ࡱ> @ ;bjbjFF +x,,U3I(uuu8u<v(V~2vv"vvvvvv}}}}}}}$RځV}vvvvv}vv~wwwvvv}wv}ww:zU}vv pW9uv} }&~0V~'}.0wp0U}((0U}vvwvvvvv}}((d;>7w((>The Shoulder David J. Rolnick, M.D. MedEx, LLC 5th Annual Workers Compensation Symposium ~ June 2, 2006 Questions to Answer Is This a Legitimate Work Injury? Is This a Workplace Exposure? Manifestation of a Preexisting Condition? Large # of WC Claims Natural History of Shoulder Symptoms Occur as we age MRI positive in large # of asymptomatic individuals Can respond to non-surgical treatment Aggressive and Rapid Surgery may not be indicated Where Is The Shoulder? The glenohumeral joint The true shoulder joint The scapula Part of the shoulder girdle The trapezius The neck Shoulder Pain Acromioclavicular joint arthritis Impingement and Cuff Tendinopathy Rotator cuff tearpartial/complete Biceps tendon Glenohumeral instability SLAP lesions Glenohumeral arthritis The History Mechanism of Injury Is the type of problem consistent with the mechanism of injury? Symptomsonset, location, characteristics Are the symptoms consistent with the problem and the injury? Previous shoulder symptoms or injury Diagnostic Tests Performed Treatment Already Given Acute Shoulder Problems Fracture Humerus, Glenoid, Clavicle, Acromion, Scapula, Coracoid Dislocation Glenohumeral Acromioclavicular Separation Acute Rotator Cuff Tears Strains and Sprains Nerve Injuries Fractures In normal bone, require significant force Usually a good history of injury Immediate paina broken bone hurts right away X-rays necessary to confirm diagnosis Stress fractures rare in shoulder Os acromiale Acute Rotator Cuff Tears History of a specific incident Immediate pain in appropriate location Often difficult to move the shoulder due to pain or muscle weakness/inhibition Can occur in a preexisting degenerative cuff MRI needed to confirm Can also have arthrogram or ultrasound The Examination Begins with observation How does the person use the shoulder? Muscle atrophy Examine painful areas last Go back to a part of the exam if you feel there is pathology or an inconsistency Ends with observation Shoulder Anatomy Acromion Clavicle Acromioclavicular Joint Biceps Tendon Rotator Cuff Scapula The Shoulder Outlet (images) Normal Shoulder Degeneration Involves all parts of the shoulder Advances with age Is common in asymptomatic individuals Is usually unrelated to heavy lifting with the exception of the acromioclavicular joint Is progressive over time Shoulder Degeneration Biceps Tendon Degeneration Acromioclavicular Degeneration Rotator Cuff Degeneration Glenohumeral Degeneration Arthritis Shoulder Degeneration Arthritis Etiology Part of the normal degenerative process Increases with age and time from onset Rate of progression unpredictable Commonly ASYMPTOMATIC Symptoms can come on quickly even without an injury or work exposure Bicipital Tendinitis Tendon of the long head of the biceps The long head tendon goes through the shoulder joint Can be caused by impingement upon acromial spurs Degeneration occurs with age Can rupture spontaneouslyno repair needed! Biceps Tendons Long and short heads Long head almost always the problem Proximal Rupture of the long head Rarely traumatic, part of a degenerative process Popeye muscle Symptomatic treatment TendonitisSLAP lesion Yergasons and Speeds tests Usually DEGENERATIVE Acromioclavicular Joint A-C Separations Mechanism of injury Physical findings Localized tenderness and/or prominent clavicle Diagnostic studiesroutine plain x-rays Treatmentearly and late Long term consequences Acromioclavicular Arthrosis Occurs with age and is progressive Known association between AC Joint arthrosis and weight lifters Can assume that long term heavy lifting of weight on the job is at least contributory Can have symptoms with shoulder motion Crossed arm adduction test Acromioclavicular Joint Arthritis Can occur with single or repeated trauma Does not occur after complete (3) acromioclavicular separation Weight lifters at high risk Can be occupational exposure Crossed arm adduction test Acromioclavicular Joint Degeneration can occur without trauma or work exposure Degeneration can follow a traumatic event such as an acromioclavicular separation Increased incidence in competitive weight liftersmay have some bearing on occupation Acromioclavicular Joint Can get symptoms from the arthritic joint Can cause impingement Easy to examine: Local Tenderness Positive Crossed Arm Adduction Test Can appear swollen Hallmark of diagnosis is injection of local anesthetic leading to pain relief Acromioclavicular Arthritis TREATMENT Injection Local Anestheticmandatory pre-surgical trial Steroids Nonsteroidals Observation Surgical Partial Clavicle ResectionMumford Rotator Cuff Degeneration Involves complete and partial tears which are degenerative 54% of asymptomatic individuals at age 60 have complete or partial rotator cuff tears on MRI Is often referred to as a partial tear or tendinopathy Should be treated conservatively if possible Glenohumeral Arthrosis Uncommon site of arthrosis or arthritis Occurs after trauma Can occur idiopathically No definite association with heavy work Rare with rotator cuff tears Loss of motion, crunching, pain with motion and stiffness Glenohumeral Arthritis A degenerative arthritis Can occur over time after trauma that alters the architecture of the glenoid or humeral head Fracture No evidence it is associated with long term heavy use of the upper extremities Impingement When the rotator cuff or sub-acromial bursa strikes a nearby structure in certain positions of the arm Occurs during overhead activities or reaching Acromial typesBigliani Impingement Neer Impingement Sign Impingement test Hawkins sign Impingement Tests Neer Impingement Test Passively forward elevate the arm while depressing the scapula Impingement Test Inject subacromial bursa to eliminate impingement pain and test cuff strength Hawkins Sign Shoulder and elbow flexed 90 then shoulder internally rotated Impingement Treatment NSAIDS Avoidance of overhead activities Physical therapystretch and strengthen Jobes exercises OK No iontophoresis, ultrasound, etc Sub-acromial injectionsteroid and local anesthetic. Avoid multiple injections which weaken the rotator cuff tissue Surgeryminority of cases Rotator Cuff Pathology Diagnostic Studies Can Show: Tendinopathy TendinitisIncreased Incidence in Obesity Partial Thickness Rotator Cuff Tears 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 Occurs from impingement Treated conservatively as outlined for impingement Sometimes requires surgical debridement and decompression Full Thickness Rotator Cuff Tears Rarely occur without a significant traumatic event in young people 54% of asymptomatic individuals at age 60 have complete or partial rotator cuff tears on MRI Treatment of Full Thickness Rotator Cuff Tears For tears that are clearly chronic and in older age group, can begin with non-surgical treatment. Exercises, NSAIDS and Injections Treatment of Full Thickness Rotator Cuff Tears Acute tears and repairable tears should be fixedespecially in a young, physically active person. Open Arthroscopic Treatment of Full Thickness Rotator Cuff Tears After surgical repair of a rotator cuff tear, there is an extended period of healing. 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 Superior Labral Anterior-Posterior The labrum contributes to shoulder stability by increasing the depth and concavity of the glenoid. SLAP lesions may be unrecognized for some timea careful history of recent or remote trauma is important. SLAP Lesions Incidence is from 3.9% to 11.8% Biceps tendon also contributes to stability Secondary problems from instability can include bursitis, impingement and A-C arthritis SLAP Lesions The mechanism of injury is very important Frequently results from a fall onto the elbow or outstretched hand with the elbow adducted or extended There may be a history of remote trauma Sometimes the SLAP lesion is old, and secondary symptoms bring the patient in for care SLAP Lesion Causes Acute compression force or traction pull on the shoulder Fall onto the shoulder Sudden upward traction SLAP Lesion Causes 84 patients reviewed 15% fall onto the shoulder 13% lifting a heavy object 13% traumatic dislocation 9% insidious onset 8% abduction and external rotation force 8% fall onto the outstretched arm 6% occurred gradually from repetitive lifting 6% motor vehicle accidents Shoulder Stability Exam Sulcus test Arm at the side Shoulder at 90 abduction Anterior and Posterior drawer Anterior apprehension test Relocation Test Posterior instability test Testing for SLAP Lesions - The OBrien Test Suddenly internally rotating the shoulder as it is adducted 30 in 90 of forward flexion Positive test Clicking in the shoulder and/or Pain radiating down the biceps tendon or posterior joint Routine Radiographs Always get plain radiographs before MRI, CT, or Arthrogram for any shoulder complaints 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 MRI Arthrogram The MRI arthrogram is considered the definitive test for SLAP tears with an accuracy of 95-100% MRI without contrast Less sensitive and less specific than MRI arthrogram Treatment of SLAP Lesions Arthroscopy is the preferred method of diagnosis and treatment Snyder identified 4 types of SLAP lesions Maffet identified 7 types of SLAP lesions Types of SLAP Lesions Type I11% Fraying of the superior labrum Type II41% Detachment of the biceps tendon with or without fraying Type III33% Bucket handle tear of the superior labrum Type IV15% Similar to type III but there was extension of the tear up into the biceps tendon Repair of SLAP Lesions Various devices are used for arthroscopic repair Post-Operative Rehabilitation is often prolonged for 6-12 weeks Suprascapular Neuropathy Nerve to the supraspinatus and infraspinatus Can be compressed by: Ganglion cystassociated with labral tear Thickened spinoglenoid ligament Viral Neuritis Direct trauma Shoulder Dislocations Can occur in any direction Can damage: Rotator Cuff Humeral Head Glenoid Labrum Axillary Nerve or Brachial Plexus CASE STUDIES 55-Year-Old Truck Driver Female, right-hand dominant Employed as a truck driver Does not load or unload cargo 3-month history of left shoulder pain Worse with overhead activity Night pain No traumatic event 55-Year-Old Truck Driver X-rayAcromioclavicular Arthritis MRISupraspinatus Tendinopathy with Partial Thickness Rotator Cuff Tear Treatment? Physical Therapy Injection Surgery 30-Year-Old Parts Inspector Male; right-hand dominant Works on a conveyer belt at waist level Lift up to 5 pounds frequently No overhead or floor level reaching Acute right shoulder pain while at work MRI shows full thickness RC Tear Outside activities: baseball, basketball, skiing 30-Year-Old Parts Inspector Is the full thickness rotator cuff tear caused by: A work related single event? A work exposure? Are symptoms: A manifestation of the tear? Aggravated by work? permanent or temporary? 30-Year-Old Forklift Driver Male; right-hand dominant No lifting at work Fell at work landing on right shoulder Acute onset of pain at time of fall Primary care MD diagnosis of Sprain Routine x-rays negative Weak rotator cuff muscles 30-Year-Old Forklift Driver MRI shows a full thickness rotator cuff tear Work Related? 60-Year-Old Secretary Right-hand dominant Uses mouse all day with right hand Has an ergonomically correct work station Slow onset of right shoulder pain X-rays negative MRIRotator cuff tendinopathy or partial thickness tear Scheduled for surgerynever had PT 60-Year-Old Secretary Is The Condition Work Related? Caused by work exposure? Aggravated by work exposure? Just a manifestation? What is the appropriate treatment, regardless of causation? 50-Year-Old Receptionist Female, right-hand dominant Height 52 - Weight 240 lbs Spontaneous Onset of Left Shoulder Pain Severe Night Pain X-rayNegative MRIMild tendinopathy Limited active and passive motion 50-Year-Old Receptionist What is the diagnosis? What is the appropriate treatment? 50-Year-Old Construction Worker Right-hand dominant Long History of Right Shoulder Ache Acute onset of right shoulder pain associated with a pop Slow improvement in painless than before the pop Normal Shoulder Motion 50-Year-Old Construction Worker X-rayMild AC Arthritis & Type II Acromion Prominent Biceps Muscle MRI shows intact rotator cuff and no biceps tendon in the bicipital groove Diagnosis Rupture of the long head of the biceps Treatment? Work Related? Conclusions The shoulder is a complex joint Take a careful history Examine the patient carefully Consider what is normal (Cuff tears over age 60??) Rehabilitate before and after surgery if possible Questions? Thank You! PAGE  David J. 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