Viewpoint: Using Evidenced-Based Medicine to Treat Shoulder Pain
The shoulder is a fragile and complex joint making injuries to this area a common occurrence. In fact, in 2020 alone, the U.S. Department of Labor reported more than 63,000 private-sector workers suffered from shoulder injuries, with healthcare, construction, and manufacturing industries accounting for the bulk of those. This article reviews some frequently seen shoulder injuries and offers evidence-based considerations to help ensure their proper diagnosis and treatment.
The shoulder is very susceptible to injuries because there is really no bone connection between the shoulder blade and the humerus. What you have there is maintained in place mostly by cartilage, tendons, and ligaments, making it a very fragile joint because when tendons tear, there is less function in the joint, causing it to become much more unstable.
Many different issues can affect the shoulder area as the result of trauma, infection, rheumatoid arthritis or other arthropathies, tumors, or referred pain stemming from issues of the lung, abdomen, or the cervical area, to name a few. It can also be one of the first symptoms of a heart attack.
There are also a variety of other factors that can increase the risk of suffering a shoulder injury. Heavy lifting, stress, depression, repetitive or monotonous work that constantly utilizes the same arm movement, obesity, and sports can also cause injury or pain in the shoulder joint.
Because of all of these variables, it is important to ensure that treating physicians are using evidence-based medicine to make proper care determinations. For injured employees, this means considering the best practice guidelines for occupational-based medical and disability care such as those established by the Official Disabilities Guidelines (ODG) and the American College of Occupational and Environmental Medicine (ACOEM).
One of the most important items to focus on when it comes to shoulder pain is rotator cuff disorders which include tendinitis and bursitis.
Tendinitis or inflammation of the tendon is an issue because when a tendon is inflamed, it becomes painful and can rupture or tear due to weakening. Tendinitis is typically diagnosed with a physical exam or ultrasound. It is worth noting that if somebody has a tear, this does not necessarily mean that they will have a lifelong limited range of motion. Other muscles in the shoulder girdle can compensate for it contingent on good therapy done appropriately. If a tear requires surgery, it needs to be done promptly and not postponed for months to a year or more.
Bursitis is swelling of the small fluid-filled sacs in the shoulder joint important to the movement of the arm. Similar to tendinitis, it can also be diagnosed by a good physical exam.
Additional frequently seen conditions affecting the shoulder include impingement syndrome and frozen shoulder. Impingement syndrome can happen when inflammation of the area makes tendons become hard to move, causing pain. It can easily be diagnosed by the symptoms and a physical exam or ultrasound and requires very aggressive physical therapy treatment. Sometimes, manipulation of the joint under sedation is necessary but reserved for cases not responding to physical therapy.
With any shoulder pain, the initial diagnosis is most important. Practicing evidence-based medicine is crucial. The provider should go back to the basics and spend time with the injured employee, inspecting, palpating, and comparing both shoulders to understand the bone structure and any types of degenerative changes that may exist. You want to rule out other diagnoses and also address fractures and dislocations.
If there was trauma, we need to understand what happened. We also need to understand what kind of job this person has. Does it involve twisting? Range of motion testing should be done to see if the injured employee can do that actively and, if not actively, passively.
When treating shoulder injuries, keep the P.R.I.C.E. principle in mind. Protect the area and use Relative Rest to minimize utilization of the joint for the first 24 to 48 hours. This should be very limited because you don’t want the injured employee to develop a frozen shoulder. Apply Ice to active injuries to help with swelling. After 48 hours, the injured employee can alternate ice and heat. Compression, using supportive wrapping, should be applied to the shoulder area to help with the instability. Finally, use Elevation to decrease the level of inflammation. These guidelines are all evidence-based from ODG and ACOEM.
Approximately 90% of shoulder injuries will require mild to moderate treatment. At the first physician visit immediately following the injury, this may involve changing the activity a little and using acetaminophen or an anti-inflammatory. During the second visit, typically a week or two later, the physician should document the progress and, if necessary, have the injured employee start physical or occupational therapy, or a combination, two to three visits a week for two weeks.
The third visit should be about three weeks to a month later. If things have not improved by then, along with continued therapy, the physician may recommend some form of an injection to provide limited improvement to the pain and inflammation. Maybe the diagnosis is tendonitis or bursitis. In general, those respond pretty well to injections. Just be aware that any time corticosteroids are injected into tendons, it weakens them tremendously so physical therapy should be continued at this point and the injured employee should also be doing home exercises.
By the time you get to the fourth visit, which generally occurs at around six weeks, in 30% of cases the physician will do some form of imaging. One thing I recommend is doing an ultrasound in the office. It’s been used often by physicians, most of them physiatrists and is a less expensive and non-invasive way to diagnose tendonitis, bursitis, and all sorts of soft tissue problems.
More aggressive treatment such as surgery or arthrograms occur in approximately 10% of the cases. These procedures require the injection of dyes into the joint so there’s a greater risk of infection and other issues that could result from opening an area that was sterile. This option should only be used after three months if the injured employee does not respond to conservative treatment. For post-surgical treatment, you shouldn’t go beyond fourteen to twenty visits with physical therapy over eight to ten weeks.
These are general guidelines based on ODG and ACOEM that can be used to determine if a medical team is following evidence-based medicine. This valuable approach can ensure that the treatment plan is effective and can help reduce the risk of having poor outcomes in terms of the diagnosis and treatment of issues involving the shoulder.
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