7 Colo. Code Regs. § 1101-3-17-08-4
Recommendation 1. A detailed history of symptom onset, past medical history, physical examination, and a detailed neurologic examination are required at the initial evaluation.
Recommendation 2. Initial functional assessment is strongly recommended. See examples of functional outcome measures in the Appendix.
Recommendation 3. Compartment pressure testing is acceptable for patients who present with symptoms consistent with compartment syndrome.
Recommendation 4. Electromyography and nerve conduction studies are recommended for patients with suspected neural involvement and persistent symptoms that are unresponsive to at least 6 weeks of conservative care emphasizing Active Therapies as outlined in Section 7.a.i. It is acceptable to test the non-affected side for comparison.
Recommendation 5. Surface electromyography and current perception threshold evaluation are not recommended.
Arthrography.
Recommendation 6. It is acceptable to add arthrography to magnetic resonance imaging (MRI) or computed tomography (CT) advanced imaging studies for patients with previous shoulder surgery, complex fractures, and those with a history and physical findings suggestive of shoulder instability, rotator cuff tear, osteochondral defects, intra-articular loose bodies, and/or labral tear.
Recommendation 7. Conventional (X-ray) arthrography is acceptable for evaluation of patients with metal implants and previous shoulder surgery.
Bone Scan (All Radioisotopes).
Recommendation 8. Radioisotope bone scanning is rarely used. It is acceptable when there is clinical suspicion for metastatic or primary bone tumors, occult or stress fractures, osteomyelitis, infection, or other inflammatory lesions.
Computed Tomography (CT).
Recommendation 9. A computed tomography (CT) scan is acceptable for better visualization of bone and further evaluation of masses and suspected fractures not clearly identified on X-ray radiographic evaluation.
Diagnostic Sonography.
Recommendation 10. Diagnostic ultrasound before 4 weeks post-injury is acceptable for cases with the presence of significant weakness on elevation or rotation, a palpable defect at the greater tuberosity, or an acute traumatic injury.
Recommendation 11. Diagnostic ultrasound is acceptable for visualization of soft tissue structures when shoulder pain and functional deficits persist after at least 4 weeks of conservative care emphasizing Active Therapies as outlined in Section 7.a.i.
Magnetic Resonance Imaging (MRI).
Recommendation 12. Magnetic resonance imaging (MRI) before 4 weeks post-injury is acceptable for cases with the presence of significant weakness on elevation or rotation, a palpable defect at the greater tuberosity, or an acute traumatic injury.
Recommendation 13. Magnetic resonance imaging (MRI) is acceptable for visualization of soft tissue structures when shoulder pain and functional deficits persist after at least 4 weeks of conservative care emphasizing Active Therapies as outlined in Section 7.a.i.
Vascular Imaging (Doppler Ultrasonography, Plethysmography, Arteriogram, or Venogram).
Recommendation 14. Doppler ultrasonography or plethysmography are acceptable for diagnosing vascular and circulatory disorders.
Recommendation 15. Arteriogram and venogram are acceptable to better visualize suspected vascular injury or disease not clearly identified following doppler ultrasonography or plethysmography.
X-ray (Radiograph).
Recommendation 16. X-ray studies of the shoulder are acceptable.
Recommendation 17. Joint aspiration and fluid analysis is acceptable in cases of suspected infection, inflammation, or crystal-induced arthropathies.
Recommendation 18. When clinically indicated, early laboratory studies are acceptable to evaluate for systemic illness, infection, neoplasia, or underlying rheumatologic or connective tissue disorder.
Recommendation 19. A psychological screen is encouraged as a routine part of clinical care and is required as soon as any of the following barriers to functional recovery are identified (see examples of psychological screens in the Appendix):
* limited patient engagement in recovery, or
* activity avoidance, or
* catastrophization due to pain, or
* avoidance of essential recovery activities, or
* low expectations of recovery, or
* ineffective coping skills, or
* loss of vocational connection.
Individuals with barriers to functional recovery may benefit from an interdisciplinary approach to care.
Recommendation 20. A formal psychological or psychosocial evaluation is acceptable for those with elevated scores on psychosocial screening tests and/or for surgical candidates. It is required for patients not making expected progress within 6 weeks of injury and whose subjective symptoms do not correlate with objective signs and tests. See the Behavioral and Psychological Interventions section.
Diabetic Screening.
Recommendation 21. Diabetic screening and monitoring is acceptable when poorly controlled diabetes is expected to negatively impact claim-related medical outcomes (e.g., prior to surgery; before and after steroid injection).
Implant Component Allergy Screening and Testing.
Recommendation 22. Screening and testing for allergy to implant components is acceptable.
Osteoporosis Screening and Treatment.
Recommendation 23. Osteoporosis screening tests, including bone density tests and vitamin D levels, are acceptable for patients who experience a fracture and are at risk for osteoporosis.
Recommendation 24. Claim-related treatment is acceptable when untreated osteoporosis is expected to negatively impact medical outcomes, but long-term care for osteoporosis is not covered under workers' compensation.
Recommendation 25. Medical causation must establish that the condition or injury results from a specific injury, an aggravation of an underlying condition, or a previously asymptomatic condition made symptomatic by a work-related exposure.
Recommendation 26. Occupational risk factors are listed in Sections 4.c.ii-4.c.x below. The risk factors are based on available evidence related to medical causation. Due to limited evidence, the occupational exposures listed are not fully comprehensive, and work-relatedness must be determined on a case-by-case basis.
Occupational risk factors may include:
* a fall with a landing on the point of the shoulder, driving the acromion downward; or
* a backward and outward force on the shoulder, such as a fall on an outstretched hand or elbow with an adducted arm.
Bursitis may occur with an occupational strain or tendinopathy. It may be caused by work-related trauma, chronic overuse (particularly repetitive reaching away from the body or overhead), abnormal scapular mechanics, scapular dyskinesia, arthritis, and/or acute or chronic infection.
Symptomatic calcific tendonitis may be related to degeneration of the rotator cuff tendons. This can be aggravated by work exposures related to the affected tendon.
Occupational risk factors may include:
* a crushing, twisting, and/or high-energy fall; or
* trauma to the shoulder, arm, hand, and/or chest wall.
Nerve Injury, General.
Occupational risk factors may include:
* trauma from an injury or surgery;
* nerve stretch such as from traction of the shoulder, arm, and/or chest wall; or
* direct internal compression, such as secondary to a hematoma or post-traumatic cyst.
Nerve Injury, Specified.
In addition to the general risk factors for nerve injury described above, there are also occupational risk factors associated with individual nerve injuries:
Axillary Nerve Injury.
* upward pressure on the axilla;
* humeral neck fracture; or
* dislocation of the shoulder.
Brachial Plexus Injury.
* weight-lifting;
* carrying heavy backpacks;
* shoulder subluxation;
* clavicular fracture;
* forceful deviation of the head away from the arm; or
* direct forceful impact to the brachial plexus region.
Long Thoracic Nerve Injury.
* chronic, repeated, or forceful shoulder depression;
* severe traction with the shoulder compressed and the head tilted; or
* repeated forward, overhead motion of the arms with the head tilted or rotated to the unaffected side.
Musculocutaneous Nerve Injury.
* backpack use;
* repetitive overhead motions with force, such as pitching a baseball;
* heavy weight-lifting;
* malposition during sleep or surgery; or
* a sudden, forceful extension of the elbow.
Spinal Accessory Nerve Injury.
* traumatic, forceful, downward compression of the shoulder; or
* deviation of the head away from the traumatized shoulder.
Suprascapular Nerve Injury.
* a fall on an outstretched arm; or
* supraclavicular trauma, stretch, friction, or compression through the suprascapular notch or the spinoglenoid notch.
Post-traumatic stiff shoulder should include a history of work-related injury or surgery resulting in significantly decreased range of motion.
Occupational risk factors may include:
* a direct traumatic blow to the shoulder;
* a fall on an outstretched arm;
* repetitive overhead motions with force, such as pitching a baseball;
* a significant traction injury to the arm;
* direct fall on the shoulder resulting in posteriorly directed forces; or
* electrocution and/or seizure.
Biceps Tendon Disorder.
Occupational risk factors may include:
* acute trauma to the long head of the biceps tendon of the shoulder girdle;
* acute distractive force or transection of the tendon; or
* an extension force applied to a flexed elbow.
Rotator Cuff Tear.
Occupational risk factors may include sudden shoulder trauma, such as breaking a fall with an overhead railing or an outstretched arm.
Rotator Cuff Tendinopathy.
Rotator cuff 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.
Chronic Shoulder Tendon Disorders.
Risk factors include any of the following; however, this is not a comprehensive list, and work-relatedness must be determined on a case-by-case basis.
* Overhead work consisting of additive time per day of at least 30 minutes/day for a minimum of 5 years.
* Work that requires shoulder movement at the rate of 15-36 repetitions per minute and no 2-second pauses for 80% of the work cycle.
* Work that requires shoulder movement with force and has no 2-second pauses for 80% of the work cycle.
* It is also likely that jobs requiring daily heavy lifting at least 10 times per day over the years may contribute to shoulder disorders.
* Vibration can also be considered an additional risk factor.
Occupational risk factors may include:
* compression injury, such as:
* a fall on an outstretched arm with the shoulder in forward flexion and abduction, or
* a direct blow to the glenohumeral joint;
* traction injury, such as:
* repetitive overhead throwing,
* experiencing a sudden pull when losing hold of a heavy object, or
* attempting to break a fall from a height;
* repetitive overhead motions with force, such as pitching a baseball;
* a fall on an adducted arm with upward force directed on the elbow; or
* driving an automobile that is rear-ended.
7 CCR 1101-3-17-08-4