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Shoulder Conditions Diagnosis and Treatment Guideline

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Shoulder Conditions Diagnosis and Treatment Guideline Shoulder Conditions Diagnosis and Treatment Guideline TABLE OF CONTENTS I. Review Criteria for Shoulder Surgery II. Introduction III. Establishing Work-Relatedness A. Shoulder Conditions as Industrial Injuries B. Shoulder Conditions as Occupational Diseases IV. Making the Diagnosis A. History and Clinical Exam B. Diagnostic Imaging V. Treatment A. Conservative Treatment B. Surgical Treatment VI. Specific Conditions A. Rotator Cuff Tears B. Subacromial Impingement Syndrome without a Rotator Cuff Tear C. Calcific tendonitis D. Labral tears including superior labral anterior-posterior (SLAP) tears E. Acromioclavicular dislocation F. Acromioclavicular arthritis G. Glenohumeral dislocation H. Tendon rupture or tendinopathy of the long head of the biceps I. Glenohumeral arthritis and arthropathy J. Manipulation under anesthesia K. Diagnostic arthroscopy VII. Post-operative Treatment and Return to Work VIII. Specific Shoulder Tests IX. Functional Disability Scales for Shoulder Conditions X. References 1 Hyperlink update September 2016 I. REVIEW CRITERIA FOR SHOULDER SURGERY Criteria for Shoulder Surgery A request may be AND this has been done If the patient has AND the diagnosis is supported by these clinical findings: appropriate for (if recommended) Surgical Procedure Diagnosis Subjective Objective Imaging Non-operative care Rotator cuff tear repair Acute full-thickness Report of an acute Patient will usually have Conventional x-rays, AP and May be offered but not rotator cuff tear traumatic injury within 3 weakness with one or true lateral or axillary view required Note: The use of allografts months of seeking care more of the following: and xenografts in rotator Forward elevation AND cuff tear repair is not AND Internal/external MRI, ultrasound or x-ray covered. Shoulder pain: rotation arthrogram reveals a full With movement and/or Abduction testing thickness rotator cuff tear Note: Distal clavicle at night resection as a routine part Routine use of contrast of acute rotator cuff tear imaging is not indicated repair is not covered. Rotator cuff tear repair Partial thickness Pain with active arc Weak or painful Conventional x-rays, AP and Conservative care* required rotator cuff tear motion 90-130° abduction true lateral or axillary view for at least 6 weeks, then: AND AND If tear is >50% of the Tenderness over rotator MRI, ultrasound or x-ray tendon thickness, may cuff arthrogram shows a partial consider surgery; thickness rotator cuff tear AND If <50% thickness, do 6 Positive impingement Routine use of contrast more weeks conservative sign imaging is not indicated care. Rotator cuff tear repair Chronic or Gradual onset of Patient will usually have Conventional x-rays, AP and Conservative care*, for at degenerative full- shoulder pain without a weakness with one or true lateral or axillary view least 6 weeks. Note: The use of allografts thickness rotator cuff traumatic event more of the following: If no improvement after 6 and xenografts in rotator tear OR Forward elevation AND weeks, and tear is cuff tear repair is not minor trauma; night Internal/external repairable, surgery may be covered. pain rotation MRI, ultrasound or x-ray considered. Abduction testing arthrogram reveals a full thickness rotator cuff tear Routine use of contrast imaging is not indicated 2 A request may be AND this has been done If the patient has AND the diagnosis is supported by these clinical findings: appropriate for (if recommended) Surgical Procedure Diagnosis Subjective Objective Imaging Non-operative care Rotator cuff tear repair Recurring full 1. New traumatic injury Patient may have Conventional x-rays, AP and Conservative care*, for at after previous rotator cuff thickness tear with good function prior weakness with forward true lateral or axillary view least 6 weeks. surgery to injury elevation, If no improvement after 6 internal/external AND weeks, and tear is 1. One revision surgery rotation, and/or MRI, ultrasound or x-ray repairable, surgery may be may be considered. abduction testing arthrogram reveals a full considered. thickness rotator cuff tear Revision surgery is not covered in the presence of Routine use of contrast a massive rotator cuff tear, imaging is not indicated as defined by one or more of the following: Note: Smoking/nicotine use is a strong relative contraindication for rotator cuff [1-4] a. >3cm of retraction surgery. b. severe rotator cuff muscle atrophy c. severe fatty infiltration 2. 2nd and subsequent Recurring full 2. No new injury, but Patient may have Conventional x-rays, AP and 2. Second revision: revisions thickness tear gradual onset of pain weakness with forward true lateral or axillary view with good function for elevation, Conservative care* for 6 Revision surgery is not over a year after internal/external AND weeks is required; if no covered in the presence of previous surgery rotation, and/or MRI, ultrasound or x-ray improvement, surgery may a massive rotator cuff tear, abduction testing arthrogram reveals a full be considered as defined by one or more 2nd revision will only be thickness rotator cuff tear of the following: considered when patient has returned to work or Routine use of contrast a. >3cm of retraction has clinically meaningful imaging is not indicated b. severe rotator cuff improvement in muscle atrophy function, on validated c. severe fatty instrument, after the infiltration most recent surgery 3 A request may be AND this has been done If the patient has AND the diagnosis is supported by these clinical findings: appropriate for (if recommended) Surgical Procedure Diagnosis Subjective Objective Imaging Non-operative care Partial claviculectomy Arthritis of AC joint Pain at AC joint; Tenderness over the AC MRI (radiologist interpretation) Conservative care* for at (includes Mumford aggravation of pain with joint reveals: least 6 weeks (if done in procedure) shoulder motion Moderate to severe isolation) AND degenerative joint disease Not authorized as a part of Documented pain relief of AC joint, or Surgery is not indicated acute rotator cuff repair with an anesthetic Distal clavicle edema, or before 6 weeks. injection Osteolysis of distal Note: Mumford procedure clavicle done alone must meet all OR these criteria. Bone scan is positive Mumford as an add-on to any other shoulder surgery OR must also meet all Radiologist’s interpretation of x diagnostic criteria ray reveals moderate to severe preoperatively. ac joint arthritis Intraoperative visualization of AC joint, in the absence of radiographic findings, is not a sufficient finding to authorize the claviculectomy. Isolated subacromial Subacromial Generalized shoulder Pain with active MRI reveals evidence of 12 weeks of conservative decompression with or impingement pain elevation tendinopathy/tendinitis care* without acromioplasty syndrome OR AND A rotator cuff tear Subacromial injection with local anesthetic gives documented pain relief Debridement of calcific Calcific tendonitis Generalized shoulder Pain with active Conventional x-rays show 12 weeks of conservative tendonitis pain elevation calcium deposit in the rotator care* cuff 4 A request may be AND this has been done If the patient has AND the diagnosis is supported by these clinical findings: appropriate for (if recommended) Surgical Procedure Diagnosis Subjective Objective Imaging Non-operative care Open treatment of acute Shoulder AC joint Pain with marked Marked deformity Conventional x-rays show Type Conservative care* only for acromioclavicular separation functional difficulty III or greater separation types I and II. dislocation Conservative care for 3 Note: Surgery for acute months for type III types I and II AC joint separations, with the dislocations is not covered. exception of early surgery being considered for heavy or overhead laborers. Immediate surgical intervention for types IV-VI. Repair, debridement, or Labral tears without Traumatic event Pain reproduced with MRI shows labral tear At least 6 weeks of biceps tenodesis for labral instability (including reported or an labral loading tests (e.g. conservative care* lesion, including SLAP tears SLAP tears) occupation with O’Brien’s test) significant overhead activity AND Pain worse with motion and active elevation Capsulorrhaphy (Bankart Glenohumeral History of a dislocation Positive Conventional x-rays If only one dislocation has procedure) instability that inhibit activities of apprehension/relocation occurred, recommend 1-2 daily living test AND weeks of immobilization MRI demonstrates one of the then PT for 6-8 weeks. If a following: positive apprehension is a. Bankart/labral lesion present at 6 weeks, surgery b. Hill Sachs lesion may be considered. c. Capsular tear Two or more dislocations in 3 months may proceed to surgery without conservative care. Early surgery may be considered in patients with large bone defects, or in patients under 35 years old. 5 A request may be AND this has been done If the patient has AND the diagnosis is supported by these clinical findings: appropriate for (if recommended) Surgical Procedure Diagnosis Subjective Objective Imaging Non-operative care Tenodesis or tenotomy of Partial biceps tear, Anterior shoulder pain, Tenderness over the MRI required if procedure Surgery almost never long head of biceps biceps instability weakness and deformity biceps groove, pain in performed in isolation. If considered in full thickness from the biceps the anterior shoulder biceps tendon pathology ruptures. groove, proximal during resisted identified and addressed biceps enlargement supination
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