The Shoulder - MedEx, LLC
The Shoulder
David J. Rolnick, M.D.
MedEx, LLC
5th Annual Worker’s Compensation Symposium ~ June 2, 2006
Questions to Answer
4 Is This a Legitimate Work Injury?
5 Is This a Workplace Exposure?
6 Manifestation of a Preexisting Condition?
Large # of WC Claims
1 Natural History of Shoulder Symptoms
1 Occur as we age
2 MRI positive in large # of asymptomatic individuals
3 Can respond to non-surgical treatment
4 Aggressive and Rapid Surgery may not be indicated
Where Is The Shoulder?
1 The glenohumeral joint
1 The true shoulder joint
2 The scapula
1 Part of the shoulder girdle
3 The trapezius
4 The neck
Shoulder Pain
1 Acromioclavicular joint arthritis
2 Impingement and Cuff Tendinopathy
3 Rotator cuff tear—partial/complete
4 Biceps tendon
5 Glenohumeral instability
6 SLAP lesions
7 Glenohumeral arthritis
The History
1 Mechanism of Injury
1 Is the type of problem consistent with the mechanism of injury?
2 Symptoms—onset, location, characteristics
1 Are the symptoms consistent with the problem and the injury?
3 Previous shoulder symptoms or injury
4 Diagnostic Tests Performed
5 Treatment Already Given
Acute Shoulder Problems
1 Fracture — Humerus, Glenoid, Clavicle, Acromion, Scapula, Coracoid
2 Dislocation — Glenohumeral
3 Acromioclavicular Separation
4 Acute Rotator Cuff Tears
5 Strains and Sprains
6 Nerve Injuries
Fractures
1 In normal bone, require significant force
2 Usually a good history of injury
3 Immediate pain—a broken bone hurts right away
4 X-rays necessary to confirm diagnosis
5 Stress fractures rare in shoulder
6 Os acromiale
Acute Rotator Cuff Tears
1 History of a specific incident
2 Immediate pain in appropriate location
3 Often difficult to move the shoulder due to pain or muscle weakness/inhibition
4 Can occur in a preexisting degenerative cuff
5 MRI needed to confirm
6 Can also have arthrogram or ultrasound
The Examination
1 Begins with observation
1 How does the person use the shoulder?
2 Muscle atrophy
2 Examine “painful” areas last
3 Go back to a part of the exam if you feel there is pathology or an inconsistency
4 Ends with observation
Shoulder Anatomy
1 Acromion
2 Clavicle
3 Acromioclavicular Joint
4 Biceps Tendon
5 Rotator Cuff
6 Scapula
The Shoulder Outlet (images)
Normal Shoulder Degeneration
1 Involves all parts of the shoulder
2 Advances with age
3 Is common in asymptomatic individuals
4 Is usually unrelated to heavy lifting with the exception of the acromioclavicular joint
5 Is progressive over time
Shoulder Degeneration
1 Biceps Tendon Degeneration
2 Acromioclavicular Degeneration
3 Rotator Cuff Degeneration
4 Glenohumeral Degeneration — Arthritis
Shoulder Degeneration — Arthritis
1 Etiology
1 Part of the normal degenerative process
2 Increases with age and time from onset
3 Rate of progression unpredictable
4 Commonly ASYMPTOMATIC
5 Symptoms can come on quickly even without an injury or work exposure
Bicipital Tendinitis
1 Tendon of the long head of the biceps
2 The long head tendon goes through the shoulder joint
3 Can be caused by impingement upon acromial spurs
4 Degeneration occurs with age
5 Can rupture spontaneously—no repair needed!
Biceps Tendons
1 Long and short heads
2 Long head almost always the problem
3 Proximal Rupture of the long head
1 Rarely traumatic, part of a degenerative process
2 “Popeye” muscle
3 Symptomatic treatment
4 Tendonitis—SLAP lesion
1 Yergason’s and Speed’s tests
5 Usually DEGENERATIVE
Acromioclavicular Joint
1 A-C Separations
1 Mechanism of injury
2 Physical findings
1 Localized tenderness and/or prominent clavicle
3 Diagnostic studies—routine plain x-rays
4 Treatment—early and late
5 Long term consequences
Acromioclavicular Arthrosis
1 Occurs with age and is progressive
2 Known association between AC Joint arthrosis and weight lifters
3 Can assume that long term heavy lifting of weight on the job is at least contributory
4 Can have symptoms with shoulder motion
5 Crossed arm adduction test
Acromioclavicular Joint Arthritis
1 Can occur with single or repeated trauma
2 Does not occur after complete (3°) acromioclavicular separation
3 Weight lifters at high risk
1 Can be occupational exposure
4 Crossed arm adduction test
Acromioclavicular Joint
1 Degeneration can occur without trauma or work exposure
2 Degeneration can follow a traumatic event such as an acromioclavicular separation
3 Increased incidence in competitive weight lifters—may have some bearing on occupation
Acromioclavicular Joint
1 Can get symptoms from the arthritic joint
2 Can cause “impingement”
3 Easy to examine:
1 Local Tenderness
2 Positive Crossed Arm Adduction Test
3 Can appear swollen
4 Hallmark of diagnosis is injection of local anesthetic leading to pain relief
Acromioclavicular Arthritis
1 TREATMENT
1 Injection
1 Local Anesthetic—mandatory pre-surgical trial
2 Steroids
2 Nonsteroidals
3 Observation
4 Surgical Partial Clavicle Resection—Mumford
Rotator Cuff Degeneration
1 Involves complete and partial tears which are degenerative
2 54% of asymptomatic individuals at age 60 have complete or partial rotator cuff tears on MRI
3 Is often referred to as a partial tear or tendinopathy
4 Should be treated conservatively if possible
Glenohumeral Arthrosis
1 Uncommon site of arthrosis or arthritis
2 Occurs after trauma
3 Can occur idiopathically
4 No definite association with heavy work
5 Rare with rotator cuff tears
6 Loss of motion, crunching, pain with motion and stiffness
Glenohumeral Arthritis
1 A degenerative arthritis
1 Can occur over time after trauma that alters the architecture of the glenoid or humeral head
1 Fracture
2 No evidence it is associated with long term heavy use of the upper extremities
Impingement
1 When the rotator cuff or sub-acromial bursa strikes a nearby structure in certain positions of the arm
2 Occurs during overhead activities or reaching
3 Acromial types—Bigliani
Impingement
1 Neer Impingement Sign
2 Impingement test
3 Hawkins sign
Impingement Tests
1 Neer Impingement Test
1 Passively forward elevate the arm while depressing the scapula
2 Impingement Test
1 Inject subacromial bursa to eliminate impingement pain and test cuff strength
3 Hawkins Sign
1 Shoulder and elbow flexed 90° then shoulder internally rotated
Impingement Treatment
1 NSAIDS
2 Avoidance of overhead activities
3 Physical therapy—stretch and strengthen
1 Jobes exercises OK
2 No iontophoresis, ultrasound, etc
4 Sub-acromial injection—steroid and local anesthetic. Avoid multiple injections which weaken the rotator cuff tissue
5 Surgery—minority of cases
Rotator Cuff Pathology
1 Diagnostic Studies Can Show:
1 Tendinopathy
2 Tendinitis—Increased Incidence in Obesity
3 Partial Thickness Rotator Cuff Tears
4 Full Thickness Rotator Cuff Tears
WHAT IS “NORMAL”?
Rotator Cuff Degeneration
AT AGE SIXTY, 54% OF ASYMPTOMATIC INDIVIDUALS HAVE COMPLETE OR PARTIAL THICKNESS ROTATOR CUFF TEARS ON MRI
Partial Thickness Cuff Tear
1 Occurs from impingement
2 Treated conservatively as outlined for impingement
3 Sometimes requires surgical debridement and decompression
Full Thickness Rotator Cuff Tears
1 Rarely occur without a significant traumatic event in young people
2 54% of asymptomatic individuals at age 60 have complete or partial rotator cuff tears on MRI
Treatment of Full Thickness Rotator Cuff Tears
1 For tears that are clearly chronic and in older age group, can begin with non-surgical treatment.
2 Exercises, NSAIDS and Injections
Treatment of Full Thickness Rotator Cuff Tears
1 Acute tears and repairable tears should be fixed—especially in a young, physically active person.
2 Open
3 Arthroscopic
Treatment of Full Thickness Rotator Cuff Tears
1 After surgical repair of a rotator cuff tear, there is an extended period of healing.
2 It is reasonable to avoid any strenuous activity for a period of at least 3 months to allow the cuff repair to heal and become strong.
SLAP Lesions
1 Superior Labral Anterior-Posterior
2 The labrum contributes to shoulder stability by increasing the depth and concavity of the glenoid.
3 SLAP lesions may be unrecognized for some time—a careful history of recent or remote trauma is important.
SLAP Lesions
1 Incidence is from 3.9% to 11.8%
2 Biceps tendon also contributes to stability
3 Secondary problems from instability can include bursitis, impingement and A-C arthritis
SLAP Lesions
1 The mechanism of injury is very important
2 Frequently results from a fall onto the elbow or outstretched hand with the elbow adducted or extended
3 There may be a history of remote trauma
4 Sometimes the SLAP lesion is old, and secondary symptoms bring the patient in for care
SLAP Lesion Causes
1 Acute compression force or traction pull on the shoulder
2 Fall onto the shoulder
3 Sudden upward traction
SLAP Lesion Causes
1 84 patients reviewed
1 15% fall onto the shoulder
2 13% lifting a heavy object
3 13% traumatic dislocation
4 9% insidious onset
5 8% abduction and external rotation force
6 8% fall onto the outstretched arm
7 6% occurred gradually from repetitive lifting
8 6% motor vehicle accidents
Shoulder Stability Exam
1 Sulcus test
1 Arm at the side
2 Shoulder at 90° abduction
2 Anterior and Posterior drawer
3 Anterior apprehension test
4 Relocation Test
5 Posterior instability test
Testing for SLAP Lesions - The O’Brien Test
1 Suddenly internally rotating the shoulder as it is adducted 30° in 90° of forward flexion
2 Positive test
1 Clicking in the shoulder and/or
2 Pain radiating down the biceps tendon or posterior joint
Routine Radiographs
1 Always get plain radiographs before MRI, CT, or Arthrogram for any shoulder complaints
2 Look at Acromioclavicular join for arthritis which can be a late sign of a SLAP lesion and superior instability and migration
Special Studies for SLAP
1 MRI Arthrogram
1 The MRI arthrogram is considered the definitive test for SLAP tears with an accuracy of 95-100%
2 MRI without contrast
1 Less sensitive and less specific than MRI arthrogram
Treatment of SLAP Lesions
1 Arthroscopy is the preferred method of diagnosis and treatment
2 Snyder identified 4 types of SLAP lesions
3 Maffet identified 7 types of SLAP lesions
Types of SLAP Lesions
1 Type I—11%
1 Fraying of the superior labrum
2 Type II—41%
1 Detachment of the biceps tendon with or without fraying
3 Type III—33%
1 Bucket handle tear of the superior labrum
4 Type IV—15%
1 Similar to type III but there was extension of the tear up into the biceps tendon
Repair of SLAP Lesions
1 Various devices are used for arthroscopic repair
2 Post-Operative Rehabilitation is often prolonged for 6-12 weeks
Suprascapular Neuropathy
1 Nerve to the supraspinatus and infraspinatus
2 Can be compressed by:
1 Ganglion cyst—associated with labral tear
2 Thickened spinoglenoid ligament
3 Viral Neuritis
4 Direct trauma
Shoulder Dislocations
1 Can occur in any direction
2 Can damage:
1 Rotator Cuff
2 Humeral Head
3 Glenoid
4 Labrum
5 Axillary Nerve or Brachial Plexus
CASE STUDIES
55-Year-Old Truck Driver
1 Female, right-hand dominant
2 Employed as a truck driver
3 Does not load or unload cargo
4 3-month history of left shoulder pain
5 Worse with overhead activity
6 Night pain
7 No traumatic event
55-Year-Old Truck Driver…
1 X-ray—Acromioclavicular Arthritis
2 MRI—Supraspinatus Tendinopathy with Partial Thickness Rotator Cuff Tear
3 Treatment?
1 Physical Therapy
2 Injection
3 Surgery
30-Year-Old Parts Inspector
1 Male; right-hand dominant
2 Works on a conveyer belt at waist level
3 Lift up to 5 pounds frequently
4 No overhead or floor level reaching
5 Acute right shoulder pain while at work
6 MRI shows full thickness RC Tear
7 Outside activities: baseball, basketball, skiing
30-Year-Old Parts Inspector…
1 Is the full thickness rotator cuff tear caused by:
1 A work related single event?
2 A work exposure?
2 Are symptoms:
1 A manifestation of the tear?
2 Aggravated by work? permanent or temporary?
30-Year-Old Forklift Driver
1 Male; right-hand dominant
2 No lifting at work
3 Fell at work landing on right shoulder
4 Acute onset of pain at time of fall
5 Primary care MD diagnosis of “Sprain”
6 Routine x-rays negative
7 Weak rotator cuff muscles
30-Year-Old Forklift Driver…
1 MRI shows a full thickness rotator cuff tear
1 Work Related?
60-Year-Old Secretary
1 Right-hand dominant
2 Uses mouse all day with right hand
3 Has an ergonomically correct work station
4 Slow onset of right shoulder pain
5 X-rays negative
6 MRI—Rotator cuff tendinopathy or partial thickness tear
7 Scheduled for surgery—never had PT
60-Year-Old Secretary…
1 Is The Condition Work Related?
1 Caused by work exposure?
2 Aggravated by work exposure?
3 Just a manifestation?
2 What is the appropriate treatment, regardless of causation?
50-Year-Old Receptionist
1 Female, right-hand dominant
2 Height 5’2” - Weight 240 lbs
3 Spontaneous Onset of Left Shoulder Pain
4 Severe Night Pain
5 X-ray—Negative
6 MRI—Mild tendinopathy
7 Limited active and passive motion
50-Year-Old Receptionist…
1 What is the diagnosis?
2 What is the appropriate treatment?
50-Year-Old Construction Worker
1 Right-hand dominant
2 Long History of Right Shoulder Ache
3 Acute onset of right shoulder pain associated with a “pop”
4 Slow improvement in pain—less than before the “pop”
5 Normal Shoulder Motion
50-Year-Old Construction Worker…
1 X-ray—Mild AC Arthritis & Type II Acromion
2 Prominent Biceps Muscle
3 MRI shows intact rotator cuff and no biceps tendon in the bicipital groove
4 Diagnosis
1 Rupture of the long head of the biceps
5 Treatment?
6 Work Related?
Conclusions
1 The shoulder is a complex joint
2 Take a careful history
3 Examine the patient carefully
4 Consider what is “normal” (Cuff tears over age 60??)
5 Rehabilitate before and after surgery if possible
Questions?
Thank You!
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