Shoulder Injuries and Workers' Compensation: the Role of the Orthopaedic Surgeon

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1 Shoulder Injuries and Workers' Compensation: the Role of the Orthopaedic Surgeon Erich Gauger, MD Major, USAF Staff Orthopaedic Surgeon USAF Academy, 10th MDG

2 Disclosures No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this study.

3 Outline Brief History of Workers Compensation Scope of the Problem Challenges to Treatment Common Injuries and Treatment Outcomes Special Focus on RTC tears Meta Analysis Time Take Home Points

Trinity Fellow servant rule: not responsible for actions of injuries due to other workers

4 Otto Von Bismarck established the Workers Sickness and Accident Laws in 1884 Mandatory tax to fund workers during times of disability from workplace injuries In America Common Law and The Unholy Trinity Fellow servant rule: not responsible for actions of injuries due to other workers Contributory negligence: fault of worker if worker s own negligence Assumption of risk: worker aware of hazards of job

5 Turning Point in America JG Brooks published Compulsory Insurance in Germany in 1893 Literary movement: Upton Sinclair, The Jungle 1906 Wisconsin passed first WC law in 1911 Now, WC is governed by each state

7 Common Law to No Fault Liability In exchange for the employer paying for the injured worker s care regardless of the cause, worker s give up their right to sue employers at common law (exceptions do exist)

8 Scope of Problem Annual losses caused by work related injuries $140-$145 billion Study aimed to identify the types of injuries that occur most frequently and the types that result in the highest costs Critical for targeting primary and secondary prevention efforts

9 Most commonly occurring single injury type 10.5% Back 5.7% Knee 5.6% Hand

10 Top 3 most expensive single injury type for Medical and Total Compensation Back Knee Shoulder

11 The combination of high frequency and high average cost of workers compensation claims for back, knee and shoulder injuries make these injury types a priority for primary and secondary prevention.

12 Challenges to Treatment Baseline Health 1063 consecutive pts presenting with shoulder problems Divided into 2 groups WC covering shoulder problem WC not covering shoulder problem Completed SF-36 and Simple Shoulder Test Pts covered by WC have SIG lower self-assessed shoulder Fxn and health status Difference not associated with diagnosis

13 SF-36

14 Challenges to Treatment - Complexity of the System Causation Disability Impairment IME

15 Challenges to Treatment Lack of Evidence Based Recommendations

16 Injuries: Common Mechanisms Overhead Repetitive FOOSH Direct Blow Catch or Restrain Falling Object Referred from Neck

17 Injuries to Cover Frozen Shoulder (Adhesive Capsulitis) Impingement Rotator Cuff Tears SLAP Tears Arthritis Proximal Humerus Fracture

entity Usually gradual onset Sx s Pain at night and deltoid origin

18 Frozen Shoulder/Adhesive Capsulitis/Shoulder Stiffness Frozen shoulder a nonspecific term Adhesive capsulitis specific pathologic entity Usually gradual onset Sx s Pain at night and deltoid origin Mechanical restraint to PROM, particularly ER Stiff Shoulder= Painful Shoulder

19 94% pts with spontaneous frozen shoulder recovered to normal levels of function and motion without treatment ( benign neglect ) 91% manipulation group 91% nonoperative group Duration of disease avg 15 mos No mention of WC pts

20 Only variables that were associated with eventual need for MUA or capsular release Prior PT WC pending litigation

My Approach Stiff Shoulder = Painful Shoulder XR to rule out OA, calcific tendinitis WC pts will often have previous MRI If not, consider if weakness, trauma, history not

21 My Approach Stiff Shoulder = Painful Shoulder XR to rule out OA, calcific tendinitis WC pts will often have previous MRI If not, consider if weakness, trauma, history not consistent with stiff shoulder PT, PT, PT, PT. Vast majority of pt s should improve without MUA or capsular release.

22 Impingement Syndrome 1972: Neer described anterior acromioplasty for impingement syndrome Belief that most RTC tears caused by mechanical compression Recent histo studies show no pathologic change on undersurface of acromion Now believed that RTC tears caused by intrinsic and extrinsic factors

23 Is Impingement syndrome real and if so, how should it be treated in WC pts?

24 Goal: evaluate the proportion of pts with residual pain after isolated SAD and look for predictors of failure Success rates of 77-90% 18 of 26 (70%) WC pts failed surgery Many Study Limitations: Concomitant pathology PreOp PostOp

25 Outcome scores were lower pre and post op but did not reach statistical significance Mean time for RTW higher in WC (13.7) compared to NWC (9.1) which was attributed to work demand level Strengths: Impingement had to be confirmed at time of surgery (ie fraying CA ligament) Limitations: Only 34 of 106 pts had preop MRI Other pathology adddress intraop (ie RTC tears)

26 My Approach Is influenced by: High rate of concomitant pathology Recent studies questioning classical impingement syndrome and No difference in outcomes in RCT with or without SAD Worse documented outcomes in WC pts Don t see utility in isolated SAD, esp WC Possible exception: type III acromion failed conservative mgmt good relief with subacromial injection negative MRI for other pathology Normal ROM

27 RTC tears WC Patient Characteristics Outcomes after repair Influence of patient expectations Psychosocial Factors Return to Work Cost Analysis

28 Multivariate analysis showed WC group were Significantly: Younger Greater work demands Lower marital rates Lower education level Lower pre-op expectations Lower PreOp SST, SF-36 (physical and social fxn) Lower 1 year PostOp SST, DASH, VAS, SF-36

29 Additional Pt characteristic: Goal: prospectively evaluate compliance and outcomes after RTC repair in WC vs NWC Post Op Non Compliance WC: 22/42 (52%) NWC: 2/50 (4%) More favorable outcomes in compliant WC pts Some WC pts have more vested interest in their outcome?

Outcomes Determine if controlling for PreOp differences b/w groups could partially explain any PostOp differences in outcomes using regression analysis When PreOp diff

30 Outcomes Determine if controlling for PreOp differences b/w groups could partially explain any PostOp differences in outcomes using regression analysis When PreOp diff accounted, WC: Lower WORC ROM no different ASES difference reduced Limitations: Strength not reliably measured Repair open, mini-open or scope Did not look at Job Demands

31 My Interpretation: despite controlling for pre op differences there still exists differences in outcomes of WC vs nonwc Same pathology yet distinct entities? Anything else that may affect outcome?

Examine the relationship bw pt s expectations regarding RTC repair and actual outcome Prospective, Level I study Multivariate analysis controlled for WC

32 Examine the relationship bw pt s expectations regarding RTC repair and actual outcome Prospective, Level I study Multivariate analysis controlled for WC status SST, DASH, VAS, SF-36 completed PreOp 1 yr Post Op Greater Preop expectations significant independent predictor of Postop performance in all measures

33 Assess recovery expectations as prognostic factor for workers with soft-tissue injuries Examined predictive role of recovery expectations among workers with injuries resulting in time off work. Pts with expectations to return to usual activities had 37% faster rate of stopping receiving benefits

34 Expectations and Psychosocial Factors Negative or uncertain expectations may indicate need for further probing and intervention on psychosocial factors to facilitate recovery

35 Psychosocial work stressors have been recognized as additional risk factors for work related MSK complaints Job Dissatisfaction Lack of autonomy Lack of social support High workload Low rewards High mental demands or pressure

36 Tested a model that links stressors to workbased MSK complaints via psychological strain Complex Dynamic of Work Stressors, Response and MSK symptoms. Supports the notion that psychosocial work stressors at work have important links to health and WRMSD

37 Goal: investigate ability of pts to return to preop work level 88.5% pts (n=69) returned to preop level of work at mean MMI 7.6 mos Subjective outcomes remained inferior to NWC historic controls.

38 Successful = return to work 2 groups I: managed by early referral to Ortho II: gatekeeper system with referral to Ortho as last resort Medical Care Cost I: $13,513 II: $35,537 Return to Work I: 6.6 mos after injury II: 18 mos More quickly the pt receives definitive care, the less the cost to pt and system

39 My Approach Less ambiguous treatment algorithm for full thickness RTC tears In General, Repair them Sooner rather than later Recognize that patient expectations and psychosocial factors play a role in outcome Counsel on relationship job demand and ability to RTW

40 Outcome Study NonOp Option? SLAP tear

Goal: determine long-term fxnal outcome of scope repair of type II SLAP lesions WC status identified as poor prognostic factor 65% Good/Excellent results (95% NWC) Lower reported

41 Goal: determine long-term fxnal outcome of scope repair of type II SLAP lesions WC status identified as poor prognostic factor 65% Good/Excellent results (95% NWC) Lower reported value of shoulder slower to regain full ROM less likely to be satisfied Important to consider WC status in managing SLAP Author belief that BTD may be more predictable Other Options?

42 Adhesive Capsulitis? Full thickness RTC tear? Severe OA? Some pt s have ambiguous surgical indications and fail to reach MMI within 4-6 mos progressing to chronic disability LBP or CTS SLAP tear? Impingement? Study evaluated the outcomes of pts with an unresolved surgical option to enter a structured, intensive rehab program and make a surgical decision based on the response to rehab

43 295 pts with chronic disabling MSK disorders underwent a Fxnal Restoration Program. At the half point of the program (10 sessions) I: 164 pts declined surgery and completed the FRP II: 43 pts had surgery III: 38 pts had surgery denied Did worse than I and II IV: 50 pts dropped out prior to decision making Did worse than I, II and III At one year post FRP, only 0.8% pts crossed over to surgery

44 23 of 31 (74%) declined surgery 5 underwent surgery 3 denied surgery The addition of a surgical option process to interdisciplinary rehabilitation may: Resolve surgical indecision Improve outcomes Promote psychosocial recovery facilitate progression to MMI

45 My Approach Every attempt is made to treat nonoperatively If failed Non Op management, then biceps tenodesis Open subpectoral vs arthroscopic

46 Very Briefly Severe GHJ OA with RTC deficiency Proximal Humerus Fracture

47 Goal: compare outcomes after rtsa in WC and NWC pts WC group Worse on nearly all outcomes compared to NWC Did have Sig improvement from PreOp to final F/U Absolute improvement from preoperative to final follow-up was nearly identical

48 Goal: Determine if there is a relation b/w subjective or objective outcome measures and RTW Fxnal status was sig lower for WC group Conclusions: There is growing realization that pts, not surgeons define whether an orthopaedic procedure is successful. It is important that pts and surgeons share an understanding of what defines success

49 Finally, META ANALYSIS TIME

50 211 studies 175 stated that the presence of WC or litigation was assoc with worse outcomes 35 no difference 1 benefit OR for unsatisfactory outcome 3.79 ( ) Consistent association despite Country Procedure Length of follow-up Completeness of follow-up Study type Type of compensation

28 studies reporting outcomes shoulder surgery with SC as part of subgroup analysis Primary outcome: OR for unsatisfactory outcomes Conclusion: Compensation status is a consistent positive

51 28 studies reporting outcomes shoulder surgery with SC as part of subgroup analysis Primary outcome: OR for unsatisfactory outcomes Conclusion: Compensation status is a consistent positive predictor of poor outcome Discussion: Many shoulder specific tests are subjective. Advocated for more tests specifically designed to delineate the psychosocial causes of shoulder pain and function.

52 Take Home Points WC pts have worse baseline health and consistently do worse than pts with same injuries that are not work related Unclear whether outcomes are related to secondary gain/financial incentive or psychosocial factors, likely combination of both There is a consistent improvement from baseline in subjective and objective outcomes when surgery properly indicated in WC pts WC status is an additional factor that should be strongly considered in deciding on a surgical procedure Patient expectations regarding treatment are positively correlated to outcome Surgeons should be candid with the patient regarding expected surgical outcomes

53 Thank You Questions?

ROTATOR CUFF INJURIES / IMPINGEMENT SYNDROME

ROTATOR CUFF INJURIES / IMPINGEMENT SYNDROME Shoulder injuries are common in patients across all ages, from young, athletic people to the aging population. Two of the most common problems occur in the