W. Va. Code R. § 85-20-40

Current through Register Vol. XLI, No. 45, November 8, 2024

Section 85-20-40 - Treatment Guidelines: Shoulder Injury Guidelines

40.1. The term "shoulder complex" refers to the humerus, clavicle, scapula and the surrounding supporting connective tissue and emphasizes their interdependent relationship. Articulations of the "shoulder complex" are the sternoclavicular, acromioclavicular, scapulothoracic, glenohumeral, and subacromial arch.

Fractures, separations, or subluxations/dislocations of components within the "shoulder complex" result from trauma to the shoulder girdle or upper extremity. Soft tissue strains or sprains may result from either trauma or longstanding accumulative microtrauma. The rotator cuff is particularly vulnerable to overuse pathology.

Treatment of "shoulder complex" injuries is directed to restoring balanced motion in the entire complex. Because of the importance of the soft tissues, physical therapy is very important and can be lengthy. On the other hand, because the shoulder complex is so adaptable, most individuals can find alternative patterns of function in their work, home, or recreational needs while they are undergoing physical rehabilitation.

40.2. The appropriate diagnostic criteria are as follows:

a. History and physical.

1. Mechanism of injury - single episode or repetitive microtrauma.

2. Pain pattern - pain at rest, pain related to work, activities of daily living, or recreational activities, night pain; painful arc of motion; position of comfort; relative position of the pain; relative position of the neck; referred pattern (pain below the elbow suggests a radicular component).

3. Range-of-motion - active glenohumeral and scapulothoracic balance; passive forward flexion, external rotation, internal rotation, and abduction compared to the opposite side.

4. Palpation - point or zone of maximum tenderness.

5. Neurological - motor, sensory, muscle stretch reflexes for C5, C6, C7, C8 and T1 roots.

6. Special tests - apprehension; drop arm; impingement; Yergason; posterior apprehension; sulcus sign; clunk; AC spring; Adson; Awinged scapular; lateral scapular slide.

40.3. The appropriate diagnostic tests are as follows:

a. Routine imaging:

1. Shoulder series - internal, external, and transaxillary or transcapular lateral (a transthoracic lateral is of no benefit except in humeral shaft fractures, posterior dislocations of the shoulder may be missed).

2. Special imaging - requires pre-authorization and specialty referral.

A. CT scan;

B. MRI;

C. Arthrogram; and

D. EMG/NCV.

40.4. The guidelines for appropriate specialty referral are as follows:

a. Failure of improvement or resolution of symptoms with conservative treatment in four weeks;

b. Radiographic evidence of fracture, subluxation, or dislocation;

c. Initial presentation of hemarthrosis;

d. Significant lack of motion compared to opposite side; and

e. Suspected neurologic injury.

40.5. Appropriate treatment is as follows:

a. Fracture - subluxation/dislocation (requires specialty referral).

1. Nonoperative or operative:

A. One to four weeks of immobilization; and

B. Physical therapy beginning in one to four weeks and continuing up to six months.

b. Sternoclavicular or acromioclavicular strain or grade 1 (non-displaced sprain).

1. Non-operative:

A. One to seven days of immobilization;

B. Physical therapy, modalities and range-of-motion, one to six weeks;

C. Duration of care - one to six weeks;

D. Anticipated results - resolution of symptoms and resumption of normal activities. May develop degenerative arthritis at a later date.

2. Operative (specialty referral) - no indication except evidence of degenerative changes after prolonged conservative management.

c. Rotator cuff tendinitis/bursitis.

1. Nonoperative.

A. Local steroid injections at three to six week intervals (not to exceed three);

B. Physical therapy - up to three months at decreasing intervals;

C. Job activity modification if indicated; and

D. NSAIDs.

2. Operative (specialty referral).

A. Indications.

1. Failure of improvement after three to six months of conservative care;

2. Positive impingement sign; and

3. Arthrogram or MRI to determine integrity of rotator cuff.

B. Physical therapy following surgery, three to six months at decreasing intervals.

d. Rotator cuff tear.

1. History - sudden onset of pain and inability to initiate active abduction; passive abduction relatively normal; plain x-rays revealed not acute bony changes.

2. Nonoperative.

A. Physical therapy one to three weeks;

B. Specialty referral if no improvement.

3. Operative (specialty referral).

A. Arthrogram or MRI confirms tear; and

B. Physical therapy following surgery, three to six months at decreasing intervals.

e. Adhesive capsulitis (frozen shoulder).

1. History - insidious pain and loss of motion in the glenohumeral joint.

2. Nonoperative.

A. Physical therapy tried one to six weeks;

B. Glenohumeral joint injection with saline distention using short acting steroids plus Xylocaine - limit two at three week intervals; and

C. Specialty referral if no improvement after six to eight weeks.

3. Operative (specialty referral).

A. Manipulation if no improvement after three months.

4. Other conditions which (require specialty referral).

A. Thoracic outlet syndrome;

B. Brachial plexus injuries; and

C. Ruptured biceps tendon, proximally or distally.

W. Va. Code R. § 85-20-40