Work-related shoulder pain

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1 Work-related shoulder pain Stadler Kirsten M.B., Ch.B. (1987) (Pret), M. Med. (Orthop) (1998) (Stell.), Orthopaedic Surgeon, Room 333, Louis Leipoldt Medical Centre, Broadway Street, Bellville Cape Town 7530 Tel: Fax: Abstract Work-related conditions have been described since the early 20th century 1. Shoulder pain can originate from many structures. The subacromial bursa, the acromio-clavicular joint, the tendons of the rotator cuff, especially the supraspinatus, biceps, subscapularis and infraspinatus tendons, as well as brachial plexus and cervical column, can contribute to mechanical type shoulder pain singularly and sometimes even in combination. The challenge is to differentiate and pinpoint the origin of the pain, and then determine how or if it relates to the work the person is doing. Management of shoulder pain in the work setting starts with a thorough conservative approach that includes physical and medical modalities and temporary occupational changes before assessment for possible surgical intervention. Furthermore, it must be determined for what period the person will be partially unable to do his/her work, before a decision of permanent disability is made. INTRODUCTION made by these role players by means of the tools Shoulder pain can originate from many structures. described in the Criteria Document for Evaluating the Work-relatedness of Upper Extremity When a patient with shoulder pain, which is a consequence of his particular occupation, consults Musculo-skeletal Disorders 1,2. an orthopaedic surgeon, he could invariably have Although certain diagnoses, such as radiating been screened by an occupational medicine practitioner, assisted by an occupational health nurse, be made by means of a comprehensive history neck complaints and rotator cuff syndrome, can physiotherapist and occupational therapist. The and physical examination, the diagnosis of other challenge is to differentiate and pinpoint the origin of the pain and to determine how it relates to due to the complexity of such diagnoses or where shoulder and neck conditions are more difficult, the work the person is doing. Diagnosis and the work-relatedness is not clearly described. relatedness to a person s specific work can be These conditions include thoracic outlet syn- TABLE 1. COMMON SYMPTOMS AND SIGNS RELATED TO SHOULDER CONDITIONS IN EMPLOYEES 2. Symptoms Clinical signs Pain Muscle weakness Burning sensation Fatigueability Stiffness Crepitus, a crackling sound or feeling on palpation of a joint Muscle spasm Muscle weakness Decreased range of motion Tenderness TABLE 2. RISK FACTORS FOR THE DEVELOPMENT OF SHOULDER AND UPPER ARM DISORDERS 1. Working with the hand behind the trunk for substantial part of the day. Working with the hand in front in the opposite part of the trunk (across body flexion) for substantial part of the day. Sustained external rotation of the shoulder. Sustained abduction (away from the trunk). Hands moving above shoulder level for a substantial part of the day. Highly repetitive upper extremity movements most of the day. JULY/AUGUST

2 drome, osteo-arthritis of the cervical spine, osteoarthritis of the glenohumeral joint and cervical radiculopathy. Symptoms in the shoulder or upper limb are mainly caused by: 1 Radiating neck symptoms. Rotator cuff syndrome. Impingement syndrome. Unlike the situation in the European Union, radiating neck pain is not regarded as a compensatable work-related upper limb disorder (WRULD) in South Africa, according to Circular Instruction 180 of the COID Act (1993) 2. In this article the focus will therefore be on the latter two conditions. (See Tables 1 and 2.) IMPINGEMENT SYNDROME Impingement syndrome is a condition mainly affecting the supraspinatus and to a lesser degree the infraspinatus muscle. (See Tables 3 and 4.) ROTATOR CUFF SYNDROME This condition refers to pain originating from the supraspinatus, biceps, subscapularis, infraspinatus tendons, the teres minor muscle and tendon, and the subacromial bursa. The symptoms arise from mechanical impingement under the acromial arch, degenerative changes in the muscle, and a reactive inflammatory process in these structures. Symptoms It presents as antero-lateral pain of the shoulder radiating to the deltoid area, the lateral arm region, the lateral elbow region and the anterior arm region. It is aggravated by abduction of the arm in the scapula plane. Provocative tests Tenderness is present over the greater tuberosity, which is palpated just off the antero-lateral corner of the acromion with the hand positioned behind the back (Figure 1). Tenderness over the biceps tendon can be palpated in its groove anteriorly over the shoulder just inferior to the acromion, but in this instance the forearm is held directly forward with the elbow flexed 90 (Figure 2). Subacromial crepitus can be normal, but when it brings on pain during the above-mentioned tests, it can be indicative of pathology in the subacromial region. Weakness of shoulder abduction in the scapular plane with the arm internally rotated with or without pain, points to supraspinatus pathology (Figure 3). Weakness of external rotation against resist- TABLE 3. STAGES OF IMPINGEMENT SYNDROME 3. Stage 1 Stage 2 Stage 3 Reversible oedema and haemorrhage: Patient <25 years. Fibrosis and tendinosis: Patient usually years of age. Pain recurs with activity. Bone spurs and tendon ruptures: Patient usually >40 years. TABLE 4. IMPINGEMENT SYNDROME INDICATIONS FOR SURGERY 4 (STIFFNESS MUST FIRST BE IMPROVED BEFORE SURGERY IS CONSIDERED). Cuff tears. Patient >40 years with persistent disability of ±1 year. Positive subacromial Lignocaine infiltration test. Stage 2 impingement lesions in patient <40 years. Patient undergoing surgery for other conditions in which impingement is likely, such as joint replacements or old fractures. 22 JULY/AUGUST 2005

THE BACK TO EXPOSE THE GREATER TUBEROSITY FOR

PALPATE THE BICEPS TENDON ANTERIOR WITH THE ARM IN

ELEVATION IN THE SCAPULAR PLANE OF THE INTERNALLY

3 FIGURE 1. INTERNALLY ROTATE THE SHOULDER WITH THE HAND BEHIND THE BACK TO EXPOSE THE GREATER TUBEROSITY FOR PALPATION ANTEROLATERAL TO THE ACROMION. FIGURE 2. PALPATE THE BICEPS TENDON ANTERIOR WITH THE ARM IN NEUTRAL ROTATION (FOREARM POINTING FORWARD). FIGURE 3. ELEVATION IN THE SCAPULAR PLANE OF THE INTERNALLY ROTATED ARM AGAINST RESISTANCE WILL CAUSE PAIN AND SHOW WEAKNESS FROM A DISEASED SUPRASPINATUS MUSCLE. JULY/AUGUST

ance with the arm at the side and the elbow flexed 90 indicates pathology in the infraspinatus and supraspinatus

The subscapularis is affected when there is weakness in the extreme of internal rotation with the hand held behind

Reduced ability to passively internally rotate the shoulder with the arm at 90 of abduction, is a sign of posterior

Pain with passive flexion of the internally rotated shoulder while stabilising scapula from cephalid with your other

If more than 50% relief of pain is achieved with this test after FIGURE 4.

4 ance with the arm at the side and the elbow flexed 90 indicates pathology in the infraspinatus and supraspinatus tendons. The subscapularis is affected when there is weakness in the extreme of internal rotation with the hand held behind the back (Figure 4). Reduced ability to passively internally rotate the shoulder with the arm at 90 of abduction, is a sign of posterior capsular tightness (Figure 5). Pain with passive flexion of the internally rotated shoulder while stabilising scapula from cephalid with your other hand, is a sign of rotator cuff syndrome (Figure 6). If more than 50% relief of pain is achieved with this test after FIGURE 4. INABILITY TO KEEP THE HAND AWAY FROM THE LUMBAR SPINOUS PROCESSES IS ONE OF THE TESTS FOR THE SUBSCAPULARIS MUSCLE POWER. FIGURE 5. IN THE SHOULDER WITH A TIGHT POSTERIOR CAPSULE THE FOREARM WILL NOT BE ABLE TO POINT DOWN DURING ABDUCTION TO 90. FIGURE 6. IN THIS POSITION THE GREATER TUBEROSITY IS SQUEEZED IN UNDERNEATH THE ACROMION WHICH WILL CAUSE PAIN WHEN IMPINGEMENT IS PRESENT. FIGURE 7. ENTRY POINT AND DIRECTION (BROKEN LINE) FOR SUBACROMIAL INJECTION. FIGURE 8. LOCATION OF ACROMIOCLAVICULAR JOINT. 24 JULY/AUGUST 2005

5 infiltration of the subacromial space with 5 ml of Lignocaine, it confirms the origin of pain to be subacromial (Figure 7). The diseased acromio-clavicular joint is painful with direct palpation (Figure 8). Glenohumeral stiffness limits the following: reaching behind the head, reaching up the back, horizontally crossing the arm over to the other shoulder, externally rotating the arm when it is held next to the body, and internally rotating the arm when it is held in 90 adduction. Time rules have been applied for shoulder pathology related to work 1. Symptoms must be present for at least four days during the course of a week for a period of 12 months following the injury. (See Tables 5, 6 and 7.) CONCLUSION Degenerative changes are not usually found with arthroscopic examination in a person less than 35 years of age. When there is insufficient response to rest, work changes, subacromial cortisone infiltration, anti-inflammatory medication, electrotherapy, strengthening of the shoulder girdle and scapula stabilizers and glenohumeral mobilization, spinal origin of the pain must be reconsidered. Referring pain can be work related. Cervical disc rupture with radiculopathy is seldom work related. One must guard against oversimplification of the diagnosis. One must also guard against surgery in the presence of cervical or brachial plexus signs and symptoms. At the most, arthroscopic evaluation will be of benefit in these cases. Acromio-clavicular pathology must be excluded clinically. Avoid surgery in a patient with widespread non-specific shoulder pain. Rather consider a change in job activities where movements are confined to below shoulder level, are non-repetitive and restricted to low mass objects. TABLE 5. SPECIAL INVESTIGATIONS FOR SHOULDER CONDITIONS. X-rays Reveal acromion morphology. Degenerative arthritis of the acromio-clavicular or glenohumeral joint. Calcification in the supraspinatus, infraspinatus and subscapularis tendons. Degenerative changes of the cervical spine. High resolution ultrasound Heterogenic appearance of the supraspinatus, subscapularis, infraspinatus or biceps tendons. Calcification in the tendons. Subacromial fluid indicative of bursal reaction or bursitis. Fluid around the biceps tendon is found with biceps tendonitis or tendinosis. Magnetic resonance More sensitive and specific for the above-mentioned soft tissue changes. imaging (MRI) JULY/AUGUST

6 TABLE 6. MANAGING SHOULDER CONDITIONS. Initial assessment Re-evaluate after 1 month Re-evaluate at 3 months Re-evaluate at 6 months 1. Arm sling Wear 1 week constantly; remove 3X/day to exercise. Thereafter at night for 1 2 weeks to keep arm in neutral position during sleep. 2. Physiotherapy Mobilise glenohumeral joints. Stretch posterior capsule. Strengthen rotator cuff, scapula retractors and scapula elevators. 3. Work Lower working level to below shoulder height and closer to trunk for 1-3 months depending on symptomatic response. 4. Medical Non-steroid, anti-inflammatory drugs. Analgesics. Subacromial infiltration with cortisone not more than twice and not less than 3 weeks apart. 1. Reconsider diagnosis. 2. Continue exercises. 3. Repeat medication and subacromial infiltration, where applicable. 4. Continue work adjustment for up to 3 months. 1. If improving, but worsening after employee returns to original job, consider permanent change of job. 2. If symptoms continue influencing work and everyday activities, consider surgical exploration and acromioplasty with rotator cuff repair, where indicated. 3. If physical signs present during examination clearly pointing to rotator cuff pathology, ultrasound confirmation of rotator cuff pathology strengthens the case for surgery. 4. After surgery, the rehabilitation programme prior to the operation is continued to mobilize, strengthen and retrain shoulder girdle muscles. This is continued for 1 3 months, depending on the symptoms. Temporary job change is made and work hardening programme is initiated. 5. Work evaluation to aid in job changes, either temporary or permanent, is of great value. If symptoms still persist, the following must be considered: 1. Irreparable or permanent pathological changes. 2. Secondary gain. 3. Psychosocial factors consider evaluation by occupational therapist. 4. Work pressure confirm that employer understands and follows work adjustment recommendations. Final assessment after 12 months Assess for possible permanent impairment with work evaluation by occupational therapist. TABLE 7. WORK CHANGES THAT SHOULD BE ADDRESSED 2 1. Reduced repetitive movements. 2. Reduce power necessary to complete a task by ergonomic changes. 3. Avoid or reduce movements at extremes of reach. Joint stabilisers, facet joints, discs and soft tissue of the neck and lower back is placed under greater strain. Objects must be handled closer to the centre point of the trunk and on the level of hip joints. 4. Limit static muscle loading to less than 30 seconds per sustained contraction by ergonomic adjustments. 5. Reduced mass loading on limbs by aids or involvement of a 2nd worker for handling heavy objects. 6. Reduce exposure to cold in order to maintain flexibility of joints. 7. The safe zones for shoulder function: 30 of external rotation to 20 of internal rotation in 90 of adduction. 30 to 90 of shoulder flexion. 10 to 90 of shoulder abduction. REFERENCES 1. Sluiter, J.K., Rest, KM, Frings-Dresen, M.H.W. Criteria document for evaluating the work-relatedness of upperextremity musculo-skeletal disorders. Scandinavian Journal of Work, Environment and Health. 2001; 27 (Supplement)(1): South Africa. Compensation Commissioner s guidelines to health practitioners and employers to manage work-related upper limb disorders in terms of Circular Instruction 180 regarding compensation for work-related upper limb disorders (WRULDs) (Compensation for Occupational Injuries and Diseases Act, 1993 (Act No 130 of 1993), as Amended). Available at: useful_docs/ doc_display.jsp?id=10173 (last accessed 14 July 2005) 3. Neer, C.S. (II): Impingement Lesions. Clin. Orthop. 1983; 73: Neer, C.S. (II). Anterior acromioplasty for the chronic impingement syndrome in the shoulder: A preliminary report. J. Bone Joint Surg. 1972; 54: JULY/AUGUST 2005

Anatomy Your shoulder is made up of three bones: your upper arm bone (humerus), your shoulder blade (scapula), and your collarbone (clavicle).

Anatomy Your shoulder is made up of three bones: your upper arm bone (humerus), your shoulder blade (scapula), and your collarbone (clavicle). Shoulder Impingement/Rotator Cuff Tendinitis One of the most common physical complaints is shoulder pain. Your shoulder is made up of several joints combined with tendons and muscles that allow a great