
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, malposition 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.
* EMG and Nerve Conduction Studies six 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.
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 4 to 6 months of active patient participation in non-operative therapy. Surgical consultation should occur at 3 to 4 months post-injury for these patients. In most cases, function will recover with conservative therapy in 6 to 12 months.
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 postoperatively.
Informed decision making should be documented for all invasive procedures. This must include a thorough discussion of the pros and cons of the procedure and the possible complications as well as the natural history of the identified diagnosis. Since most patients with the most common conditions will improve significantly over time, without invasive interventions, patients must be able to make well-informed decisions regarding their treatment.
Smoking may affect soft tissue healing through tissue hypoxia. Patients should be strongly encouraged to stop smoking and be provided with appropriate counseling by the physician. If a treating physician recommends a specific smoking cessation program peri-operatively, this should be covered by the insurer. Physicians may monitor smoking cessation with laboratory tests such as cotinine levels. The surgeon will make the final determination as to whether smoking cessation is required prior to surgery.
* Exploration and repair.
Continuous interscalene blocks (ISB) are not recommended. For more information, please refer to Section G.7. Interscalene Anesthesia.
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.
* Frequency: Suggested frequency pattern is 3 to 5 times per week for the first 2 weeks, 2 - 3 times per week for the following 2 weeks, then 1 to 2 times per week. The exact frequency per week will depend on the severity and the recommendation of the surgeon.
* Optimum Duration: 6 to 8 weeks with progression to home exercise and/or aquatic therapy.
* 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.
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. The injured worker should adhere to the written return to work restrictions not only in the workplace, but at home and for 24 hours a day.
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.
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.
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 4 to 6 months of active participation in non-operative therapy. Surgical consultation should occur at 3 to 4 months post-injury for these patients. In most cases, function will recover with conservative therapy in 6 to 12 months.
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.
Informed decision making should be documented for all invasive procedures. This must include a thorough discussion of the pros and cons of the procedure and the possible complications as well as the natural history of the identified diagnosis. Since most patients with the most common conditions will improve significantly over time, without invasive interventions, patients must be able to make well-informed decisions regarding their treatment.
Smoking may affect soft tissue healing through tissue hypoxia. Patients should be strongly encouraged to stop smoking and be provided with appropriate counseling by the physician. If a treating physician recommends a specific smoking cessation program peri-operatively, this should be covered by the insurer. Physicians may monitor smoking cessation with laboratory tests such as cotinine levels. The surgeon will make the final determination as to whether smoking cessation is required prior to surgery.
* Exploration and repair.
* Tendon transfer - Trapezius, levator scapular, rhomboids.
* Scapular fixation for cases with heavy work demands and failed previous procedures.
Continuous interscalene blocks (ISB) are not recommended. For more information, please refer to Section G.7. Interscalene Anesthesia.
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 scapula stabilizers.
* Frequency: Suggested frequency pattern is 3 to 5 times per week for the first 2 weeks, 2 - 3 times per week for the following 2 weeks, then 1 to 2 times per week. The exact frequency per week will depend on the severity and the recommendation of the surgeon.
* Optimum Duration: 6 to 8 weeks with progression to home exercise and/or aquatic therapy.
* 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.
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. The injured worker should adhere to the written return to work restrictions not only in the workplace, but at home and for 24 hours a day.
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.
Supraclavicular trauma, stretch, and friction through the suprascapular notch or against the transverse ligament at the notch, or a fall on an outstretched arm can cause injury 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 1/3 of volleyball players in one study had asymptomatic infraspinatus atrophy secondary to nerve damage. Pain may be worsened by cross-body adduction and internal rotation. Exacerbation or fatigue with overhead throwing activities is common. 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 large rotator cuff tear. Symptoms include deep aching pain at the top of the shoulder.
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 3 to 6 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. (Refer to Section B.9 Surgical Interventions)
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.
Informed decision making should be documented for all invasive procedures. This must include a thorough discussion of the pros and cons of the procedure and the possible complications as well as the natural history of the identified diagnosis. Since most patients with the most common conditions will improve significantly over time, without invasive interventions, patients must be able to make well-informed decisions regarding their treatment.
Smoking may affect soft tissue healing through tissue hypoxia. Patients should be strongly encouraged to stop smoking and be provided with appropriate counseling by the physician. If a treating physician recommends a specific smoking cessation program peri-operatively, this should be covered by the insurer. Physicians may monitor smoking cessation with laboratory tests such as cotinine levels. The surgeon will make the final determination as to whether smoking cessation is required prior to surgery.
Continuous interscalene blocks (ISB) are not recommended. For more information, please refer to Section G.7. Interscalene Anesthesia.
An individualized rehabilitation program based upon communication between the surgeon and the therapist using the treatments found in Section F. Therapeutic Procedures - Non-operative. Treatment may include the following:
Early therapeutic rehabilitation interventions are recommended to maintain ROM with progressive strengthening.
* Frequency: Suggested frequency pattern is 3 to 5 times per week for the first 2 weeks, 2 - 3 times per week for the following 2 weeks, then 1 to 2 times per week. The exact frequency per week will depend on the severity and the recommendation of the surgeon.
* Optimum Duration: 6 to 8 weeks with progression to home exercise and/or aquatic therapy.
* 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.
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. The injured worker should adhere to the written return to work restrictions not only in the workplace, but at home and for 24 hours a day.
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.
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.
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. Bursitis is often a sequela of an occupational strain or tendinopathy in the absence of other mitigating factors.
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.
There is some evidence that in patients with subacromial bursitis or subacromial impingement syndrome, a single ultrasound-guided subacromial injection of botulinum toxin B may be more effective than a steroid injection in pain reduction and shoulder function 3 months after the injection, but the usefulness of repeated botulinum toxin injections is not known.
Surgery is not commonly indicated for bursitis. Refer to impingement syndrome and other related diagnoses in Section E. Specific Diagnosis Testing and Treatment Procedures.
Continuous interscalene blocks (ISB) are not recommended. For more information, please refer to Section G.7. Interscalene Anesthesia.
Calcific tendinitis 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 pain-producing symptoms in some adults (7.5% to 20%). The calcific 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, and by impingement signs. After resorption, granulation tissue replaces the area of calcification.
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.
Symptomatic calcific tendinitis does not have a known direct occupational relationship. It is thought to be related to degeneration of the supraspinatus tendon. This can be aggravated by specific work exposures.
Surgical procedure is rarely necessary for this condition. When functional deficits interfere with activities of daily living and/or job duties after 3 to 4 months of active patient participation in non-operative therapy, it may be considered. 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.
Informed decision making should be documented for all invasive procedures. This must include a thorough discussion of the pros and cons of the procedure and the possible complications as well as the natural history of the identified diagnosis. Since most patients with the most common conditions will improve significantly over time, without invasive interventions, patients must be able to make well-informed decisions regarding their treatment.
Smoking may affect soft tissue healing through tissue hypoxia. Patients should be strongly encouraged to stop smoking and be provided with appropriate counseling by the physician. If a treating physician recommends a specific smoking cessation program peri-operatively, this should be covered by the insurer. Physicians may monitor smoking cessation with laboratory tests such as cotinine levels. The surgeon will make the final determination as to whether smoking cessation is required prior to surgery.
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 3 to 6 months.
Continuous interscalene blocks (ISB) are not recommended. For more information, please refer to Section G.7. Interscalene Anesthesia.
Individualized rehabilitation programs are based upon communication between the surgeon and the therapist using the treatments found in Section F. Therapeutic Procedures - Non-operative. Treatment may include the following:
* Frequency: Suggested frequency pattern is 3 to 5 times per week for the first 2 weeks, 2 - 3 times per week for the following 2 weeks, then 1 to 2 times per week. The exact frequency per week will depend on the severity and the recommendation of the surgeon.
* Optimum Duration: 6 to 8 weeks with progression to home exercise and/or aquatic therapy.
* 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.
Work restrictions should be evaluated every 4 to 6 weeks during postoperative 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.
There are five common types of shoulder fractures; each type is addressed separately and in the order of most frequent occurrence.
* Pain along the clavicle;
* Abrasions on the chest wall, clavicle or shoulder;
* Deformities in the above regions; and/or
* Pain with palpation and motion at the shoulder joint area.
All female patients over 65 and male patients over 70 should be screened for osteoporosis. Patients who have been on prednisone at a dose of 5mg or more for more than 3 months should be evaluated for glucocorticoid induced osteoporosis. An osteoporosis evaluation may be considered for younger post-menopausal or menopausal in transition women, for patients on medications that can cause bone loss, or patients who have suffered a fracture due to a low-impact fall or with minimum to no provocation. Risk factors for osteoporosis include current smoking, alcohol 3 or more drinks per day, low body mass index, rheumatoid arthritis, and other associated conditions such as hypogonadism, type 1 diabetes. Vitamin D levels may also be ordered. Patients may require additional medication based on bone mineral density testing. All patients should be encouraged to participate in regular weight-bearing and muscle-strengthening exercise, eat a diet rich in fruits and vegetables, and avoid excessive alcohol intake. Long-term care for osteoporosis is not covered under workers compensation even though it may be discovered due to an injury-related acute fracture.
Completely displaced midclavicular fractures and those with clavicular shortening of 15 mm or more, may be an indication for surgical repair.
There is strong evidence that operative treatment of displaced midshaft clavicular fractures lead to lower rates of nonunion and symptomatic malunion compared to treatment with a sling, but patients with preferences for nonoperative treatment may be counseled that they will probably do well, even though their fractures may not heal as well. There is inadequate evidence that patient-reported functional outcomes are significantly better for surgery than for conservative treatment at one year. A two year follow-up of one of the studies showed no change in functional status.
There is some evidence that open reduction and internal fixation of comminuted midshaft clavicle fractures leads to less pain and disability at one year than closed treatment of the same fractures.
Surgical correction is generally not necessary for midshaft fractures but may be considered based on severe displacement or presence of risk factors.
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.
Informed decision making should be documented for all invasive procedures. This must include a thorough discussion of the pros and cons of the procedure and the possible complications as well as the natural history of the identified diagnosis. Since most patients with the most common conditions will improve significantly over time, without invasive interventions, patients must be able to make well-informed decisions regarding their treatment.
There is some evidence that tobacco use is also a risk factor for poor fracture healing; therefore it is recommended that insurers cover a smoking cessation program peri-operatively. If a treating physician recommends a specific smoking cessation program peri-operatively, this should be covered by the insurer. Physicians may monitor smoking cessation with laboratory tests such as cotinine levels. The surgeon will make the final determination as to whether smoking cessation is required prior to surgery.
Continuous interscalene blocks (ISB) are not recommended. For more information, please refer to Section G.7. Interscalene Anesthesia.
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.
* Pain in the upper arm;
* Swelling and bruising in the upper arm, shoulder and chest wall;
* Abrasions about the shoulder; and/or
* Pain with any attempted passive or active shoulder motion.
* Time to Produce Effect: 6 sessions.
* Optimum Duration: 9 sessions.
* Maximum Duration: 12 to 24 sessions.
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.
Informed decision making should be documented for all invasive procedures. This must include a thorough discussion of the pros and cons of the procedure and the possible complications as well as the natural history of the identified diagnosis. Since most patients with the most common conditions will improve significantly over time, without invasive interventions, patients must be able to make well-informed decisions regarding their treatment.
There is some evidence that tobacco use is also a risk factor for poor fracture healing; therefore it is recommended that insurers cover a smoking cessation program peri-operatively. If a treating physician recommends a specific smoking cessation program peri-operatively, this should be covered by the insurer. Physicians may monitor smoking cessation with laboratory tests such as cotinine levels. The surgeon will make the final determination as to whether smoking cessation is required prior to surgery.
Percutaneous or internal fixation of the fracture or arthroplasty.
Continuous interscalene blocks (ISB) are not recommended. For more information, please refer to Section G.7. Interscalene Anesthesia.
* Deformity of the arm;
* Bruising and swelling; and/or
* Possible sensory and/or motor dysfunction of the radial nerve.
* Indications for operative care would include:
* Open fracture;
* Associated forearm or elbow fracture (i.e. the floating elbow injury);
* Burned upper extremity;
* Associated paraplegia;
* Multiple injuries (polytrauma);
* A radial nerve palsy which presented after closed reduction;
* Pathologic fracture related to an occupational injury; and/or
* Inability to perform basic activities of daily living while following conservative care.
* Non-union of conservatively treated fractures (closed fracture treatment for 6-8 weeks) is an indication for open reduction with internal fixation and plating with bone graft. This procedure has good functional outcomes and greater than 90% rate of union.
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.
Informed decision making should be documented for all invasive procedures. This must include a thorough discussion of the pros and cons of the procedure and the possible complications as well as the natural history of the identified diagnosis. Since most patients with the most common conditions will improve significantly over time, without invasive interventions, patients must be able to make well-informed decisions regarding their treatment.
There is some evidence that tobacco use is also a risk factor for poor fracture healing; therefore it is recommended that insurers cover a smoking cessation program peri-operatively. If a treating physician recommends a specific smoking cessation program peri-operatively, this should be covered by the insurer. Physicians may monitor smoking cessation with laboratory tests such as cotinine levels. The surgeon will make the final determination as to whether smoking cessation is required prior to surgery.
* A broad plate and screws; and/or
* Intramedullary rodding with or without cross-locking screws may be used but is associated with increased shoulder pain;
No randomized trials of rh-BMP2 for humerus fractures have been found at the time of this guideline publication. Currently, there is a paucity of evidence for its use in fractures of the upper extremity.
Continuous interscalene blocks (ISB) are not recommended. For more information, please refer to Section G.7. Interscalene Anesthesia.
An individualized rehabilitation program based upon communication between the surgeon and the therapist using the treatments found in Section F. Therapeutic Procedures - Non-operative. Treatment may include the following:
Early therapeutic rehabilitation interventions are recommended to maintain ROM and progressive strengthening.
* Frequency: Suggested frequency pattern is 3 to 5 times per week for the first 2 weeks, 2 - 3 times per week for the following 2 weeks, then 1 to 2 times per week. The exact frequency per week will depend on the severity and the recommendation of the surgeon.
* Optimum Duration: 6 to 8 weeks with progression to home exercise and/or aquatic therapy.
* 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.
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.
* Pain about the shoulder and thorax;
* Bruising and abrasions;
* Possibility of associated humeral or rib fractures; and/or
* Vascular problems (pulse evaluation and Doppler examination).
* Trauma x-ray series - AP view, axillary view, and a lateral view in the plane of the scapula.
* Arteriography if a vascular injury is suspected.
* Electromyographic exam if nerve injuries are noted.
* CT tomography with holographic reconstruction is a valuable pre-operative evaluative tool.
* Displaced acromial fractures.
* Displaced glenoid fractures.
* Displaced scapular body fractures in rare circumstances.
* Displaced fractures of the scapular neck and the ipsilateral clavicle.
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.
Informed decision making should be documented for all invasive procedures. This must include a thorough discussion of the pros and cons of the procedure and the possible complications as well as the natural history of the identified diagnosis. Since most patients with the most common conditions will improve significantly over time, without invasive interventions, patients must be able to make well-informed decisions regarding their treatment.
There is some evidence that tobacco use is also a risk factor for poor fracture healing; therefore it is recommended that insurers cover a smoking cessation program peri-operatively. If a treating physician recommends a specific smoking cessation program peri-operatively, this should be covered by the insurer. Physicians may monitor smoking cessation with laboratory tests such as cotinine levels. The surgeon will make the final determination as to whether smoking cessation is required prior to surgery.
Continuous interscalene blocks (ISB) are not recommended. For more information, please refer to Section G.7. Interscalene Anesthesia.
An individualized rehabilitation program based upon communication between the surgeon and the therapist using the appropriate therapeutic procedures as indicated in Section F. Therapeutic Procedures - Non-operative. Treatment may include the following:
* Frequency: Suggested frequency pattern is 3 to 5 times per week for the first 2 weeks, 2 - 3 times per week for the following 2 weeks, then 1 to 2 times per week. The exact frequency per week will depend on the severity and the recommendation of the surgeon.
* Optimum Duration: 8 to 10 weeks with progression to home exercise and/or aquatic therapy.
* 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.
* Dysphagia and shortness of breath which requires emergency reduction.
* Pain at the sternoclavicular area;
* Abrasions on the chest wall, clavicle and shoulder;
* Deformities in the above regions; and/or
* Pain with palpation and motion at the sternoclavicular joint area.
* Failure of closed reduction, or recurrent dislocation.
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.
Informed decision making should be documented for all invasive procedures. This must include a thorough discussion of the pros and cons of the procedure and the possible complications as well as the natural history of the identified diagnosis. Since most patients with the most common conditions will improve significantly over time, without invasive interventions, patients must be able to make well-informed decisions regarding their treatment.
There is some evidence that tobacco use is also a risk factor for poor fracture healing; therefore it is recommended that insurers cover a smoking cessation program peri-operatively. If a treating physician recommends a specific smoking cessation program peri-operatively, this should be covered by the insurer. Physicians may monitor smoking cessation with laboratory tests such as cotinine levels. The surgeon will make the final determination as to whether smoking cessation is required prior to surgery.
* Reduction with soft tissue reconstruction is preferred.
* Internal fixation - significant complications can occur with use of pins due to migration into other tissues.
Continuous interscalene blocks (ISB) are not recommended. For more information, please refer to Section G.7. Interscalene Anesthesia.
An individualized rehabilitation program based upon communication between the surgeon and the therapist. This program would begin with a shoulder immobilizer for 4 to 6 weeks, followed by therapeutic rehabilitation interventions.
* Frequency: Suggested frequency pattern is 3 to 5 times per week for the first 2 weeks, 2 - 3 times per week for the following 2 weeks, then 1 to 2 times per week. The exact frequency per week will depend on the severity and the recommendation of the surgeon.
* Optimum Duration: 6 to 8 weeks with progression to home exercise and/or aquatic therapy.
* 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.
Capsular contraction or stiffness may occur secondary to trauma or surgery. Therapy and additional treatment recommendations for other specific diagnoses should be strictly followed to decrease the occurrence of secondary restricted ROM.
There should be some history of work related injury or surgery resulting in decreased range of motion.
Restricted active and passive glenohumeral ROM is often uniplanar. Posterior capsule tightness often presents with loss of internal rotation. The contralateral asymptomatic limb is useful to help diagnose ROM loss. A 20 degree difference is usually significant.
Address the goal to restore and maintain function and may include the following:
* Time to Produce Effect for active therapy: 8 sessions.
* Frequency: 2 times per week for the first 2 weeks and 2 or less thereafter per week.
* Optimum Duration: 12 to 14 sessions.
* 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.
Surgery may be considered when functional deficits interfere with activities of daily living and/or job duties after 3 to 6 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.
Contraindications to 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.
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.
Informed decision making should be documented for all invasive procedures. This must include a thorough discussion of the pros and cons of the procedure and the possible complications as well as the natural history of the identified diagnosis. Since most patients with the most common conditions will improve significantly over time, without invasive interventions, patients must be able to make well-informed decisions regarding their treatment.
Smoking may affect soft tissue healing through tissue hypoxia. Patients should be strongly encouraged to stop smoking and be provided with appropriate counseling by the physician. If a treating physician recommends a specific smoking cessation program peri-operatively, this should be covered by the insurer. Physicians may monitor smoking cessation with laboratory tests such as cotinine levels. The surgeon will make the final determination as to whether smoking cessation is required prior to surgery.
Manipulation under anesthesia may be done in combination with steroid injection or capsular release.
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.
Continuous interscalene blocks (ISB) are not recommended. For more information, please refer to Section G.7. Interscalene Anesthesia.
An individualized rehabilitation program based upon communication between the surgeon and the therapist using the treatments found in Section F. Therapeutic Procedures - Non-operative.
Early therapeutic rehabilitation interventions are recommended to maintain ROM and should progress to strengthening exercises.
* Frequency: Suggested frequency pattern is 3 to 5 times per week for the first 2 weeks, 2 - 3 times per week for the following 2 weeks, then 1 to 2 times per week. The exact frequency per week will depend on the severity and the recommendation of the surgeon.
* Optimum Duration: 6 to 8 weeks with progression to home exercise and/or aquatic therapy.
* 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.
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. The injured worker should adhere to the written return to work restrictions not only in the workplace, but at home and for 24 hours a day.
Patient should be approaching full recovery for this condition within 8 to 12 weeks post-operatively; however, co-existence of other pathology should be taken into consideration.
A collection of symptoms, not a pathologic diagnosis. The extrinsic theory of pathology attributes most symptoms to 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:
* Shape of the coracoacromial arch that allows passage of the subjacent rotator cuff;
* Normal undersurface of the AC joint;
* Normal bursa;
* Normal capsular laxity; and
* Coordinated scapulothoracic function.
The intrinsic theory would relate symptoms to issues with scapular motion and other muscle function. It is thought that impingement may occur in part because of abnormal scapular motion with increased upper trapezius activation and lesser involvement of middle, lower trapezius and the serratus anterior. 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.
Tendinopathy: includes the terms tendinitis, an inflammation of the tendon and tendinosis, non-inflammatory degenerative processes. Rotator cuff tendinopathy 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. These structures include one internal rotator (subscapularis), and two external rotators (infraspinatus and teres minor), and the supraspinatus which assists in abduction.
Onset of symptoms, date, mechanism of onset, occupational history, and current job requirements should be correlated with the intensity, character, duration and frequency of associated pain and discomfort. Tendinopathies are often seen with frequent overhead motion. Symptoms may include pain and/or achiness that occur after blunt trauma or repetitive use of the shoulder. For details refer to Section C.2. Relationships to Work and Other Activities.
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:
Impingement syndromes commonly co-exist with other shoulder abnormalities such as rotator cuff tears, AC joint arthritis, biceps tendon ruptures, calcific tendinitis, 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.
Commonly used clinical tests include the following:
* Hawkins;
* Neer;
* Horizontal adduction;
* Drop arm test;
* Yergason's;
* Speed test.
Refer to Section C.1.c. Initial Diagnostic Procedures, for a description of each test.
If there is a concern regarding needle placement, sonography, fluoroscopy or referral to a specialist may be appropriate.
There is some evidence that subacromial injection of 60 mg of ketorolac is at least as effective as an injection of 40 mg of triamcinolone in the short-term treatment of subacromial impingement syndrome. For more information on steroid injections, please refer to Section F.4.d. Shoulder Joint Steroid Injections.
There is strong evidence for those with subacromial impingement syndrome that;
There is some evidence that a specific exercise strategy, focusing on strengthening eccentric exercises for the rotator cuff and concentric/eccentric exercises for the scapula stabilizers, is effective in reducing pain and improving shoulder function in patients with persistent subacromial impingement syndrome. In addition, this specific exercise strategy reduces the need for arthroscopic subacromial decompression within the three month timeframe used in the study. There is some evidence that a scapular focused exercise treatment protocol that includes scapular motor control exercises, scapular mobilizations, and stretching is effective for reducing pain and improving shoulder function in patients with subacromial impingement syndrome.
Exercise programs 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. In patients with scapular dyskinesis, neuromuscular reeducation may first be needed to assure the patient will be able to perform these exercises with the necessary proper scapular stabilization. Therapy should progress to strengthening and an independent home exercise program targeted to further improve ROM and neuromuscular re-education of the shoulder girdle musculature. Refer to Section F. Therapeutic Procedures - Non-operative.
* Time to effect: 6 sessions
* Optimum Duration: 12 sessions
* Maximum duration:18 sessions
There is some evidence that in the setting of non-traumatic subacromial impingement syndrome, bursectomy can decrease shoulder pain and improve function. There is also some evidence that adding acromioplasty to bursectomy is not likely to significantly enhance the outcome of surgery.
One high quality study compared two groups of patients undergoing arthroscopic acromioplasty: one group had an individualized home exercise program from a physiotherapist which used a painless series of repetitions with elastic stretch bands and light weights, aimed at strengthening the rotator cuff tendon and other shoulder girdle muscles. The other group had the same exercise program following arthroscopic acromioplasty plus release of the coracoacromial ligament. The results at 24 months were similar, but recovery occurred more rapidly in the acromioplasty patients. Thus, there is good evidence that in patients who have shoulder impingement but do not have osteoarthritis or rotator cuff tears, an individualized exercise program yields long-term (24 month) pain relief comparable to the same program following acromioplasty, but also that recovery is more rapid with acromioplasty. Therefore, acromioplasty is not generally recommended.
When functional deficits interfere with activities of daily living and/or job duties after 3 to 6 months of active patient participation in an appropriate shoulder rehabilitation program, 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.
Informed decision making should be documented for all invasive procedures. This must include a thorough discussion of the pros and cons of the procedure and the possible complications as well as the natural history of the identified diagnosis. Since most patients with the most common conditions will improve significantly over time, without invasive interventions, patients must be able to make well-informed decisions regarding their treatment.
Smoking may affect soft tissue healing through tissue hypoxia. Patients should be strongly encouraged to stop smoking and be provided with appropriate counseling by the physician. If a treating physician recommends a specific smoking cessation program peri-operatively, this should be covered by the insurer. Physicians may monitor smoking cessation with laboratory tests such as cotinine levels. The surgeon will make the final determination as to whether smoking cessation is required prior to surgery.
Procedures for impingement without a rotator cuff tear might include bursectomy with or without acromioplasty. An open or arthroscopic acromioplasty is not always necessary as an adjunct to rotator cuff repair and acromioplasty is not generally recommended.
If after three months of active therapy and injection there is insufficient function, surgery may be considered. Spurs from the acromion may be removed. The distal clavicle should not be removed unless there is AC joint pain reproducible with direct compression. Preservation of the coracoacromial ligament is recommended to maintain joint stability.
Continuous interscalene blocks (ISB) are not recommended. For more information, please refer to Section G.7. Interscalene Anesthesia.
An individualized rehabilitation program will be based upon communication between the surgeon and the therapist using the treatments found in Section F. Therapeutic Procedures - Non-operative. Treatment may include the following:
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 4 to 6 weeks during postoperative 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.
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; however, they are uncommon. Approximately 25% of asymptomatic patients over 60 have full thickness tears and between 40-60% have partial thickness tears. About 50%of those with asymptomatic full thickness tears will become symptomatic with tear progression in 2 years. This is more common with larger initial tears. Only about 10% of partial tears increase in size over time. Tendons do not repair themselves over time. The patient usually complains of pain along anterior, lateral shoulder or posterior glenohumeral joint.
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. May be caused by 1) sudden trauma to the shoulder such as breaking a fall using an overhead railing or an out-stretched arm; or 2) chronic use. For details refer to Section C.2 Relationships to Work and Other Activities.
Rotator cuff tears commonly co-exist with other shoulder abnormalities such as impingement, AC joint arthritis, biceps tendon ruptures, and calcific tendinitis. In older patients, tears may co-exist 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:
* Hawkins.
* Drop arm.
* Lift off.
* Subscapularis strength test.
* Empty can test.
* External rotation lag test.
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.
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 4 to 6 weeks of an appropriate shoulder rehabilitation program. 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.
Rotator cuff tears, both full-thickness and partial, appear to occur commonly in asymptomatic individuals. MRI diagnostic criteria for full rotator cuff tear may be met in approximately 28% of asymptomatic persons, and in asymptomatic persons over age 60, contralateral rotator cuff tears may occur in approximately 35%. 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. A small minority of patients younger than age 40 demonstrate these changes. Correlation of radiological and clinical findings is an important part of patient management.
There is good evidence that MRI, MRA, and US are all accurate at identifying full thickness rotator cuff tears in patients whose history and physical examination makes them candidates for possible surgery. There is no evidence to suggest that any of the three is superior for this purpose. There is inadequate evidence regarding the comparative accuracy for diagnosing partial thickness tears. Available studies utilize clinically very different categories which lead to equivocal interpretation of the findings.
There is good evidence that in the setting of rotator cuff tendinopathy, a single dose of PRP provides no additional benefit over saline injection when the patients are enrolled in a program of active physical therapy.
There is strong evidence that platelet rich therapy does not show a clinically important treatment effect for shoulder pain or function when given as an adjunct to arthroscopic rotator cuff repair. However, at present, there is also a lack of standardization of platelet preparation methods, which precludes clear conclusions about the effect of platelet-rich therapies for musculoskeletal soft tissue injuries. Therefore, PRP is not generally recommended except under specific circumstances. Refer to Section F. 4, b., Platelet-Rich Plasma.
There is some evidence that in patients over 55 with nontraumatic small tears of the supraspinatus tendon, an intervention of home exercise supervised by a shoulder-trained physiotherapist, may be as beneficial at one year as the same physiotherapy program initiated after acromioplasty or acromioplasty with repair of the rotator cuff.
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.
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.
Full thickness tears are uncommon in the 40-60 age groups. About 25%of asymptomatic patients over 60 will have a full thickness tear. Full- thickness tears greater than 1 cm, in individuals less than 60 should generally be repaired. Smaller tears appear to show less likelihood of progression (25%). Only about 10 percent of partial tears increase in size over time. The recovery rate for those with a full thickness tear without surgery is 60%. 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. For patients with lack of active elevation above 90 degrees, arthroscopic biceps tenotomy may be effective in returning some elevation. The recurrence rate may be up to 50% in older patients with multiple tendon full-thickness tears. Pseudo paralysis or severe rotator cuff arthropathy are contraindications to the procedure.
Failure of healing after a rotator cuff tear (RCT) repair is not uncommon with a re-tear rate of about 30% and a re-operative rate of 20%. Those with intact tendon repairs had a re-operative rate at 7 years of 5% due to impingement. Success rates as high as 90% have been reported in some centers, but these may not represent all patients undergoing rotator cuff repair. Grade 2 fatty infiltration and age (over 65) are both associated with worse outcomes, forty-three percent healed repair versus 86%.
Another factor with prognostic significance is supraspinatus atrophy. Thomazeau 1996 used an oblique-sagittal MRI view of the supraspinatus fossa to estimate the degree of atrophy of the muscle belly in relation to the fossa, classifying the results into three classes. Stage I was considered normal or only slightly atrophied, with the muscle filling 60% or more of the supraspinatus fossa. Stage II, moderate atrophy, filled 40-60% of the fossa, and Stage III, severe atrophy, filled less than 40% of the fossa. Liem 2007 used a slightly modified version of the Thomazeau classification of supraspinatus atrophy, comparing the rates of retear between Stage I and Stage II. There were 35 cases with Stage I, with 5 re-tears (14%). There were 10 cases with Stage II atrophy, with 5 re-tears (50%). The degree of supraspinatus atrophy on the preoperative MRI is likely to predict the probability of a retear after arthroscopic rotator cuff repair.
Early repair is suggested for acute full thickness tears greater than 1 cm. If age is greater than 65 an appropriate shoulder rehabilitation program should be implemented for 6 to 8 weeks before surgery. Partial thickness tears and full thickness tears less than 1 cm are treated non-operatively initially.
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.
Informed decision making should be documented for all invasive procedures. This must include a thorough discussion of the pros and cons of the procedure and the possible complications as well as the natural history of the identified diagnosis. Since most patients with the most common conditions will improve significantly over time without invasive interventions, patients must be able to make well-informed decisions regarding their treatment.
Smoking may affect soft tissue healing through tissue hypoxia. Patients should be strongly encouraged to stop smoking and be provided with appropriate counseling by the physician. If a treating physician recommends a specific smoking cessation program peri-operatively, this should be covered by the insurer. Physicians may monitor smoking cessation with laboratory tests such as cotinine levels. The surgeon will make the final determination as to whether smoking cessation is required prior to surgery.
There is some evidence that in patients over 55 with nontraumatic small tears of the supraspinatus tendon, an intervention of home exercise supervised by a shoulder-trained physiotherapist may be as beneficial at one year as the same physiotherapy program initiated after acromioplasty or acromioplasty with repair of the rotator cuff.
There is good evidence that symptomatic full thickness rotator cuff tears less than 3 cm in size receive more benefit from surgical intervention than from physical therapy one year after the injury.
There is some evidence that in patients with reparable full-thickness rotator cuff tears and a Type II acromion, there are no appreciable differences in pain and shoulder function between rotator cuff repairs done with and without subacromial decompression up to one year after surgery.
Options would include arthroscopic or open debridement and/or repair.
Routine acromioplasty is not recommended.
Tenodesis is a more complex procedure and requires more time off work compared to tenotomy and is not generally recommended.
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.
Distal clavicular resection is not recommended for patients without AC joint pain. This should only be performed on patients with reproducible pain at the AC joint which is relieved with a local anesthetic injection.
In cases with extensive rotator cuff tear, preservation of the coracoacromial ligament is recommended to prevent instability.
Arthroscopic laser treatment is not recommended due to lack of evidence regarding outcomes.
Use of porcine submucosa grafts are not recommended due to a high failure rate.
Platelet-rich plasma therapy is not recommended due to lack of evidence.
Acellular dermal matrix augmentation of rotator cuff tears larger than 3 cm and less than 5 cm require prior authorization.
Continuous interscalene blocks (ISB) are not recommended. For more information, please refer to Section G.7. Interscalene Anesthesia.
Continuous subacromial infusion are not recommended, refer to Section G.8. Continuous Subacromial Anesthesia Injection, for more information.
There is some evidence that interscalene regional blocks (ISB) at the time of elective arthroscopic rotator cuff repair results in faster hospital discharge than general anesthesia, therefore ISB is recommended. There is some evidence that continuous ISB for 48 hours is associated with somewhat greater pain relief at the seventh postoperative day than single injection ISB, but there is little if any difference in the use of opioids at that time between continuous and single injection anesthesia. Therefore, continuous ISB is not recommended.
There is some evidence that in the setting of arthroscopic rotator cuff repair, a subacromial infusion of 4 ml/hour of 0.5% bupivacaine for 50 hours does not reduce post-operative pain or oxycodone consumption in a clinically meaningful way. Therefore, it is not recommended.
There is good evidence that in the setting of surgical repair of full thickness rotator cuff tears, routine acromioplasty does not improve the outcome of surgery compared to cuff repair alone.
There is some evidence, with data pooled from two studies, that reoperations are done less often in the two years following surgery when an acromioplasty is included as part of the arthroscopic rotator cuff repair operation. It is unknown to what extent the second surgery increased function.
An additional study provided some evidence that patient-reported pain and function does not differ greatly when acromioplasty is either done or not done in the setting of full thickness rotator cuff tears repaired arthroscopically. There is inadequate evidence that physician-measured outcomes are equivalent for the two operations.
There is good evidence that in the setting of arthroscopic repair of full-thickness rotator cuff tears, two-year patient-reported outcomes are similar with and without acromioplasty.
There is strong evidence that platelet rich therapy does not show a clinically important treatment effect for shoulder pain or function when given as an adjunct to arthroscopic rotator cuff repair. However, at present, there is also a lack of standardization of platelet preparation methods, which precludes clear conclusions about the effect of platelet-rich therapies for musculoskeletal soft tissue injuries. Therefore it is not recommended.
There is some evidence that acellular dermal matrix augmentation of reparable rotator cuff tears larger than 3 cm but less than 5 cm may improve tendon repair and reduce the rate of recurrent rotator cuff tears in the first 12 to 24 months after surgery, provided that the patients are nonsmokers. This may be allowed with prior authorization.
There is good evidence that arthroscopic and open rotator cuff surgery do not differ in long-term outcome results. There is a lack of evidence about the comparative effectiveness of surgery and active PT for supraspinatous syndrome.
There is good evidence that symptomatic full thickness rotator cuff tears less than 3 cm in size, in the absence of severe supraspinatus atrophy, receive more benefit from arthroscopic tendon repair than from physical therapy at 12 months.
There is some evidence that in the setting of full thickness rotator cuff tears smaller than 3 cm in the longest direction and in the absence of acromial spurs, acromioplasty with cuff repair does not improve the 2 year pain and functional outcomes compared to cuff repair alone.
There is some evidence that in the setting of repairable rotator cuff tears with lesions of the long head of the biceps, there is little difference in functional outcome at two years between tenotomy and tenotomy accompanied by tenodesis. Because tenodesis is a more complex procedure and requires more time off work, it is generally not recommended.
There is good evidence that in patients over 55 with reparable rotator cuff tears and lesions of the long head of the biceps, tenotomy and tenodesis at the intertubercular groove provide equal functional and symptomatic benefits two years after surgery.
There is some evidence that in patients over 50 who have both rotator cuff repairs and Type II SLAP lesions, the outcomes of a tenotomy of the long head of the biceps are at least as good as those of repairing the SLAP lesion, and the operating time is likely to be shorter.
There is some evidence that in patients over 60 with symptomatic rotator cuff tears, repair of the tear at the time of acromioplasty/tenotomy leads to better function at one year than acromioplasty/tenotomy alone.
An individualized rehabilitation program will be based upon communication between the surgeon and the therapist. Treatment may include the following:
* Optimum: 24 sessions.
* Maximum: 36 sessions. If functional gains are being achieved, additional visits may be authorized for the patient to achieve their functional goal.
There is some evidence that a postoperative rehabilitation protocol of early or delayed initiation of passive range of motion exercises demonstrate very similar clinical outcomes and range of motion at 1-year after arthroscopic repair of a full-thickness supraspinatus tear, indicating no significant advantage to beginning early passive ROM after surgery. Patients in the delayed range of motion group had a slightly higher rotator cuff healing rate per ultrasound imaging (91% vs. 85%). However, there was no statistically significant difference. It is possible that there is a potential benefit to delaying passive ROM in an effort to protect the surgical repair.
There is some evidence that aggressive early passive rehabilitation consisting of passive shoulder stretching and manual therapy without range of motion limits yields faster recovery of range of motion at 3 months after arthroscopic single-row rotator cuff repair than limited early passive rehabilitation, but after 12 months postoperatively, no differences in range of motion were found between the 2 groups. The re-tear rate of the aggressive early passive rehabilitation group was more than twice the rate of the limited early passive rehabilitation group.
Subluxation (partial dislocation), or dislocation of the glenohumeral joint in either an anterior, inferior, posterior or a combination of positions.
History may include:
* A slipping sensation in the arm;
* Severe pain with inability to move the arm;
* Abduction and external rotation producing a feeling that the shoulder might "come out" (apprehension); or
* Feeling of shoulder weakness.
* Instability may be caused by any of the following:
* A direct traumatic blow to the shoulder;
* A fall on an outstretched arm;
* Performing repetitive forceful overhead activities similar to pitching a baseball;
* A significant traction injury to the arm.
Posterior dislocations are uncommon. They 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.
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).
* Sulcus sign.
* Inferior instability.
* Posterior instability.
* Apprehension, also known as, crank, fulcrum or Fegin.
* Relocation.
* Load and shift or anterior and posterior drawer.
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. 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.
The injured worker should adhere to the written return to work restrictions not only in the workplace, but at home and for 24 hours a day.
Practitioners should reduce and immobilize dislocations if in an acceptable position. Consultation should be obtained as soon as possible, because surgical repair may be necessary.
Return-to-work will be directly related to the time it takes the fracture to heal.
Chronic dislocations should first be treated similarly to acute dislocation. If continuing treatment is unsuccessful and there are findings of instability, operative repair should be considered.
Usual treatment after reduction includes bracing for at least 6 weeks in neutral or external rotation. Non-operative treatment is suggested for older patients with low physical demands, those with no posterior instability or with less than 10% defect of the humeral head. Reverse Hill-Sachs lesions, posterior Bankart lesions, and fractures of the surgical neck of the humerus are all relatively common. In patients with humeral head defects involving 10-40% of the articular surface, biologic reconstruction with allograft or autograft are appropriate treatment options. If the defect covers 45% or more of the articular surface, total shoulder arthroplasty may be necessary. Instability in the first year for posterior dislocations is usually around 18%. Patients older than 50 may have rotator cuff lesions amenable to physical therapy. Patients should be assessed for hyper-mobility or ability to sublux at will. They may require muscle retraining to correct. Patients with posterior dislocations are likely to have limited internal rotation after treatment.
Patients over 40 are more likely to suffer this entity and should be evaluated by an orthopedic surgeon if there is continual difficulty with abduction.
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 good evidence that in active young persons engaged in physical activities, a first anterior shoulder dislocation treated surgically is less likely to redislocate than a dislocation treated with sling immobilization only. There is strong evidence that in the setting of first-time traumatic shoulder dislocation in patients aged between 16 and 40, surgical Bankart repair more effectively prevents later recurrence of instability than more conservative treatment, and some evidence that the effects of Bankart repair are likely to last for five years or longer.
A study describing long-term arthropathy after initial anterior dislocation found more moderate / severe cases in patients who were aged 26-33 at first dislocation and less moderate / severe arthropathy in those with no recurrence or who were initially surgically addressed.
Consider surgical intervention for young patients active in sports, or older patients with significant rotator cuff tears. There is some evidence that open Bankart repair of first time anterior shoulder dislocation reduces the risk of redislocation for up to ten years, and that the risk of recurrence is greatest in younger patients age 15 to 24. One systematic review reported a risk of instability at 10 years of between 34% and 35%. Risk factors were age below 22 years old, male gender, the number of preoperative dislocations and participation in competitive sports. If additional pathology is present, consult appropriate diagnostic categories.
Those with Hill-Sachs lesions, bony Bankart injuries, or significant glenoid bone loss have a worse prognosis for recurrences. In one study of cost effectiveness, primary arthroscopic stabilization for first time dislocations in 15 year old and 25 year old men was cost effective. It was effective but costly for 25 year old women and 35 year old men.
Fractures not amenable to immobilization and/or with 1 cm displacement 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 decision for surgery should carefully consider the desire to prevent recurrent dislocations and the need for full ROM.
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 Section E.10. Rotator Cuff Tear.
In general, older patients without the above lesions will suffer few recurrences, and, therefore, are treated conservatively. Operative repair may be considered 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. For anterior dislocations there may be limitation in external rotation. Patients with multi-directional laxity and/or laxity in the contralateral shoulder are usually not good candidates for operative repair.
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.
Informed decision making should be documented for all invasive procedures. This must include a thorough discussion of the pros and cons of the procedure and the possible complications as well as the natural history of the identified diagnosis. Since most patients with the most common conditions will improve significantly over time, without invasive interventions, patients must be able to make well-informed decisions regarding their treatment.
Smoking may affect soft tissue healing through tissue hypoxia. Patients should be strongly encouraged to stop smoking and be provided with appropriate counseling by the physician. If a treating physician recommends a specific smoking cessation program peri-operatively, this should be covered by the insurer. Physicians may monitor smoking cessation with laboratory tests such as cotinine levels. The surgeon will make the final determination as to whether smoking cessation is required prior to surgery.
Specific Indications:
* Dislocation with a fracture not amenable to immobilization such as those with 1 cm displacement;
* First time dislocations in younger patients up to age 40, and those less than 60 who perform lifting and overhead work;
* Repeat dislocations when not accompanied by multiple joint laxity.
Continuous interscalene blocks (ISB) are not recommended. For more information, please refer to Section G.7. Interscalene Anesthesia.
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.
* Symptoms with overhead throwing motions;
* Dislocation, subluxation, or subjective sense of instability;
* Poorly localized shoulder pain that is exacerbated by overhead activities;
* Catching, locking, popping or snapping;
* Subtle instability.
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. A combination of test results usually assists in diagnosis. The most common test are listed below, however other physical exam maneuvers may be used. Refer to Section C. Initial Diagnostic Procedures for specific descriptions of these signs and tests.
* Speed test.
* Yergason's Test.
* Active Compression (O'Brien) Test.
* Jobe Relocation Test.
* Crank Test.
* Anterior Apprehension Maneuver.
* Tenderness at the bicipital groove.
* Anterior Slide (Kibler) Test.
* Compression Rotation Test.
* Pain Provocation Test.
* Biceps Load Test II.
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.
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. Given the total available evidence at this time, SLAP repair is most likely to improve outcomes for those under 35, laborers who need supination strength, or those with current instability. Therefore, when the below indications are met, an arthroscopy can be performed with appropriate surgical repair.
Arthroscopic SLAP repair is usually not recommended in cases of severe arthritis. The rotator cuff should generally be intact or repairable. In one study overall total shoulder arthroplasty success was good with an 85% 15-20 year survival rate. Another study reported secondary rotator cuff dysfunction at initially low levels but increasing to 55% at 15 years.
Informed decision making should be documented for all invasive procedures. This must include a thorough discussion of the pros and cons of the procedure and the possible complications as well as the natural history of the identified diagnosis. Since most patients with the most common conditions will improve significantly over time, without invasive interventions, patients must be able to make well-informed decisions regarding their treatment.
Smoking may affect soft tissue healing through tissue hypoxia. Patients should be strongly encouraged to stop smoking and be provided with appropriate counseling by the physician. If a treating physician recommends a specific smoking cessation program peri-operatively, this should be covered by the insurer. Physicians may monitor smoking cessation with laboratory tests such as cotinine levels. The surgeon will make the final determination as to whether smoking cessation is required prior to surgery.
Operative treatment of SLAP lesions depends on the type of lesion present and whether any other intra-articular abnormalities are present. A five-year follow-up of patients over 40 years old with an isolated Type II SLAP repair, found high patient satisfaction and improvement in the Rowe score for function and disability. One case series reported better return to sports for younger patients with an isolated Type II SLAP, who had a biceps tenodesis versus a more classic repair. Overall results from both an anchor SLAP repair and biceps tenodesis are good with long-term follow up of demonstrating around 80% good results and about 70% or greater return to athletic overhead activities. However, patients 40 and older were less likely to do well with a SLAP repair and more likely to have a biceps tenodesis. Advantages of a biceps tenodesis are shorter recovery time with return to work in 6 - 8 weeks and possible better outcome for those who participate in overhead throwing activities. Biceps tenodesis may be considered for those over 40 years of age, for revision surgery and those with glenohumeral arthritis. Tenotomy appears to have equally reliable results with a shorter recovery time of 2 weeks and should be an additional option, especially for those with a rotator cuff tear. The following are generally accepted protocols for surgical intervention; however, due to current lack of evidence, operative treatment is not limited to these.
Continuous interscalene blocks (ISB) are not recommended. For more information, please refer to Section G.7. Interscalene Anesthesia.
SLAP repair usually results in some permanent range of motion deficits and may limit ability to participate in overhead competitive sports. Other complications may include anchor failure and suprascapular nerve damage. In one series, over 30% had revision surgery. Biceps tenodesis is less likely to have complications, frequently less than 3%.
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 3 to 6 weeks. Elbow, wrist, and hand ROM exercises may be used at this time. The sling is removed at 3 to 4 weeks and active ROM is usually begun with restrictions directed by the surgeon. Active biceps exercise may be restricted for 12 weeks. Biceps tenodesis patients require fewer restrictions and may frequently return to full duty at 6 - 8 weeks.
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. The injured worker should adhere to the written return to work restrictions not only in the workplace, but at home and for 24 hours a day. Most patients will be able to return to full duty by seven months.
Before initiation of any therapeutic procedure, the authorized treating provider, employer, and insurer must consider these four important issues in the care of the injured worker.
First, patients undergoing therapeutic procedure(s) should be released or returned to modified or restricted duty during their rehabilitation at the earliest appropriate time. Refer to F.12. Return to Work for detailed information.
Second, cessation and/or review of treatment modalities should be undertaken when no further significant subjective or objective improvement in the patient's condition is noted. If patients are not responding within the recommended duration periods, alternative treatment interventions, further diagnostic studies, or consultations should be pursued.
Third, providers should provide and document patient education. Functional progression is expected through prescribed activity such as neuromuscular and postural re-education/re-patterning exercises. Before diagnostic tests or referrals for invasive treatment take place, the patient should be able to clearly articulate the goals of the intervention, the general side effects and associated risks, and the patient's agreement with the expected treatment plan.
Last, formal psychological or psychosocial evaluation should be performed on patients not making expected progress within 6 to 12 weeks following injury and whose subjective symptoms do not correlate with objective signs and tests.
Home therapy is an important component of therapy and may include active and passive therapeutic procedures as well as other modalities to assist in alleviating pain, swelling, and abnormal muscle tone.
The following procedures are listed in alphabetical order.
A sham procedure is a non-therapeutic procedure that appears similar to the patient as the purported therapeutic procedure being tested. In most controlled studies, sham and classic acupuncture have produced similar effects. However, the sham controlled studies have shown consistent advantages of both true and sham acupuncture over no acupuncture when the studies have included a third comparison group that was randomized to usual medical care. Having this third comparison group has been advantageous in the interpretation of the non-specific effects of acupuncture, since the third comparison group controls for some influences on study outcome. These influences include more frequent contact with providers, the natural history of the condition, regression to the mean, the effect of being observed in a clinical trial, and, if the follow-up observations are done consistently in all three treatment groups, for biased reporting of outcomes. Controlling for these factors enables researchers to more closely estimate the contextual and personal interactive effects of acupuncture as it is generally practiced.
Because the sham acupuncture interventions in the clinical trials are generally done by trained acupuncturists, and not by totally untrained personnel, the sham acupuncture interventions may include some of the effects of true acupuncture, much as a partial agonist of a drug may produce some of the effects of the actual drug. For example, a sham procedure involving toothpicks rather than acupuncture needles may stimulate cutaneous afferents in spite of not penetrating the skin, much as a neurological sensory examination may test nociceptor function without skin penetration. To the extent that afferent stimulation is part of the mechanism of action of acupuncture, interpreting the sham results as purely a control group would lead to an underestimation of the analgesic effects of acupuncture. Thus we consider in our analysis that "sham" or non-classic acupuncture may have a positive clinical effect when compared to usual care.
Clinical trials of acupuncture typically enroll participants who are interested in acupuncture, and who may respond to some of the non-specific aspects of the intervention more than would be expected of patients who have no interest in or desire for acupuncture. The non-specific effects of acupuncture may not be produced in patients who have no wish to be referred for it.
Another study provides good evidence that true acupuncture at traditional medians is marginally better than sham acupuncture with blunt needles in reducing pain, but effects on disability are unclear. In these studies 5-15 treatments were provided. Comparisons of acupuncture and sham acupuncture have been inconsistent, and the advantage of true over sham acupuncture has been small in relation to the advantage of sham over no acupuncture.
Acupuncture is recommended for subacute or chronic pain patients who are trying to increase function and/or decrease medication usage and have an expressed interest in this modality. It is also recommended for subacute or acute pain for patients who cannot tolerate NSAIDs or other medications.
Acupuncture is not the same procedure as dry needling for coding purposes; however, some acupuncturists may use acupuncture treatment for myofascial trigger points. Dry needling is performed specifically on myofascial trigger points. Refer to F.4.h. Trigger Point Injections and Dry Needling Treatment.
Acupuncture should generally be used in conjunction with manipulative and physical therapy/rehabilitation.
Credentialed practitioners with experience in evaluation and treatment of chronic pain patients must perform acupuncture evaluations prior to acupuncture treatments. The exact mode of action is only partially understood. Western medicine studies suggest that acupuncture stimulates the nervous system at the level of the brain, promotes deep relaxation, and affects the release of neurotransmitters. Acupuncture is commonly used as an alternative or in addition to traditional Western pharmaceuticals. It may be used when pain medication is reduced or not tolerated; as an adjunct to physical rehabilitation and surgical intervention; and/or as part of multidisciplinary treatment to hasten the return of functional activity. Acupuncture must be performed by practitioners with the appropriate credentials in accordance with state and other applicable regulations. Therefore, if not otherwise within their professional scope of practice and licensure, those performing acupuncture must have the appropriate credentials, such as L.A.c. R.A.c, or Dipl. Ac.
There is some evidence that both subacromial corticosteroid injection and a series of 10 acupuncture treatments combined with home exercises significantly decreased pain and improved shoulder function in patients with subacromial impingement syndrome, but neither treatment was significantly superior to the other.
Indications include joint pain, joint stiffness, soft tissue pain and inflammation, paresthesia, post-surgical pain relief, muscle spasm, and scar tissue pain.
It is indicated to treat chronic pain conditions, radiating pain along a nerve pathway, muscle spasm, inflammation, scar tissue pain, and pain located in multiple sites.
* Time to Produce Effect: 3 to 6 treatments.
* Frequency: 1 to 3 times per week.
* Optimum Duration: 1 to 2 months.
* Maximum Duration: 15 treatments.
Any of the above acupuncture treatments may extend longer if objective functional gains can be documented and when symptomatic benefits facilitate progression in the patient's treatment program. Treatment beyond 14 treatments must be documented with respect to need and ability to facilitate positive symptomatic and functional gains. Such care should be re-evaluated and documented with each series of treatments.
Indications for biofeedback include cases of musculoskeletal injury, in which muscle dysfunction or other physiological indicators of excessive or prolonged stress response affects and/or delays recovery. Other applications include training to improve self-management of pain, anxiety, panic, anger or emotional distress, opioid withdrawal, insomnia/sleep disturbance, and other central and autonomic nervous system imbalances. Biofeedback is often utilized for relaxation training. Mental health professionals may also utilize it as a component of psychotherapy, where biofeedback and other behavioral techniques are integrated with psychotherapeutic interventions. Biofeedback is often used in conjunction with physical therapy or medical treatment.
Recognized types of biofeedback include the following:
The goal in biofeedback treatment is normalizing the physiology to the pre-injury status to the extent possible and involves transfer of learned skills to the workplace and daily life. Candidates for biofeedback therapy or training should be motivated to learn and practice biofeedback and self-regulation techniques. In the course of biofeedback treatment, patient stressors are discussed and self-management strategies are devised. If the patient has not been previously evaluated, a psychological evaluation should be performed prior to beginning biofeedback treatment for chronic pain. The psychological evaluation may reveal cognitive difficulties, belief system conflicts, somatic delusions, secondary gain issues, hypochondriasis, and possible biases in patient self-reports, which can affect biofeedback. Home practice of skills is often helpful for mastery and may be facilitated by the use of home training tapes.
Psychologists or psychiatrists who provide psycho-physiological therapy, which integrates biofeedback with psychotherapy, should be either Biofeedback Certification International Alliance (BCIA) certified or practicing within the scope of their training. All non-licensed health care providers of biofeedback for chronic pain patients must be BCIA certified and shall have their biofeedback treatment plan approved by the authorized treating psychologist or psychiatrist. Biofeedback treatment must be done in conjunction with the patient's psychosocial intervention. Biofeedback may also be provided by health care providers who follow a set treatment and educational protocol. Such treatment may utilize standardized material or relaxation tapes.
* Coordination between the biofeedback provider and the other health care providers is strongly encouraged.
* Time to Produce Effect: 3 to 4 sessions.
* Frequency: 1 to 2 times per week.
* Optimum Duration: 6 to 8 sessions.
* Maximum Duration: 10 to 12 sessions. Treatment beyond 12 sessions must be documented with respect to need, expectation, and ability to facilitate positive symptomatic and functional gains.
Indications - patients with calcific tendinitis who have not achieved functional goals after 2 to 3 months of active therapy. The calcium deposits must be Type I, homogenous calcification with well-defined borders or Type II, heterogeneous with sharp border or homogenous with no defined border.
* Time to Produce Effect: 3 days.
* Frequency: Every 4 to 7 days.
* Optimum Duration: 2 sessions. Progress can be documented by functional reports and/or x-ray or sonographic decrease in calcium.
* Maximum Duration: 4 sessions.
Description - Therapeutic injection procedures are generally accepted, well-established procedures that may play a significant role in the treatment of patients with upper extremity pain or pathology. Therapeutic injections involve the delivery of anesthetic and/or anti-inflammatory medications to the painful structure. Therapeutic injections have many potential benefits. Ideally, a therapeutic injection will:
Caution should be used when ordering four or more steroid injections total for all anatomic sites in one year. Please refer to Section F.4.d. Shoulder Joint Steroid Injections.
Diagnostic injections are procedures which may be used to identify pain generators or pathology. For additional specific clinical indications, see Specific Diagnosis, Testing and Treatment Procedures.
Contraindications - General contraindications include local or systemic infection, bleeding disorders, allergy to medications used and patient refusal. Specific contraindications may apply to individual injections.
There is strong evidence that botulinum toxin A has objective and symptomatic benefits over placebo for cervical dystonia.
There is some evidence that in patients with subacromial bursitis or subacromial impingement syndrome, a single ultrasound-guided subacromial injection of botulinum toxin B may be more effective than a steroid injection in pain reduction and shoulder function 3 months after the injection, but the usefulness of repeated botulinum injections is not known.
Indications - For conditions which produce cervical dystonia, bursitis, or impingement. There should be evidence of limited range-of-motion prior to the injection.
There is insufficient evidence to support its use for other myofascial trigger points for longer-term pain relief and it is likely to cause muscle weakness or atrophy if used repeatedly. Examples of such consequences include subacromial impingement, as the stabilizers of the shoulder are weakened by repeated injections of trigger points in the upper trapezii. Therefore it is not recommended for use for other myofascial trigger points.
Complications - There is good evidence that cervical botulinum toxin A injections cause transient dysphagia and neck weakness. Allergic reaction to medications, dry mouth and vocal hoarseness may also occur. Rare systemic effects include flu-like syndrome, and weakening of distant muscle. There is an increased risk of systemic effects in patients with motor neuropathy or disorders of the neuromuscular junction.
* Time to Produce Effect: 24 to 72 hours post injection with peak effect by 4 to 6 weeks.
Frequency: No less than 3 months between re-administration. Patients should be reassessed after each injection session for an 80% improvement in pain (as measured by accepted pain scales) and evidence of functional improvement for 3 months. A positive result would include a return to base line function, return to increased work duties, and measurable improvement in physical activity goals including return to baseline after an exacerbation.
* Optimum Duration: 3 to 4 months.
* Maximum Duration: 1 time. Prior authorization is required for additional injections. Repeat injections should be based upon functional improvement and therefore used sparingly in order to avoid development of antibodies that might render future injections ineffective. In most cases, not more than four injections are appropriate due to accompanying muscle atrophy.
There is good evidence that in the setting of rotator cuff tendinopathy, a single dose of PRP provides no additional benefit over saline injection when the patients are enrolled in a program of active physical therapy.
There is strong evidence that platelet rich therapy does not show a clinically important treatment effect for shoulder pain or function when given as an adjunct to arthroscopic rotator cuff repair. However, at present, there is also a lack of standardization of platelet preparation methods, which precludes clear conclusions about the effect of platelet-rich therapies for musculoskeletal soft tissue injuries. The preponderance of the evidence suggests that PRP is not likely to have long term beneficial effects.
Therefore, PRP is not generally recommended. It may be considered in unusual circumstances for cases which meet the following three criteria:
* tendon damage; and
* those who have not responded to appropriate conservative measures; and
* those for whom the next level of guideline-consistent therapy would involve an invasive procedure with risk of significant complications.
If PRP is found to be indicated in these select patients, the first injection may be repeated once after 4 weeks when significant functional benefit is reported but the patient has not returned to full function or full duty at work.
Laboratory studies may lend some biological plausibility to claims of connective tissue growth, but high quality published clinical studies are lacking. The dependence of the therapeutic effect on the inflammatory response is poorly defined, raising concerns about the use of conventional anti-inflammatory drugs when proliferant injections are given. The evidence in support of prolotherapy is insufficient and therefore, its use is not recommended in upper extremity injuries.
Complications: General complications of injections may include transient neurapraxia, nerve injury, infection, hematoma, glucose elevation, and endocrine changes.
The majority of diabetic patients will experience an increase in glucose following steroid injections. Average increases in one study were 125mg/dL and returned to normal in 48 hours, whereas in other studies, the increased glucose levels remained elevated up to 7 days, especially after multiple injections. All diabetic patients should be told to follow their glucose levels carefully over the 7 days after a steroid injection. For patients who have not been diagnosed with diabetes, one can expect some increase in glucose due to insulin depression for a few days after a steroid injection. Clinicians may consider diabetic screening tests for those who appear to be at risk for type 2 diabetes.
Intra-articular or epidural injections cause rapid drops in plasma cortisol levels which usually resolve in one to 4 weeks. There is some evidence that an intra-articular injection of 80 mg of methylprednisolone acetate into the knee has about a 25% probability of suppressing the adrenal gland response to exogenous adrenocortocotrophic hormone ACTH for four or more weeks after injection, but complete recovery of the adrenal response is seen by week 8 after injection. This adrenal suppression could require treatment if surgery or other physiologically stressful events occur.
Case reports of Cushing's syndrome, hypopituitarism and growth hormone deficiency have been reported uncommonly and have been tied to systemic absorption of intra-articular and epidural steroid injections. Cushing's syndrome has also been reported from serial occipital nerve injections and paraspinal injections.
Morning cortisol measurements may be ordered prior to repeating steroid injections or prior to the initial steroid injection when the patient has received multiple previous steroid injections.
The effect of steroid injections on bone mineral density (BMD) and any contribution to osteoporotic fractures is less clear. Patients on long term steroids are clearly more likely to suffer from fractures than those who do not take steroids. However, the contribution from steroid injections to this phenomena does not appear to be large. A well-controlled, large retrospective cohort study found that individuals with the same risk factors for osteoporotic fractures were 20% more likely to suffer a lumbar fracture if they had an epidural steroid injection. The risk increased with multiple injections. Other studies have shown inconsistent findings regarding BMD changes.
Given this information regarding increase in blood glucose levels, effects on the endocrine system, and possible osteoporotic influence, it is suggested that intraarticular and epidural injections be limited to a total of 3 to 4 per year [all joints combined].
* Time to Produce Effect: Immediate with local anesthesia, or within 5 days if no anesthesia
* Optimum Duration: Usually 1 or 2 injections are adequate.
* Maximum Duration: 3 or 4 injections in one year at least 4 to 8 weeks apart, when functional benefits are demonstrated with each injection.
The risk of tendon rupture should be discussed with the patient and the need for restricted duty emphasized.
* Frequency: Usually 1 or 2 injections are adequate.
* Time to Produce Effect: Immediate with local anesthesia, or within 3 days if no anesthesia.
* Optimum/Maximum Duration: 3 steroid injections at the same site per year.
There is some evidence that in patients with chronic shoulder pain with or without accompanying stiffness, individually-tailored exercise therapy aimed at restoring dynamic joint stabilizing mechanisms and muscle coordination, or a single unguided subacromial injection of corticosteroid, or a combination of various physical modalities and ROM exercises is equally effective in the short term.
There is some evidence that a subacromial injection of 60 mg of ketorolac is at least as effective as injection of 40 mg of triamcinolone in the short-term treatment of subacromial impingement syndrome.
There is some evidence that 6 sessions of manual physical over a three week period are as effective as an injection of 40 mg triamcinolone for relief of symptoms of shoulder impingement symptoms and impairment up to one year after initial treatment. The same study also showed reduced use of health care services one year in the manual therapy group.
There is strong evidence that subacromial steroid injections for rotator cuff tendinopathy have a rapid benefit. However, there is no evidence that differ from alternative therapies for intermediate or long-term relief.
There is some evidence that both subacromial corticosteroid injection and a series of 10 acupuncture treatments combined with home exercises significantly decreased pain and improved shoulder function in patients with subacromial impingement syndrome, but neither treatment was significantly superior to the other.
A study of a small group of healthy volunteers showed that a non-radiographically guided injection did not affect shoulder strength in the normal shoulder and was accurately placed in the subacromial bursa 90% of the time.
There is some evidence that ultrasound-guided injections of corticosteroid into the shoulder provides a more anatomically accurate injection and is likely to have a small to moderate advantage over landmark-guided injection for pain relief at 6 weeks after the injection.
There is some evidence that when subacromial injections are done without imaging guidance, there are no differences between anteromedial versus posteromedial approaches to subacromial injection with respect to accuracy or effectiveness, however the rotator cuff is frequently inadvertently injected with either approach.
If there is a concern regarding needle placement, sonography or fluoroscopy may be used. The subacromial injection may also be repeated by a specialist skilled in this procedure to confirm the diagnosis.
Please refer to Section F.4.d. Shoulder Joint Steroid Injections, for steroid complications and number of treatments.
* Time to Produce Effect: One block should demonstrate increased ability to perform exercises and/or range-of-motion.
* Maximum Duration: 3 per year.
There is no indication for conscious sedation for patients receiving trigger point injections. The patient must be alert to help identify the site of the injection.
Trigger point injections are indicated in those patients where well circumscribed trigger points have been consistently observed, demonstrating a local twitch response, characteristic radiation of pain pattern and local autonomic reaction, such as persistent hyperemia following palpation. Generally, these injections are not necessary unless consistently observed trigger points are not responding to specific, noninvasive, myofascial interventions within approximately a 6-week time frame. However, trigger point injections may be occasionally effective when utilized in the patient with immediate, acute onset of pain.
* Time to produce effect: Local anesthetic 30 minutes; 24 to 48 hours for no anesthesia.
* Frequency: Weekly. Suggest no more than 4 injection sites per session per week to avoid significant post-injection soreness.
* Optimum duration: 4 Weeks total for all injection sites.
* Maximum duration: 8 weeks total for all injection sites. Occasional patients may require 2 to 4 repetitions of trigger point injection series over a 1 to 2 year period.
There is insufficient evidence of the effectiveness of hyaluronate in rotator cuff tendonopathy, therefore it is not recommendedfor this condition.
There is some evidence that hyaluronic acid (HA) added to physical therapy (PT) does not improve symptomatic and functional outcomes of adhesive capsulitis over the improvements seen with PT alone. Therefore, it is not recommended.
There is good evidence that subacromial injection of hyaluronic acid is not more effective than steroid or placebo for pain relief and functional improvement of subacromial impingement syndrome. Therefore, it is not recommended.
There is good evidence that three weekly injections of HA alleviate the symptoms of glenohumeral osteoarthritis for up to 26 weeks in the absence of other shoulder pathology.
* Indications - glenohumeral osteoarthritis in the absence of other symptomatic shoulder pathology.
* Optimum Duration- 1 series of injections or a single injection, depending on the product used. Time parameters will vary according to the treatment regime as directed on the package insert. The regimes vary, from a single injection to a series of weekly injections over a period of several weeks. Providers must review brand name package insert prior to prescribing this treatment.
* Maximum Duration -sessions can be repeated only after a period of 6 months to encourage active therapy or delay joint replacement.
Chronic pain patients need to be treated as outpatients within a continuum of treatment intensity. Outpatient chronic pain programs are available with services provided by a coordinated interdisciplinary team within the same facility (formal) or as coordinated among practices by the authorized treating physician (informal). Formal programs are able to provide a coordinated, high-intensity level of services and are recommended for most chronic pain patients who have received multiple therapies during acute management.
Patients with addiction problems, high-dose opioid use, or use of other drugs of abuse may require inpatient and/or outpatient chemical dependency treatment programs before or in conjunction with other interdisciplinary rehabilitation. Guidelines from the American Society of Addiction Medicine are available and may be consulted relating to the intensity of services required for different classes of patients in order to achieve successful treatment.
Informal interdisciplinary pain programs may be considered for patients who are currently employed, those who cannot attend all-day programs, those with language barriers, or those living in areas not offering formal programs. Before treatment has been initiated, the patient, physician, and insurer should agree on treatment approach, methods, and goals. Generally, the type of outpatient program needed will depend on the degree of impact the pain has had on the patient's medical, physical, psychological, social, and/or vocational functioning.
When referring a patient for formal outpatient interdisciplinary pain rehabilitation, an occupational rehabilitation program, or an opioid treatment program, the Division recommends the program meets the criteria of the Commission on Accreditation of Rehabilitation Facilities (CARF).
Inpatient pain rehabilitation programs are rarely needed but may be necessary for patients with any of the following conditions:
Whether formal or informal programs, they should be comprised of the following dimensions:
* Communication: To ensure positive functional outcomes, communication between the patient, insurer, and all professionals involved must be coordinated and consistent. Any exchange of information must be provided to all professionals, including the patient. Care decisions should be communicated to all and should include the family and/or support system.
* Documentation: Through documentation by all professionals involved and/or discussions with the patient, it should be clear that functional goals are being actively pursued and measured on a regular basis to determine their achievement or need for modification. It is advisable to have the patient undergo objective functional measures.
* Treatment Modalities: Use of modalities may be necessary early in the process to facilitate compliance with and tolerance to therapeutic exercise, physical conditioning, and increasing functional activities. Active treatments should be emphasized over passive treatments. Active and self-monitored passive treatments should encourage self-coping skills and management of pain, which can be continued independently at home or at work. Treatments that can foster a sense of dependency by the patient on the caregiver should be avoided. Treatment length should be decided based upon observed functional improvement. For a complete list of active and passive therapies, refer to F.12. Therapy - Active and F.13. Therapy - Passive. All treatment timeframes may be extended based on the patient's positive functional improvement.
* Therapeutic Exercise Programs: A therapeutic exercise program should be initiated at the start of any treatment rehabilitation. Such programs should emphasize education, independence, and the importance of an on-going exercise regimen. There is good evidence that exercise alone or part of a multi-disciplinary program results in decreased disability for workers with non-acute low back pain. There is not sufficient evidence to support the recommendation of any particular exercise regimen over any other exercise regimen.
* Return to Work: The authorized treating physician should continually evaluate the patient for their potential to return to work. For patients currently employed, efforts should be aimed at keeping them employed. Formal rehabilitation programs should provide assistance in creating work profiles. For more specific information regarding return to work, refer to F.11. Return to Work.
* Patient Education: Patients with pain need to re-establish a healthy balance in lifestyle. All providers should educate patients on how to overcome barriers to resuming daily activity, including pain management, decreased energy levels, financial constraints, decreased physical ability, and change in family dynamics.
* Psychosocial Evaluation and Treatment: Psychosocial evaluation should be initiated, if not previously done. Providers of care should have a thorough understanding of the patient's personality profile, especially if dependency issues are involved. Psychosocial treatment may enhance the patient's ability to participate in pain treatment rehabilitation, manage stress, and increase their problem-solving and self-management skills.
* Vocational Assistance: Vocational assistance can define future employment opportunities or assist patients in obtaining future employment. Refer to F.13. Return to Work for detailed information.
Interdisciplinary programs are characterized by a variety of disciplines that participate in the assessment, planning, and/or implementation of the treatment program. These programs are for patients with greater levels of perceived disability, dysfunction, de-conditioning, and psychological involvement. Programs should have sufficient personnel to work with the individual in the following areas: behavioral, functional, medical, cognitive, pain management, psychological, social, and vocational.
Rehabilitation Program provides outcome-focused, coordinated, goal-oriented interdisciplinary team services to measure and improve the functioning of persons with pain and encourage their appropriate use of health care system and services. The program can benefit persons who have limitations that interfere with their physical, psychological, social, and/or vocational functioning. The program shares information about the scope of the services and the outcomes achieved with patients, authorized providers, and insurers.
The interdisciplinary team maintains consistent integration and communication to ensure that all interdisciplinary team members are aware of the plan of care for the patient, are exchanging information, and implement the plan of care. The team members make interdisciplinary team decisions with the patient and then ensure that decisions are communicated to the entire care team.
The Medical Director of the pain program should ideally be board certified in pain management; or he/she should be board certified in his/her specialty area and have completed a one-year fellowship in interdisciplinary pain medicine or palliative care recognized by a national board or have two years of experience in an interdisciplinary pain rehabilitation program. Teams that assist in the accomplishment of functional, physical, psychological, social, and vocational goals must include: a medical director, pain team physician(s), who should preferably be board certified in an appropriate specialty, and a pain team psychologist. Professionals from other disciplines on the team may include, but are not limited to: a biofeedback therapist, an occupational therapist, a physical therapist, a registered nurse (RN), a case manager, an exercise physiologist, a psychologist, a psychiatrist, and/or a nutritionist.
* Time to Produce Effect: 3 to 4 weeks.
* Frequency: Full time programs - No less than 5 hours per day, 5 days per week; part-time programs - 4 hours per day, 2-3 days per week.
* Optimum Duration: 3 to 12 weeks at least 2-3 times a week. Follow-up visits weekly or every other week during the first 1 to 2 months after the initial program is completed.
* Maximum Duration: 4 months for full-time programs and up to 6 months for part-time programs. Periodic review and monitoring thereafter for 1 year, and additional follow-up based on the documented maintenance of functional gains.
There is some evidence that an integrated care program, consisting of workplace interventions and graded activity teaching that pain need not limit activity, is effective in returning patients with chronic low back pain to work, even with minimal reported reduction of pain.
The occupational medicine rehabilitation interdisciplinary team should, at a minimum, be comprised of a qualified medical director who is board certified with documented training in occupational rehabilitation; team physicians having experience in occupational rehabilitation; an occupational therapist; and a physical therapist.
As appropriate, the team may also include any of the following: chiropractor, an RN, a case manager, a psychologist, a vocational specialist, or a certified biofeedback therapist.
* Time to Produce Effect: 2 weeks.
* Frequency: 2 to 5 visits per week, up to 8 hours per day.
* Optimum Duration: 2 to 4 weeks.
* Maximum Duration: 6 weeks. Participation in a program beyond 6 weeks must be documented with respect to need and the ability to facilitate positive symptomatic and functional gains.
This program is different from a formal program in that it involves lower frequency and intensity of services/treatment. Informal rehabilitation is geared toward those patients who do not need the intensity of service offered in a formal program or who cannot attend an all-day program due to employment, daycare, language, or other barriers.
Patients should be referred to professionals experienced in outpatient treatment of chronic pain. The Division recommends the authorized treating physician consult with physicians experienced in the treatment of chronic pain to develop the plan of care. Communication among care providers regarding clear objective goals and progress toward the goals is essential. Employers should be involved in return to work and work restrictions, and the family and/or social support system should be included in the treatment plan. Professionals from other disciplines likely to be involved include: a biofeedback therapist, an occupational therapist, a physical therapist, an RN, a psychologist, a case manager, an exercise physiologist, a psychiatrist, and/or a nutritionist.
* Time to Produce Effect: 3 to 4 weeks.
* Frequency: Full-time programs - No less than 5 hours per day, 5 days per week; Part-time programs - 4 hours per day for 2-3 days per week.
* Optimum Duration: 3 to 12 weeks at least 2-3 times a week. Follow-up visits weekly or every other week during the first 1 to 2 months after the initial program is completed.
* Maximum Duration: 4 months for full-time programs and up to 6 months for part-time programs. Periodic review and monitoring thereafter for 1 year, and additional follow-up based upon the documented maintenance of functional gains.
The job analysis and modification should include input from the employee, employer, and ergonomist or other professional familiar with work place evaluation. The employee must be observed performing all job functions in order for the jobsite analysis to be valid. Periodic follow-up is recommended to evaluate effectiveness of the intervention and need for additional ergonomic changes.
Temporary restrictions may be needed while recommended ergonomic or adaptive equipment is obtained; employers should obtain recommended equipment in a timely manner.
Nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen are useful in the treatment of injuries associated with degenerative joint disease and/or inflammation. These same medications can be used for pain control.
Topical agents may be beneficial for pain management in some patients with upper extremity injuries. This includes topical capsaicin, nonsteroidal, as well as, topical iontphoretics/phonophoretics, such as steroid creams and lidocaine.
The following are listed in alphabetical order.
* Optimum Duration: 7 to 10 days.
* Maximum Duration: Long-term use as indicated on a case-by-case basis. Use of this substance long-term (for 3 days per week or greater) may be associated with rebound pain upon cessation.
* Optimum Duration: 1 week.
* Maximum Duration: 2 weeks (or longer if used only at night).
There is some evidence that in the setting of long bone fractures of the femur, tibia, and humerus, NSAID administration in the first 48 hours after injury is associated with poor healing of the fracture.
Certain NSAIDs may have interactions with various other medications. Individuals may have adverse events not listed above. Intervals for metabolic screening are dependent on the patient's age and general health status and should be within parameters listed for each specific medication. Complete Blood Count (CBC) and liver and renal function should be monitored at least every six months in patients on chronic NSAIDs and initially when indicated.
Includes NSAIDs and acetylsalicylic acid. Serious GI toxicity, such as bleeding, perforation, and ulceration can occur at any time, with or without warning symptoms, in patients treated with traditional NSAIDs. Physicians should inform patients about the signs and/or symptoms of serious GI toxicity and what steps to take if they occur. Anaphylactoid reactions may occur in patients taking NSAIDs. NSAIDs may interfere with platelet function. Fluid retention and edema have been observed in some patients taking NSAIDs.
* Optimal Duration: 1 week.
* Maximum duration: 1 year. Use of these substances long-term (3 days per week or greater) is associated with rebound pain upon cessation.
COX-2 inhibitors differ from the traditional NSAIDs in adverse side effect profiles. The major advantages of selective COX-2 inhibitors over traditional NSAIDs are that they have less GI toxicity and no platelet effects. COX-2 inhibitors can worsen renal function in patients with renal insufficiency; thus, renal function may need monitoring.
COX-2 inhibitors should not be first-line for low risk patients who will be using an NSAID short-term but are indicated in select patients for whom traditional NSAIDs are not tolerated. Serious upper GI adverse events can occur even in asymptomatic patients. Patients at high risk for GI bleed include those who use alcohol, smoke, are older than 65, take corticosteroids or anti-coagulants, or have a longer duration of therapy. Celecoxib is contraindicated in sulfonamide allergic patients.
* Optimal Duration: 7 to 10 days.
* Maximum Duration: Chronic use is appropriate in individual cases. Use of these substances long-term (3 days per week or greater) is associated with rebound pain upon cessation.
Opioids medications should be prescribed with strict time, quantity, and duration guidelines, and with definitive cessation parameters. Pain is subjective in nature and should be evaluated using a pain scale and assessment of function to rate effectiveness of the opioid prescribed. Any use beyond the maximum should be documented and justified based on the diagnosis and/or invasive procedures.
* Optimum Duration: Up to 10 days.
* Maximum Duration: 2 weeks. Use beyond 2 weeks is acceptable in appropriate cases when functional improvement is documented. Refer to the Division's Chronic Pain Disorder Medical Treatment Guidelines, which give a detailed discussion regarding medication use in chronic pain management. Use beyond 30 days after non-traumatic injuries, or 6 weeks post-surgery after the original injury or post-operatively is not recommended. If necessary the physician should access the Colorado Prescription Drug Monitoring Program (PDMP) and follow recommendations in Chronic Pain Guideline. This system allows the prescribing physician to see most of the controlled substances prescribed by other physicians for an individual patient.
Anti-anxiety medications are best used for short-term treatment (i.e. less than 6 months). Accompanying sleep disorders are best treated with sedating antidepressants prior to bedtime. Frequently, combinations of the above agents are useful. As a general rule, physicians should assess the patient's prior history of substance abuse or depression prior to prescribing any of these agents. Due to the habit-forming potential of the benzodiazepines and other drugs found in this class, they are not generally recommended. Refer to the Division's Chronic Pain Disorder Medical Treatment Guidelines, which give a detailed discussion regarding medication use in chronic pain management.
* Optimum Duration: 1 to 6 months.
* Maximum Duration: 6 to 12 months, with monitoring.
* Optimum Duration: 3 to 7 days.
* Maximum Duration: 2 weeks. Use beyond 2 weeks is acceptable in appropriate cases.
There is no evidence that topical agents are more effective than oral medications. Therefore, they should not generally be used unless the patient has an intolerance to oral anti-inflammatories.
* Optimum Duration: One week.
* Maximum Duration: 2 weeks per episode.
* Optimum Duration: One week.
* Maximum Duration: 2 weeks per episode.
* Optimum Duration: Varies with drug or compound.
* Maximum Duration: Varies with drug or compound.
* Time to Produce Effect: 1 to 3 sessions (includes wearing schedule evaluation).
* Frequency: 1 to 2 times per week.
* Optimum/Maximum Duration: 4 sessions of evaluation, casting, fitting, and re-evaluation.
* Time to Produce Effect: 2 to 6 sessions.
* Frequency: 3 times per week.
* Optimum/Maximum Duration: 2 to 4 months.
* Time to Produce Effect: Immediate.
* Frequency: 1 to 3 sessions or as indicated to establish independent use.
* Optimum/Maximum Duration: 1 to 3 sessions.
Informed decision making is the hallmark of a successful treatment plan. In most cases the continuum of treatment from the least invasive to the most invasive (e.g. surgery) should be discussed. The intention is to find the treatment along this continuum which most completely addresses the condition. Patients should identify their personal functional goals of treatment at the first visit. It is recommended that specific individual goals are articulated at the beginning of treatment as this is likely to lead to increased patient satisfaction above that achieved from improvement in pain or other physical function. Progress toward the individual functional goals identified should be addressed at follow up visits and throughout treatment by other members of the health care team as well as the authorized physicians.
Documentation of this process should occur whenever diagnostic tests or referrals from the authorized treating physician are contemplated. The informed decision making process asks the patient to set their personal functional goals of treatment, describe their current health status and any concerns they have regarding adhering to the diagnostic or treatment plan proposed. The provider should clearly describe the following:
* The expected functional outcomes from the proposed treatment, or expected results and plan of action if diagnostic tests are involved.
* Any side effects and risks to the patient.
* Required post treatment rehabilitation time and impact on work, if any.
* Alternative therapies or diagnostic testing.
Before diagnostic tests or referrals for invasive treatment take place the patient should be able to clearly articulate the goals of the intervention, the general side effects and risks associated with it and their decision regarding compliance with the suggested plan. There is some evidence that information provided only by video is not sufficient education.
Practitioners must develop and implement an effective strategy and skills to educate patients, employers, insurance systems, policy makers, and the community as a whole. An education-based paradigm should always start with providing reassuring information to the patient and informed decision making. More in-depth education currently exists within a treatment regimen employing functional restoration, prevention, and cognitive behavioral techniques. Patient education and informed decision making should facilitate self-management of symptoms and prevention.
* Time to produce effect: Varies with individual patient
* Frequency: Should occur at every visit.
If a diagnosis consistent with the standards of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM) has been determined, the patient should be evaluated for the potential need for psychiatric medications. Use of any medication to treat a diagnosed condition may be ordered by the authorized treating physician or by the consulting psychiatrist. Visits for management of psychiatric medications are medical in nature and are not a component of psychosocial treatment. Therefore, separate visits for medication management may be necessary, depending on the patient and medications selected.
Psychosocial interventions include psychotherapeutic treatments for mental health conditions, as well as behavioral medicine treatments. These interventions may similarly be beneficial for patients without psychiatric conditions, but who may need to make major life changes in order to cope with pain or adjust to disability. Examples of these treatments include cognitive behavioral therapy (CBT), relaxation training, mindfulness training, and sleep hygiene training.
The screening or diagnostic workup should clarify and distinguish between pre-existing, aggravated, and/or purely causative psychological conditions. Therapeutic and diagnostic modalities include, but are not limited to, individual counseling and group therapy. Treatment can occur within an individualized model, a multi-disciplinary model, or a structured pain management program.
A psychologist with a PhD, PsyD, EdD credentials, or a psychiatric MD/DO may perform psychosocial treatments. Other licensed mental health providers or licensed health care providers with training in CBT, or certified as CBT therapists who have experience in treating chronic pain disorders in injured workers, may also perform treatment in consultation with a PhD, PsyD, EdD, or psychiatric MD/DO.
CBT refers to a group of psychological therapies that are sometimes referred to by more specific names, such as Rational Emotive Behavior Therapy, Rational Behavior Therapy, Rational Living Therapy, Cognitive Therapy, and Dialectic Behavior Therapy. Variations of CBT methods can be used to treat a variety of conditions, including chronic pain, depression, anxiety, phobias, and post-traumatic stress disorder (PTSD). For patients with multiple diagnoses, more than one type of CBT might be needed. The CBT used in research studies is often "manualized CBT," meaning that the treatment follows a specific protocol in a manual. In clinical settings, CBT may involve the use of standardized materials, but it is also commonly adapted by a psychologist or psychiatrist to the patient's unique circumstances. If the CBT is being performed by a non-mental health professional, a manual approach would be strongly recommended. CBT must be distinguished from neuropsychological therapies used to teach compensatory strategies to brain injured patients, which are also called "cognitive therapy."
It should be noted that most clinical trials on CBT exclude subjects who have significant psychiatric diagnoses. Consequently, the selection of patients for CBT should include the following considerations. CBT is instructive and structured, using an educational model with homework to teach inductive rational thinking. Because of this educational model, a certain level of literacy is assumed for most CBT protocols. Patients who lack the cognitive and educational abilities required by a CBT protocol are unlikely to be successful. Further, given the highly structured nature of CBT, it is more effective when a patient's circumstances are relatively stable. For example, if a patient is about to be evicted, is actively suicidal, or is coming to sessions intoxicated, these matters will generally preempt CBT treatment for pain, and require other types of psychotherapeutic response. Conversely, literate patients whose circumstances are relatively stable, but who catastrophize or cope poorly with pain or disability are often good candidates for CBT for pain. Similarly, literate patients whose circumstances are relatively stable, but who exhibit unfounded medical phobias, are often good candidates for CBT for anxiety.
There is good evidence that cognitive intervention reduces low back disability in the short term and in the long term. In one of the studies the therapy consisted of 6, 2-hour sessions given weekly to workers who had been sick-listed for 8-12 weeks. Comparison groups included those who received routine care. There is good evidence that psychological interventions, especially CBT, are superior to no psychological intervention for chronic low back pain, and that self-regulatory interventions, such as biofeedback and relaxation training, may be equally effective. There is good evidence that six group therapy sessions lasting one and a half hours each focused on CBT skills improved function and alleviated pain in uncomplicated sub-acute and chronic low back pain patients. There is some evidence that CBT provided in seven two-hour small group sessions can reduce the severity of insomnia in chronic pain patients. A Cochrane meta-analysis grouped very heterogenous behavioral interventions and concluded that there was good evidence that CBT may reduce pain and disability but the effect size was uncertain. In total, the evidence clearly supports CBT, and it should be offered to all chronic pain patents who do not have other serious issues, as discussed above.
CBT is often combined with active therapy in an interdisciplinary program, whether formal or informal. It must be coordinated with a psychologist or psychiatrist. CBT can be done in a small group or individually, and the usual number of treatments varies between 8 and16 sessions.
Before CBT is done, the patient must have a full psychological evaluation. The CBT program must be done under the supervision of a PhD, PsyD, EdD, or psychiatric MD/DO.
Psychological Diagnostic and Statistical Manual of Mental Disorders (DSM) Axis I disorders are common in chronic pain. One study demonstrated that the majority of patients who had failed other therapy and participated in an active therapy program also suffered from major depression. However, in a program that included CBT and other psychological counseling, the success rate for return to work was similar for those with and without a DSM IV diagnosis. This study further strengthens the argument for having some psychological intervention included in all chronic pain treatment plans.
For all psychological/psychiatric interventions, an assessment and treatment plan with measurable behavioral goals, time frames, and specific interventions planned, must be provided to the treating physician prior to initiating treatment. A status report must be provided to the authorized treating physician every two weeks during initial more frequent treatment and monthly thereafter. The report should provide documentation of progress toward functional recovery and a discussion of the psychosocial issues affecting the patient's ability to participate in treatment. The report should also address pertinent issues such as pre-existing, aggravated, and/or causative issues, as well as realistic functional prognosis.
* Time to Produce Effect: 6 to 8 1-2 hour session, group or individual (1-hour individual or 2-hour group).
* Maximum Duration: 16 sessions.
NOTE: Before CBT is done, the patient must have a full psychological evaluation. The CBT program must be done under the supervision of a PhD, PsyD, EdD, or Psychiatric MD/DO.
* Time to Produce Effect: 6 to 8 weeks.
* Frequency: 1 to 2 times weekly for the first 2 weeks (excluding hospitalization, if required), decreasing to 1 time per week for the second month. Thereafter, 2 to 4 times monthly with the exception of exacerbations, which may require increased frequency of visits. Not to include visits for medication management
* Optimum Duration: 2 to 6 months.
* Maximum Duration: 6 months. Not to include visits for medication management. For select patients, longer supervised psychological/psychiatric treatment may be required, especially if there are ongoing medical procedures or complications. If counseling beyond 6 months is indicated, the management of psychosocial risks or functional progress must be documented. Treatment plan/progress must show severity.
Some level of immobility may occasionally be appropriate which could include bracing. While these interventions may occasionally have been ordered in the acute phase, the provider should be aware of their impact on the patient's ability to adequately comply with and successfully complete rehabilitation. Activity should be increased based on the improvement of core strengthening.
Patients should be educated regarding the detrimental effects of immobility versus the efficacious use of limited rest periods. Adequate rest allows the patient to comply with active treatment and benefit from the rehabilitation program. In addition, complete work cessation should be avoided, if possible, since it often further aggravates the pain presentation and promotes disability. Modified return to work is almost always more efficacious and rarely contraindicated in the vast majority of injured workers.
Because a prolonged period of time off work will decrease the likelihood of return to work, the first weeks of treatment are crucial in preventing and/or reversing chronicity and disability mindset. In complex cases, experienced nurse case managers may be required to assist in return to work. Other services, including psychological evaluation and/or treatment, jobsite analysis, and vocational assistance, may be employed.
Two counseling sessions with an occupational physician, and work site visit if necessary, may be helpful for workers who are concerned about returning to work.
At least one study suggests that health status is worse for those who do not return to work than those who do. Self-employment and injury severity predict return to work. Difficulty with pain control, ADLs, and anxiety and depression were common.
The following should be considered when attempting to return an injured worker with chronic pain to work.
Recommendations to Employers and Employees of Small Businesses: employees of small businesses who are diagnosed with chronic pain may not be able to perform any jobs for which openings exist. Temporary employees may fill those slots while the employee functionally improves. Some small businesses hire other workers, and if the injured employee returns to the job, the supervisor/owner may have an extra employee. To avoid this, it is suggested that case managers be accessed through their payer or third-party administrator. Case managers may assist with resolution of these problems, as well as assist in finding modified job tasks, or find jobs with reduced hours, etc. depending on company philosophy and employee needs.
Recommendations to Employers and Employees of Mid-sized and Large Businesses: Employers are encouraged by the Division to identify modified work within the company that may be available to injured workers with chronic pain who are returning to work with temporary or permanent restrictions. To assist with temporary or permanent placement of the injured worker, it is suggested that a program be implemented that allows the case manager to access descriptions of all jobs within the organization.
The following active therapies are widely used and accepted methods of care for a variety of work-related injuries. They are based on the philosophy that therapeutic exercise and/or activity are beneficial for restoring flexibility, strength, endurance, function, range of motion, and can alleviate discomfort. Active therapy requires an internal effort by the individual to complete a specific exercise or task. This form of therapy requires supervision from a therapist or medical provider such as verbal, visual and/or tactile instruction(s). At times, the provider may help stabilize the patient or guide the movement pattern but the energy required to complete the task is predominately executed by the patient.
The use and integration of active and passive therapies should be directed at addressing impairments found in the clinical examination which may include abnormal posture, head tilting forward, scapula dyskinesia and joint/tissue hypomobility/hypermobility. These clinical findings are frequently contributors to shoulder and thoracic outlet symptoms and many times result in scapula anterior tipping and altered motor control of the scapula/thoracic and glenohumeral joints. In this classification of scapula dysfunction, the primary external visual feature is the anterior tilting of the scapula in the sagittal plane which produces the prominent inferior angle of the scapula. Many times the anterior tilting is associated with shortening of the pectoralis minor and poor function of the scapula muscles controlling the inferior angle. This myofascial and scapula dysfunction places the acromion in a position closer to the rotator cuff and humeral head and can thereby compromise the subacromial space. Additionally, this resultant scapula dyskinesia disrupts the length tension relationships of the shoulder complex's static and dynamic constraints and subsequently facilitates poor humeral head positioning on the glenoid. (The static constraints are the glenohumeral ligaments and the dynamic constraints are the deltoid and cuff musculature.) Therefore the treatment of this scapula dyskinesia and myofascial dysfunction is important for restoration of the normal upper quarter function.
The healthy function of the shoulder is inextricably dependent on the proper function and balanced relationships with its neighboring structures: cervical, thoracic, costal, and when one acknowledges the role of fascia, particularly the thoracodorsal fascia. Therefore, effective and expedient rehabilitation requires providers to have an excellent understanding of the functional anatomy of these structures and their dynamic inter-relatedness. Shoulder injuries are complex. Successful treatment of these injuries requires the providers have expert skills. Collaboration is essential in achieving optimal outcomes.
Patients should be instructed to continue active therapies at home as an extension of the treatment process in order to maintain improvement levels. Follow-up visits to reinforce and monitor progress and proper technique are recommended. Home exercise can include exercise with or without mechanical assistance or resistance and functional activities with assistive devices. Frequency times and duration of treatment apply only to diagnoses not previously covered in Section E.
The use of a patient completed pain drawing, visual analog scale (VAS), and functional outcome tools is highly recommended to help providers track progress. Functional objective goals including minimum clinically important difference (MCID) of the functional tools should be monitored and documented regularly to determine the effectiveness of treatment.
On occasion, specific diagnoses and post-surgical conditions may warrant durations of treatment beyond those listed as "maximum." Factors such as exacerbation of symptoms, re-injury, interrupted continuity of care and co-morbidities may also extend durations of care. Specific goals with objectively measured functional improvement during treatment must be cited to justify extended durations of care. It is recommended that, if no functional gain is observed after the number of treatments under "time to produce effect" have been completed, then alternative treatment interventions, further diagnostic studies, or further consultations should be pursued.
The following active therapies are listed in alphabetical order:
* Time to Produce Effect: 4 to 5 treatments.
* Frequency: 3 to 5 times per week.
* Optimum Duration: 4 to 6 weeks.
* Maximum Duration: 6 weeks.
* Postoperative therapy as ordered by the surgeon;
* Intolerance for active land-based or full-weight bearing therapeutic procedures;
* Symptoms that are exacerbated in a dry environment; and/or
* Willingness to follow through with the therapy on a regular basis.
The pool should be large enough to allow full extremity ROM and fully erect posture. Aquatic vests, belts, snorkels, and other devices may be used to provide stability, balance, buoyancy, and resistance.
* Time to Produce Effect: 4 to 5 treatments.
* Frequency: 3 to 5 times per week.
* Optimum Duration: 4 to 6 weeks.
* Maximum Duration: 8 weeks.
A self-directed program is recommended after the supervised aquatics program has been established, or, alternatively a transition to a self-directed dry environment exercise program.
* Time to Produce Effect: 4 to 5 treatments.
* Frequency: 3 to 5 times per week.
* Optimum Duration: 4 to 6 weeks.
* Maximum Duration: 6 weeks.
* Time to Produce Effect: 2 to 6 treatments.
* Frequency: 3 times per week.
* Optimum Duration: 8 weeks.
* Maximum Duration: 8 weeks. If functional gains are documented by a therapist, a home unit may be provided.
* Time to Produce Effect: 2 to 6 treatments.
* Frequency: 3 times per week.
* Optimum Duration: 4 to 8 weeks.
* Maximum Duration: 8 weeks.
There is strong evidence for those with subacromial impingement syndrome that;
There is some evidence that a scapular focused exercise treatment protocol that includes scapular motor control exercises, scapular mobilizations, and stretching is effective for reducing pain and improving shoulder function in patients with subacromial impingement syndrome.
Therapeutic exercise, with or without mechanical assistance or resistance, may include isoinertial, isotonic, isometric and isokinetic types of exercises. The exact type of program and length of therapy should be determined by the treating physician with the physical or occupational therapist. Refer to Section E. regarding specific diagnoses for details. In most cases, the therapist instructs the patient in a supervised clinic and home program to increase motion and subsequently increase strength. Usually, isometrics are performed initially, progressing to isotonic exercises as tolerated.
* Time to Produce Effect: 2 to 6 treatments.
* Frequency: 2 to 3 times per week.
* Optimum Duration: 16 to 24 sessions.
* Maximum Duration: 36 sessions. Additional visits may be necessary in cases of re-injury, interrupted continuity of care, exacerbation of symptoms, and in those patients with co-morbidities. Functional gains (including increased ROM) must be demonstrated to justify continuing treatment.
On occasion, specific diagnoses and post-surgical conditions may warrant durations of treatment beyond those listed as "maximum." Factors such as exacerbation of symptoms, re-injury, interrupted continuity of care, and comorbidities may also extend durations of care. Specific goals with objectively measured functional improvement during treatment must be cited to justify extended durations of care. It is recommended that, if no functional gain is observed after the number of treatments under "time to produce effect" have been completed, alternative treatment interventions, further diagnostic studies, or further consultations should be pursued.
The following passive therapies and modalities are listed in alphabetical order.
This is not generally recommended, please refer to Rotator Cuff Tear, Section E.10.
* Time to Produce Effect: 2 to 4 treatments.
* Frequency: Varies. Depending upon indication, between 2 to 3 times per day to 1 time a week. Provide home unit if frequent use.
* Optimum Duration: 1 month.
* Maximum Duration: Use beyond 6 weeks requires a home unit.
* Time to Produce Effect: One day.
* Frequency: Once.
* Optimum Duration: One week.
* Maximum Duration: 12 weeks.
* The arm may be immobilized in a sling for 1 to 12 weeks post-injury, depending upon the age of the patient and diagnosis. The patient is instructed in isometric exercises while in the sling for the internal and external rotators and the deltoid. Refer to specific diagnosis for details.
* Time to Produce Effect: 1 to 4 treatments.
* Frequency: 3 times per week with at least 48 hours between treatments.
* Optimum Duration: 8 to 10 treatments.
* Maximum Duration: 10 treatments.
High velocity, low amplitude (HVLA) technique, chiropractic manipulation, osteopathic manipulation, muscle energy techniques, counter strain, and non-force techniques are all types of manipulative treatment. This may be applied by osteopathic physicians (D.O.), chiropractors (D.C.), properly trained physical therapists (P.T.), properly trained occupational therapists (O.T.), or properly trained medical physicians. Under these different types of manipulation exist many subsets of different techniques that can be described as a) direct- a forceful engagement of a restrictive/pathologic barrier, b) indirect- a gentle/non-forceful disengagement of a restrictive/pathologic barrier, c) the patient actively assists in the treatment and d) the patient relaxing, allowing the practitioner to move the body tissues. When the proper diagnosis is made and coupled with the appropriate technique, manipulation has no contraindications and can be applied to all tissues of the body. Pre-treatment assessment should be performed as part of each manipulative treatment visit to ensure that the correct diagnosis and correct treatment is employed.
* Time to Produce Effect for all types of manipulative treatment: 1 to 6 treatments.
* Frequency: Up to 3 times per week for the first 3 weeks as indicated by the severity of involvement and the desired effect.
* Optimum Duration: 10 treatments.
* Maximum Duration: 12 treatments. Additional visits may be necessary in cases of re-injury, interrupted continuity of care, exacerbation of symptoms, and in those patients with co-morbidities. Functional gains including increased ROM must be demonstrated to justify continuing treatment.
* Time to Produce Effect: Variable, depending upon use.
* Frequency: 3 to 7 times per week.
* Optimum Duration: 8 weeks.
* Maximum Duration: 2 months.
* Time to Produce Effect: Immediate.
* Frequency: 1 to 2 times per week.
* Optimum Duration: 6 weeks.
* Maximum Duration: 2 months.
There is some evidence that 6 sessions of manual physical therapy over a three week period are as effective as an injection of 40 mg triamcinolone for relief of symptoms of shoulder impingement symptoms and impairment up to one year after initial treatment. The same study also showed reduced use of health care services one year in the manual therapy group.
* Time to Produce Effect: 6 to 9 treatments.
* Frequency: 3 times per week.
* Optimum Duration: 6 weeks.
* Maximum Duration: 2 months.
* Time to Produce Effect: 2 to 3 weeks.
* Frequency: 2 to 3 times per week.
* Optimum Duration: 4 to 6 weeks.
* Maximum Duration: 6 weeks.
* Time to Produce Effect: Immediate.
* Frequency: 2 to 5 times per week.
* Optimum Duration: 3 weeks as primary, or up to 2 months if used intermittently as an adjunct to other therapeutic procedures.
* Maximum Duration: 2 months.
* Time to Produce Effect: Immediate.
* Frequency: Variable.
* Optimum Duration: 3 sessions.
* Maximum Duration: 3 sessions. If beneficial, provide with home unit or purchase if effective.
Ultrasound with electrical stimulation is concurrent delivery of electrical energy that involves a dispersive electrode placement. Indications include muscle spasm, scar tissue, and pain modulation and muscle facilitation. There is some evidence that ultrasound compared with sham ultrasound as part of an overall rehabilitation protocol including exercise, stretching, and heat treatments have approximately equal effects in the treatment of patients with adhesive capsulitis. There is no evidence that phonophoresis should be used as an isolated treatment. All phonophoresis should be used in conjunction with manipulative and physical therapy/rehabilitation.
Phonophoresis is the transfer of medication to the target tissue to control inflammation and pain through the use of sonic generators. These topical medications include, but are not limited to, steroidal anti-inflammatories and anesthetics.
* Time to Produce Effect: 6 to 15 treatments.
* Frequency: 3 times per week.
* Optimum Duration: 4 to 8 weeks.
* Maximum Duration: 2 months.
All operative interventions must be based upon positive correlation of clinical findings, clinical course and diagnostic tests. A comprehensive assimilation of these factors must lead to a specific diagnosis with positive identification of pathologic condition(s). It is imperative to rule out non-physiologic modifiers of pain presentation or non-operative conditions mimicking operative conditions (e.g. peripheral neuropathy, myofascial pain, scleratogenous or sympathetically mediated pain syndromes, psychological), prior to consideration of elective surgical intervention.
In addition, operative treatment is indicated when the natural history of surgically treated lesions is better than the natural history for non-operatively treated lesions. All patients being considered for surgical intervention should first undergo a comprehensive neuro-musculoskeletal examination to identify mechanical pain generators that may respond to non-surgical techniques or may be refractory to surgical intervention.
Structured rehabilitation interventions should strongly be considered post-operatively in any patient not making expected functional progress within three weeks after surgery.
Post-operative therapy will frequently require a repeat of the therapy provided pre-operatively. Refer to Section F. Therapeutic Procedures - Non-operative, and consider the first post-operative visit as visit number one, for the time frame parameters provided.
Return-to-work restrictions should be specific according to the recommendation in Section F.13. Return-To-Work.
The patient and treating physician have identified 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 including home exercise. The provider should be especially careful to make sure the patient understands the amount of postoperative treatment required and the length of partial- and full-disability expected post-operatively. The patient should have committed to the recommended post-operative treatment plan and fully completed the recommended active, manual and pre-operative treatment plans.
Informed decision making should be documented for all invasive procedures. This must include a thorough discussion of the pros and cons of the procedure and the possible complications as well as the natural history of the identified diagnosis. Since most patients with the most common conditions will improve significantly over time, without invasive interventions, patients must be able to make well-informed decisions regarding their treatment.
Fusion of the shoulder. Used as a salvage procedure.
Secondary to severe trauma and failure of other procedures.
Shoulder function is minimal and is usually associated with severe rotator cuff pathology.
See Specific Diagnostic sections.
Inability to perform activities of daily living due to failed previous procedures and severe chronic pain unresponsive to non-addicting medication.
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.
Informed decision making should be documented for all invasive procedures. This must include a thorough discussion of the pros and cons of the procedure and the possible complications as well as the natural history of the identified diagnosis. Since most patients with the most common conditions will improve significantly over time, without invasive interventions, patients must be able to make well-informed decisions regarding their treatment.
Smoking may affect soft tissue healing through tissue hypoxia. Patients should be strongly encouraged to stop smoking and be provided with appropriate counseling by the physician. If a treating physician recommends a specific smoking cessation program peri-operatively, this should be covered by the insurer. Physicians may monitor smoking cessation with laboratory tests such as cotinine levels. The surgeon will make the final determination as to whether smoking cessation is required prior to surgery.
An individualized rehabilitation program will be based upon communication between the surgeon and the therapist. Therapy may begin 6 weeks to 3 months after surgery, depending on recovery. Occupational therapy is critical to improve function in activities of daily living. Assistive devices may be necessary.
* Time frames for therapy (excluding aquatic therapy).
* Optimum: 12 to 24 sessions.
* Maximum: 36 sessions. If functional gains are being achieved, additional visits may be authorized for the patient to achieve their functional goal.
Surgical removal of internal or external fixation device, commonly related to fracture repairs.
Following healing of a post-traumatic injury that required fixation or reconstruction using instrumentation.
Local pain to palpation, swelling, erythema.
Active and/or passive therapy for local modalities, activity modification. Nonsteroidal Anti-Inflammatory Drugs (NSAIDs).
Persistent local pain, irritation around hardware.
Removal of instrumentation may be accompanied by scar release/resection, capsular release, and/or manipulation. Some instrumentation may be removed in the course of standard treatment without local irritation.
Include an individualized rehabilitation program based upon communication between the surgeon and the therapist.
Early rehabilitation interventions are recommended to maintain range-of-motion and progressive strengthening.
* Frequency: 3 to 5 times per week for the first 2 weeks, 3 times per week for the following 2 weeks, then 1 to 2 times per week.
* Optimum Duration: 6 to 8 weeks with progression to home exercise and or aquatic therapy.
* 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.
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. The injured worker should adhere to the written return to work restrictions not only in the workplace, but at home and for 24 hours a day.
Osteoarticular allograft transplantation is a procedure which places a plug of cadaveric bone tissue into a chondral defect at the articular surface of an injured bone. Its use has been described in case reports in the treatment of recurrent shoulder instability when large humeral head defects (Hill-Sachs lesions) are thought to be responsible for repeated episodes of subluxation.
Cases with cartilaginous damage to both the humeral head and the glenoid fossa, or larger areas of damage, tend to have more complications and worse outcomes with or without treatment. There is no evidence to support osteochondral allograft transplantation, nor autologous chondrocyte implantation in the shoulder. Debridement and microfracture are commonly performed, especially when cartilage damage is found during other procedures and are acceptable procedures in these cases. At this time, there is limited information concerning the effectiveness of OATS and appropriate application.
Implantation and transplantation require prior authorization or are not generally recommended. They may be appropriate for younger active patients with full thickness cartilage damage who would otherwise qualify for hemiarthroplasty. Hemiarthroplasty or total shoulder replacement are not recommended for younger patients.
No randomized trials of rhBMP-2 for humerus fractures have been found at the time of this guideline publication. Currently, there is a paucity of evidence for its use in fractures of the upper extremity.
Prosthetic replacement of the articulating surfaces of the shoulder joint. There are three types of procedures commonly performed:
Usually from post-traumatic arthritis, or from trauma resulting in severe humeral head fractures.
Radiographs or CTs demonstrating humeral head fracture. CTs to explore the status of rotator cuff and associated muscles and tendons, the presence of arthritis or subluxation, or superior migration of the humeral head. For revision procedures, a non-MRI arthrography or sonogram may be important to better visualize associated pathology.
The decision of whether a patient receives a total arthroplasty or a hemiarthroplasty depends on the surgeon's discretion. Factors to consider are the presence of glenoid erosions, humeral head subluxation, and rotator cuff strength. There is good evidence that functional outcomes are better at two years for total shoulder arthroplasty as compared with hemiarthroplasty in patients with glenohumeral osteoarthritis.
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.
Informed decision making should be documented for all invasive procedures. This must include a thorough discussion of the pros and cons of the procedure and the possible complications as well as the natural history of the identified diagnosis. Since most patients with the most common conditions will improve significantly over time, without invasive interventions, patients must be able to make well-informed decisions regarding their treatment.
Allergy to implant components can play a role in arthroplasty failure. Pre-operative screening of patients with the following questions is suggested:
If there are positive or equivocal responses to any of the questions, patch and or lymphocyte proliferation testing is recommended in advance of surgery.
Because smokers have a higher risk of delayed bone healing and post-operative costs, it is recommended that insurers cover a smoking cessation program peri-operatively. If a treating physician recommends a specific smoking cessation program peri-operatively, this should be covered by the insurer. Physicians may monitor smoking cessation with laboratory tests such as cotinine levels. The surgeon will make the final determination as to whether smoking cessation is required prior to surgery.
Partial humeral head prosthesis may be useful in some cases. Cementless surface humeral head replacement may be indicated in young patients with glenohumeral arthritis and retained glenoid cartilage or osteonecrosis of the humeral head.
A large follow-up of more than 1000 cases found that total shoulder arthroplasty function was better than hemiarthroplasty at one year and that resurfacing hemiarthroplasty appeared better at one year than stemmed hemiarthroplasty. The revision rate for resurfacing hemiarthroplasty was 10% at 5 year follow-up and patients younger than 55 had a worse functional score than older patients. A small follow-up of ten patients with hemiarthroplasty versus total shoulder replacement (TSR) found no statistical difference in pain or function although more TSR patients were pain free. Glenoid erosion resulted in reversion to TRS for 1/3 of the hemiarthroplasty patients.
Reverse arthroplasty may also be the treatment for failed hemiarthroplasty with extensive cuff tears and/or instability. Most literature confirms that the complication rate is higher and the success rate lower when reverse arthroplasty is performed on a previously operated joint. Older patients report similar activity levels after reverse arthroplasty compared to those with total or hemiarthroplasty. Fifty-three percent of patients with reverse arthroplasty are able to perform high demand activities. The most common complaint was inability to reach overhead.
Prosthetic replacement of the articular surfaces of the shoulder.
* Aquatic exercises initially under therapists or surgeon's direction then progressed to independent pool program.
* Progression to a home exercise is essential. Therapy should continue for at least 10 weeks with transition to home exercises at the beginning of each new phase of therapy.
* Gradual resistive exercise from 3 to 12 months, with gradual return to full activity at 6 to 12 months.
* Time frames for therapy (excluding aquatic therapy).
* Optimum: 12 to 24 sessions.
* Maximum: 36 sessions. If functional gains are being achieved additional visits may be authorized for the patient to achieve their functional goal.
depending on the procedure.
Interscalene anesthesia is generally performed for surgical procedures such as subacromial debridement with or without rotator cuff repair. There is some evidence that interscalene regional anesthetic block (ISB) at the time of elective arthroscopic rotator cuff repair results in faster hospital discharge than general anesthesia, therefore ISB is recommended, provided the following precautions are taken.
Interscalene brachial plexus blocks (ISBs) almost always cause hemidiaphragmatic dysfunction acutely, which causes respiratory impairment. This can be symptomatic. Smaller volumes and lower concentrations of bupivacaine may be preferable. Permanent injury of the phrenic nerve has been reported rarely. Permanent or temporary paralysis of the hemidiaphragm can cause significant respiratory impairment, particularly in those with underlying lung disease. There is some evidence that in the setting of elective shoulder surgery when interscalene brachial plexus block is being used for anesthesia, and in the absence of chronic pulmonary or cardiac disease, needle guidance with ultrasound reduces the risk of diaphragmatic paresis in comparison to nerve stimulation guidance.The use of ultrasound guidance on all ISBs is encouraged. Alternative blocks and/or pre-operative pulmonary evaluation should be considered in patients with underlying lung disease and in smokers.
There is some evidence that continuous ISB for 48 hours is associated with somewhat greater pain relief at the seventh postoperative day than single injection ISB, but there is little if any difference in the use of opioids at that time between continuous and single injection anesthesia. There is no convincing evidence that continuous ISB is advantageous and due to the higher cost of ISB and the common respiratory compromise that may be prolonged with continuous use, continuous ISB is not recommended.
There is some evidence that in the setting of arthroscopic rotator cuff repair, a subacromial infusion of 4 ml/hour of 0.5% bupivacaine for 50 hours does not reduce postoperative pain or oxycodone consumption in a clinically meaningful way. Therefore, it is not recommended.
7 CCR 1101-3 R17 Ex 04
7 CCR 1101-3 has been divided into smaller sections for ease of use. Versions prior to 01/01/2011 and rule history are located in the first section, 7 CCR 1101-3. Prior versions can be accessed from the All Versions list on the rule's current version page. To view versions effective on or after 01/01/2011, select the desired part of the rule, for example 7 CCR 1101-3 Rules 1-17, or 7 CCR 1101-3 Rule 18: Exhibit 1.