5.1 ACROMIOCLAVICULAR JOINT SPRAINS/DISLOCATIONS An acute acromioclavicular (AC) joint injury is frequently referred to as a shoulder separation. There are six classifications of an AC joint separation which are based upon the extent of ligament damage and bony displacement: . Type I Partial disruption of the AC ligament and capsule.
. Type II Sprains consisting of a ruptured AC ligament and capsule with incomplete injury to the coracoclavicular (CC) ligament, resulting in minimal AC joint subluxation.
. Type III Separation or complete tearing of the AC ligament and/or CC ligaments, possible deltoid trapezius fascial injury, and dislocation of the AC joint.
. Type IV Dislocation consisting of a displaced clavicle that penetrates posteriorly through or into the trapezius muscle.
. 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.
Types 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, see section 5.4.8, Impingement Syndrome.
5.1.1 History and Initial Diagnostic Procedures (AC Joint Sprains/Dislocations): . Occupational Relationship - generally, workers sustain an AC joint injury when they land on the point of the shoulder, driving the acromion downward, or fall on an outstretched hand or elbow, creating a backward and outward force on the shoulder. It is important to rule out other sources of shoulder pain from an acute injury, including rotator cuff tear, fracture and nerve injury.
5.1.2 Physical Findings (AC Joint Sprains/Dislocations) may include:5.1.2.1 Tenderness at the AC joint with, at times, contusions and/or abrasions at the joint area; prominencesymmetry of the shoulder can be seen; and/or5.1.2.2 One finds decreased shoulder motion and with palpation, the distal end of the clavicle is painful; there may be increased clavicular translation; cross-body adduction can cause exquisite pain.5.1.3 Laboratory Tests (AC Joint Sprains/Dislocations): are not indicated unless a systemic illness or disease is suspected.5.1.4 Testing Procedures (AC Joint Sprains/Dislocations):5.1.4.1 Plain x-rays may include:5.1.4.1.2 AP radiograph of the shoulder with the beam angled 10 cephalad (Zanca view);5.1.4.1.3 Axillary lateral views; and5.1.4.1.4 Y-view also called a StrykerStyrker notch view;5.1.4.1.5 Stress view; side-to-side comparison with 10-15 lbs. of weight in each hand.5.1.4.2 Adjunctive testing, such as standard radiographic techniques (sonography, arthrography or MRI), should be considered when shoulder pain is refractory to 4-6 weeks of non-operative conservative treatment and the diagnosis is not readily identified by a good history and clinical examination.5.1.5 Non-operative Treatment Procedures (AC Joint Sprains/Dislocations): may include: 5.1.5.1 Procedures outlined in this Section 5.3.5 such as thermal treatment and immobilization (up-to-6 weeks for Type I-III AC joint separations). Immobilization treatments for Type III injuries are controversial and may range from a sling to surgery.5.1.5.2 Medication, such as nonsteroidal anti-inflammatories and analgesics, would be indicated; narcotics are not normally indicated but may be needed after an acute injury. In the face of chronic acromioclavicular joint pain, a series of injections with or without cortisone, may be injected 6-8 times per year.5.1.5.3 Physical medicine interventions, as outlined in Section 5.3.5, should emphasize a progressive increase in range of motion without exacerbation of the AC joint injury. With increasing motion and pain control, a strengthening program should be instituted and return to modified/limited duty would be considered at this time. By 8-11 weeks, with restoration of full motion, return to full duty should be anticipated.5.1.6 Operative Procedures (AC Joint Sprains/Dislocations): 5.1.6.1 With a Type III AC joint injury, an appropriate orthopedic consultation should be considered initially, but must be considered when conservative care fails to increase function.5.1.6.2 With a Type IV-VI AC joint injury, an orthopedic surgical consultation is recommended initially.5.1.7 Post-Operative Procedures (AC Joint Sprains/Dislocations): should be coordinated by the orthopedic physician working with the interdisciplinary team. Keeping with the therapeutic and rehabilitation procedures found in this Section 5.3.5. Non-operative Treatment Procedures, the patient could be immobilized for 2-3 weeks, restricted in activities, both work-related and avocational for 8-12 weeks while undergoing rehabilitation, and be expected to progress to return to full duty based upon the his/her response to rehabilitation and the demands of the job.5.2 ADHESIVE CAPSULITIS/FROZEN SHOULDER DISORDERS Adhesive capsulitis of the shoulder, also known as frozen shoulder disorder, is a soft tissue lesion of the glenohumeral joint resulting in restrictions of passive and active range of motion. Occupational adhesive capsulitis arises secondarily to any chest or upper extremity trauma. Primary adhesive capsulitis is rarely occupational in origin. The disorder goes through stages, specifically: . Stage 1 Consists of acute pain with some limitation in range of motion; generally lasting 2-9 months.
. Stage 2 Characterized by progressive stiffness, loss of range-of-motion, and muscular atrophy; it may last an additional 4-12 months beyond Stage 1.
. Stage 3 Characterized by partial or complete resolution of symptoms and restoration of range-of-motion and strength; it usually takes an additional 6-9 months beyond Stage 2.
5.2.1 History and Initial Diagnostic Procedures (Adhesive Capsulitis/Frozen Shoulder Disorder): 5.2.1.1 Occupational Relationship - There should be some history of work related injury. Often adhesive capsulitis is seen with impingement syndrome or other shoulder disorders; refer to appropriate subsection of this guideline.5.2.1.2 Patient will usually complain of pain in the sub-deltoid region, but occasionally over the long head of the biceps or radiating down the lateral aspect of the arm to the forearm. Pain is often worse at night with difficulty sleeping on the involved side. Motion is restricted and painful.5.2.2 Physical Findings (Adhesive Capsulitis/Frozen Shoulder Disorder): Restricted active and passive glenohumeral range of motion is the primary physical finding. It may be useful for the examiner to inject the glenohumeral joint with lidocaine and then repeat range of motion to rule out other shoulder pathology; lack of range of motion confirms the diagnosis. Postural changes and secondary trigger points along with atrophy of the deltoid and supraspinatus muscles may be seen.5.2.3 Laboratory Tests (Adhesive Capsulitis/Frozen Shoulder Disorder): are not indicated unless systemic illness or disease is suspected.5.2.4 Testing Procedures (Adhesive Capsulitis/Frozen Shoulder Disorder): 5.2.4.1 Plain x-rays are generally not helpful except to rule out concomitant pathology.5.2.4.2 Adjunctive testing, such as standard radiographic techniques (sonography, arthrography or MRI), to rule out concomitant pathology should be considered when shoulder pain is refractory to 4-6 weeks of non-operative conservative treatment and the diagnosis is not readily identified by a good history and clinical examination.5.2.4.3 Arthrography may be helpful in ruling out other pathology. Arthrography can also be therapeutic as steroids and/or anesthetics may be injected and a brisement or distension arthrogram can be done at the same time (refer to the next subsection on non-operative treatment procedures for further discussion).5.2.5 Non-operative Treatment (Adhesive Capsulitis/Frozen Shoulder Disorder): address the goal to restore and maintain function and may include: 5.2.5.1 A home exercise program either alone or in conjunction with a supervised rehabilitation program is the mainstay of treatment. Additional interventions may include thermal treatment, ultrasound, TENS, manual therapy, and passive and active range-of-motion exercises; as the patient progresses, strengthening exercises should be included in the exercise regimen; refer to Section 5.3.5, Non-operative Treatment Procedures.5.2.5.2 Medications, such as NSAIDs and analgesics, may be helpful. Rarely, the use of oral steroids is indicated to decrease acute inflammation. Narcotics narcotics can be used for short-term pain control; narcotics are indicated for post-manipulation or post-operative cases; refer to this Section 6.0, Medications.5.2.5.3 Occasionally, subacromial bursal and/or glenohumeral steroid injections can decrease inflammation and allow the therapist to progress functional exercise and range of motion. Injections should be limited to two injections to any one site, given at least one month apart.5.2.5.4 In cases that are refractory to conservative therapy lasting at least 3-6 months and in whom range of motion remains significantly restricted (abduction less than 90°), the following more aggressive treatment may be considered: 5.2.5.4.1 Distension arthrography or "brisement" in which saline, an anesthetic and usually a steroid are forcefully injected into the shoulder joint causing disruption of the capsule. Early and aggressive physical medicine to maintain range of motion and restore strength and function should follow distension arthrography or manipulation under anesthesia; return to work with restrictions should be expected within one week of the procedure; return to full duty is expected within 4-6 weeks.5.2.6 Operative Procedures (Adhesive Capsulitis/Frozen Shoulder Disorder): For cases failing conservative therapy of at least 3-6 months duration and which are significantly limited in range-of-motion (abduction less than 90°), the following operative procedures may be considered: 5.2.6.1 Manipulation under anesthesia which may be done in combination with steroid injection(s) or distension arthrography; and5.2.6.2 In rare cases, refractory to conservative treatment and in which manipulation under anesthesia is contraindicated, an open capsular release or arthroscopy with resection of the coracohumeral and/or coracoacromial ligaments may be done; other disorders, such as impingement syndrome, may also be treated at the same time.5.2.7 Post-Operative Procedures (Adhesive Capsulitis/Frozen Shoulder Disorder): would include an individualized rehabilitation program based upon communication between the surgeon and the therapist. . Early, aggressive and frequent physical medicine interventions are recommended to maintain range of motion and progress strengthening; return to work with restrictions after surgery should be discussed with the treating provider; patient should be approaching MMI within 8-12 weeks post-operative, however, coexistence of other pathology should be taken into consideration.
5.5 BURSITIS OF THE SHOULDER 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 that generally presents with localized pain and tenderness of the shoulder. 5.5.1 History and Initial Diagnostic Procedures (Bursitis of the Shoulder): . Occupational Relationship - onset of symptoms, date, mechanism of onset, and occupational history and current requirements should be correlated with the intensity, character, duration and frequency of associated pain and discomfort.
. History may include nocturnal pain, pain with over-the-shoulder activities, feeling of shoulder weakness, prior treatment for presenting complaint(s), specific limitations of movement and pertinent familial history.
5.5.2 Physical Findings (Bursitis of the Shoulder): may include: . Palpation elicits localized tenderness over the particular bursa or inflamed tendon; loss of motion during activity;
. Painful arc may be seen between 40-120° and/or
. Bursitis may be associated with other shoulder injury diagnoses such as impingement, rotator cuff instability, tendonitis, etc.; refer to applicable diagnosis subsections for additional guidelines.
5.5.3 Laboratory Tests (Bursitis of the Shoulder): may be used to rule out systemic illness or disease when proper clinical presentation indicates the necessity for such testing. Testing could include sedimentation rate, rheumatoid profile, complete blood count (CBC) with differential, serum uric acid level, routine screening of other medical disorders may be necessary, as well as bursal aspiration with fluid analysis.5.5.4 Testing Procedures (Bursitis of the Shoulder):5.5.4.1 Plain x-rays include: 5.5.4.1.1 AP view visualizes elevation of the humeral head, indicative of absence of the rotator cuff due to a tear;
5.5.4.1.2 Lateral view in the plane of the scapula or an axillary view determines if there is anterior or posterior dislocation or the presence of a defect in the humeral head (a
Hill-Sachs lesion);
5.5.4.1.3 30° caudally angulated AP view determines if there is a spur on the anterior/ interior surface of the acromion and/or the far end of the clavicle; and
5.5.4.1.4 Outlet view determines if there is a downwardly tipped acromion.5.5.4.2 Adjunctive testing, such as standard radiographic techniques (sonography, arthrography or MRI), should be considered when shoulder pain is refractory to 4-6 weeks of non-operative conservative treatment and the diagnosis is not readily identified by a good history and clinical examination.5.5.5 Non-operative Treatment Procedures (Bursitis of the Shoulder): 5.5.5.1 Benefits may be achieved through procedures outlined in Section 5.3.5. Non-operative Treatment Procedures, such as immobilization, therapeutic exercise, alteration of occupation and work station, thermal therapy, TENS unit, and ultrasound.5.5.5.2 May return to work without overhead activities and lifting with involved arm until cleared by physician for those and heavier activities.5.5.5.3 Additional modalities/treatment procedures may include biofeedback; physical medicine and rehabilitation including instruction in therapeutic exercise, proper work technique and manual therapy; vocational rehabilitation, vocational assessment and interdisciplinary team approach.5.5.5.4 Medications such as nonsteroidal anti-inflammatories and analgesics. Subacromial space injection may be therapeutic but should be limited to 3 injections per year in the same location. Injection of the corticosteroids directly into the tendons should be avoided due to possible tendon breakdown and degeneration. There are rare occasions where intratendinous injections may be cautiously considered if calcific tendonitis is present. Rarely are injections used in patients under 30 years of age.
5.5.6 Operative Procedures (Bursitis of the Shoulder): are not commonly indicated for pure bursitis; refer to other appropriate diagnoses in Section 5.0. Specific Diagnosis, Testing and Treatment Procedures.5.6 IMPINGEMENT SYNDROME A collection of symptoms, not a pathologic diagnosis. The symptoms result from the encroachment of the acromion, coracoacromial ligament, coracoid process, and/or the AC joint of the rotator cuff mechanism that passes beneath them as the shoulder is moved. The cuff mechanism is intimately related to the coracoacromial arch. Separated only by the thin lubricating surfaces of the bursa, compression and friction can be minimized by several factors, such as . 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 impingement syndrome may be associated with AC joint arthritis, both partial- and full-thickness rotator cuff tears, adhesive capsulitis/frozen shoulder and bursitis. Normal function of the rotator cuff mechanism and biceps tendon assist to diminish impingement syndrome.
5.6.1 History and Initial Diagnostic Procedures (Impingement Syndrome): 5.6.1.1 Occupational Relationship - established repetitive overuse of the upper extremity; many times this is seen with constant overhead motion.5.6.1.2 History may include: 5.6.1.2.1 Delayed presentation; since the syndrome is usually not an acute problem; patients will access care if their symptoms have not resolved with rest, time and
"trying to work it out";
5.6.1.2.2 Complaints of functional losses due to pain, stiffness, weakness and catching when the arm is flexed and internally rotated; and
5.6.1.2.3 Poor sleep is common and pain is often felt down the lateral aspect of the upper arm near the deltoid insertion or over the anterior proximal humerus.
5.6.2 Physical Findings (Impingement Syndrome): may include:5.6.2.1 Inspection of the shoulder may reveal deltoid and rotator cuff atrophy;5.6.2.2 Range of motion is limited particularly in internal rotation and in cross-body adduction;5.6.2.3 Passive motion through the 60-90° arc of flexion may be accompanied by pain and crepitus; this is accentuated as the shoulder is moved in-and-out of internal rotation;5.6.2.4 Active elevation of the shoulder is usually more uncomfortable than passive elevation;5.6.2.5 Pain on maximum active forward flexion is frequently seen with impingement syndrome, but is not specific for diagnosis;5.6.2.6 Strength testing may reveal weakness of flexion and external rotation in the scapular plane; this weakness may be the result of disuse, tendon damage, or poor scapulothoracic mechanics;5.6.2.7 Pain on resisted abduction or external rotation may also indicate that The integrity of the rotator cuff tendons may be compromised; and/or5.6.2.8 Weakness of the posterior scapular stabilizers can also be seen as a contributing factor to impingement syndrome by altering the mechanics of the glenohumeral joint.5.6.3 Laboratory Tests (Impingement Syndrome): are not indicated unless a systemic illness or disease is suspected.5.6.4 Testing Procedures (Impingement Syndrome): 5.6.4.1 Plain x-rays include: 5.6.4.1.1 AP view visualizes elevation of the humeral head, indicative of rotator cuff fiber failure with diminished space at the subacromial area;
5.6.4.1.2 Lateral view in the plane of the scapula or an axillary view can help to determine aspects of instability which can give symptoms similar to impingement syndrome;
5.6.4.1.3 30° caudally angulated AP view can assess for a spur on the anterior/inferior surface of the acromion and/or the distal end of the clavicle which can lead to
encroachment on the rotator cuff mechanism with motion; and
5.6.4.1.4 Outlet view determines if there is a downwardly tipped acromion.5.6.4.2 Adjunctive testing, such as standard radiographic techniques (sonography, arthrography or MRI), should be considered when shoulder pain is refractory to 4-6 weeks of non-operative conservative treatment and the diagnosis is not readily identified by a good history and clinical examination.5.6.5 Non-operative Treatment Procedures (Impingement Syndrome) may include: 5.6.5.1 Medications, such as nonsteroidal anti-inflammatories and analgesics, should be prescribed as seen in Section 6.5 Medications. Subacromial space injection may be therapeutic. Injections of corticosteroids into the subacromial space should be limited to 3 injections per year at the same site, and rarely used in patients less than 30 years.5.6.5.2 In order to have the most favorable outcome from a conservative approach, an aggressive attempt should be made to define the contributing factors which are driving the syndrome, such as shoulder stiffness, humeral head depressor weakness (rotator cuff fiber failure), and subacromial crowding AC Joint arthritis.5.6.5.3 Procedures outlined in Section 5.3.5. Non-operative Treatment Procedures should be considered, such as relative rest, immobilization, thermal treatment, ultrasound, therapeutic exercise and physical medicine and rehabilitation.5.6.6 Operative Procedures (Impingement Syndrome): should restore functional anatomy by reducing the potential for repeated impingement; procedures might include distal clavicular resection, coracoacromial ligament release, and/or acromioplasty.5.6.7 Post-Operative Procedures (Impingement Syndrome): would include an individualized rehabilitation program based upon communication between the surgeon and the therapist. 5.6.7.1 Individualized rehabilitation programs might include: 5.6.7.1.1 Sling or abduction splint;5.6.7.1.2 Gentle pendulum exercise, passive glenohumeral range of motion and aggressive posterior scapular stabilizing training can be instituted;
5.6.7.1.3 At 4 weeks post-operative, begin isometrics and ADL involvement; and/or5.6.7.1.4 Depending upon the patient's functional response, at 4 weeks post-operative consider beginning light resistive exercise; concomitantly, return to a light
modified duty may be plausible given the ability to accommodate "no repetitive
overhead activities."
5.6.7.2 Progressive resistive exercise from 2 months with gradual returning to full activity at 5-7 months; all active non-operative procedures listed in this Section 5.3.5. Non-operative Treatment Procedures should be considered.5.6.7.3 Work restrictions should be evaluated every 4-6 weeks during post-operative recovery and rehabilitation with appropriate written communications to both the patient and the employer. Should progress plateau, the provider should reevaluate the patient's condition and make appropriate adjustments to the treatment plan.