dr js kirsten louis leipoldt medical centre bellville shoulder... · louis leipoldt medical centre...

WorkWork--related shoulder painrelated shoulder pain

Dr JS KirstenDr JS Kirsten

Louis Louis LeipoldtLeipoldt Medical CentreMedical Centre

BellvilleBellville

IntroductionIntroduction

•• Work related conditions described since Work related conditions described since

early 20early 20thth centurycentury

•• Current tools for evaluationCurrent tools for evaluation

–– Criteria document for evaluating work Criteria document for evaluating work

relatedness of UEMSDrelatedness of UEMSD

•• ((SluiterSluiter 2001)2001)

–– Comp Comp CommComm guidelines for WRULDguidelines for WRULD


•• Shoulder pain origin in work environmentShoulder pain origin in work environment

–– SubacromialSubacromial bursabursa

–– Rotator cuff tendonRotator cuff tendon

–– AC jointAC joint

–– Biceps tendonBiceps tendon

–– CC--spinespine

–– Brachial plexusBrachial plexus


•• With proper history taking + physical With proper history taking + physical examination diagnoseexamination diagnose

–– Rotator cuff syndromeRotator cuff syndrome

–– Radiating neck painRadiating neck pain

•• Relation to work questionable inRelation to work questionable in–– TUSTUS

–– Symptoms from Symptoms from synovitissynovitis AC joint AC joint

–– Symptoms from Symptoms from spondilosisspondilosis CC--spinespine


•• ChallengeChallenge

–– Locate originLocate origin

–– Prove relationship to workProve relationship to work

–– Determine disability (temporary/permanent)Determine disability (temporary/permanent)

Rotator cuff syndromeRotator cuff syndrome

•• Pain originating fromPain originating from–– Rotator cuff tendon/sRotator cuff tendon/s

–– SubacromialSubacromial bursabursa

–– Biceps tendonBiceps tendon

•• Pathology range fromPathology range from–– Reactive inflammatory processReactive inflammatory process

–– Mechanical impingement under SA archMechanical impingement under SA arch

–– Degenerative changesDegenerative changes


•• BursitisBursitis •• InflamationInflamation of of

subacromialsubacromial bursa bursa

from mechanical from mechanical

irritationirritation


•• TendinitisTendinitis

–– InflamationInflamation of of

tendontendon


•• TendinosisTendinosis

–– Degeneration Degeneration

of tendonof tendon

–– ArticularArticular sideside



–– BursalBursal sideside


•• TearTear

BiomechanicsBiomechanics

•• GlenohumeralGlenohumeral jointjoint

–– Ball in socketBall in socket

–– Different elements of movement active at the Different elements of movement active at the

same timesame time

–– Undesired ones canceled out by opposing Undesired ones canceled out by opposing

muscles to allow desired actionmuscles to allow desired action

BiomechanicsBiomechanics

•• Rotator cuff Rotator cuff

–– Compress in head Compress in head glenoidglenoid

–– Rotate headRotate head

–– Provide muscle balance during rotationProvide muscle balance during rotation

–– Provide stability while rest of shoulder girdle Provide stability while rest of shoulder girdle

performs the motionperforms the motion

ImpingementImpingement

•• Mainly Mainly supraspinatussupraspinatus

•• Lesser degree Lesser degree infraspinatusinfraspinatus

•• Three stagesThree stages


•• Stage 1Stage 1 •• OedemaOedema

•• HemorrhageHemorrhage

•• < 25yr< 25yr

•• ReversibleReversible


•• Stage 2Stage 2 •• FibrosisFibrosis


•• 25 25 –– 40yrs40yrs

•• Pain recurs with Pain recurs with

activityactivity


•• Stage 3Stage 3 •• Bone spursBone spurs

•• Tendon ruptureTendon rupture

•• > 40 yrs> 40 yrs

PathologyPathology

•• Ineffective contraction of rotator cuff Ineffective contraction of rotator cuff

muscle + upward pull of deltoid >muscle + upward pull of deltoid >

•• Unbalanced force couples >Unbalanced force couples >

•• Riding up of humeral headRiding up of humeral head

•• Compress cuff undersurface Compress cuff undersurface coracocoraco--

acromialacromial archarch

–– Rockwood 2004Rockwood 2004

PathologyPathology

•• Tight posterior capsule >Tight posterior capsule >

•• Eccentric rotation of head in Eccentric rotation of head in glenoidglenoid

•• Compress cuff undersurface Compress cuff undersurface coracocoraco--

acromialacromial archarch

–– CofieldCofield 1984, 1984, HarrymanHarryman 19901990

PathologyPathology

•• Shape of Shape of acromionacromion

correlates with correlates with

incidence of tearsincidence of tears

–– BiglianiBigliani 19861986

PathologyPathology

•• Results of Results of

arthroscopic arthroscopic

acromioplastyacromioplasty closely closely

correlates conversion correlates conversion

of hooked to flat of hooked to flat

undersurfaceundersurface

–– MorissonMorisson 19881988

PathologyPathology

•• Tendon degenerationTendon degeneration

–– Age related changes main reasonAge related changes main reason

–– PettersenPettersen 1942, Meyer 19311942, Meyer 1931

–– PainlessPainless

•• Calcification or rupture of tendon is Calcification or rupture of tendon is

painfullpainfull

–– PettersenPettersen 19421942

PathologyPathology

•• Cuff defectsCuff defects–– No clear association with strenuous physical No clear association with strenuous physical work or heavy manual work or heavy manual labourlabour

–– NeerNeer 19831983

–– Age relatedAge related•• uncommon < 40yrsuncommon < 40yrs

•• 5050--60 yrs incidence increases60 yrs incidence increases

•• Relatively common > 70 yrsRelatively common > 70 yrs

–– Meyer 1931Meyer 1931

OccupationOccupation

•• Assembly line workersAssembly line workers

–– Probable relationship of some workload Probable relationship of some workload

factors to upper limb factors to upper limb dissordersdissorders

–– LuoparjarfeLuoparjarfe 19791979


•• Higher incidence of shoulder pain Higher incidence of shoulder pain

–– Repetitive use of tool/repetitive forceful Repetitive use of tool/repetitive forceful

movement movement egeg. hitting. hitting

–– Arm above shoulder level for substantial Arm above shoulder level for substantial

periodperiod

–– Bending forward during work with armsBending forward during work with arms

–– Use of vibrating tool??Use of vibrating tool??

–– LeclercLeclerc 20042004


•• Higher incidence of shoulder pain Higher incidence of shoulder pain

–– Presence of depressive symptomsPresence of depressive symptoms

–– Low level of job control by workerLow level of job control by worker

–– Low social supportLow social support

–– LeclercLeclerc 20042004

SymptomsSymptoms

•• PainPain

•• Muscle weaknessMuscle weakness

•• Burning sensationBurning sensation

•• Fatigue abilityFatigue ability

•• StiffnessStiffness

SignsSigns

•• CrepitisCrepitis

•• Muscle weaknessMuscle weakness

•• Muscle spasmMuscle spasm

•• Decreased range of motionDecreased range of motion

•• Tenderness Tenderness


•• Pain Pain anteroantero--lateral shoulder >lateral shoulder >

–– Deltoid regionDeltoid region

–– Lateral armLateral arm

–– Lateral elbowLateral elbow

–– Anterior forearmAnterior forearm


•• Tenderness over Tenderness over

greater greater tuberositytuberosity

•• SubacromialSubacromial crepitiscrepitis

that is painfulthat is painful


•• Pain aggravated by Pain aggravated by

abduction in scapular abduction in scapular

planeplane


•• Weakness of Weakness of

supraspinatussupraspinatus


•• Impingement test Impingement test

positivepositive


•• LignocaineLignocaine infiltationinfiltation

test positivetest positive


•• Weakness of ERWeakness of ER


•• Tenderness over Tenderness over

biceps tendonbiceps tendon


•• Weakness of Weakness of

subscapularissubscapularis


•• Posterior capsular Posterior capsular

tightnesstightness

AC JointAC Joint

•• Tenderness of AC Tenderness of AC

jointjoint

AC JointAC Joint

•• HorisontalHorisontal adduction adduction

pain over AC jointpain over AC joint

GlenohumeralGlenohumeral stiffnessstiffness

•• Limits the following:Limits the following:

–– Reaching behind headReaching behind head



–– Reaching behind backReaching behind back



–– Horizontal adductionHorizontal adduction



–– External rotation in External rotation in

neutralneutral



–– Internal rotation in 90 Internal rotation in 90

degrees of abductiondegrees of abduction

Time RulesTime Rules

•• Symptoms for at least 4 days during Symptoms for at least 4 days during

coarse of a week over last 12 months coarse of a week over last 12 months

since symptoms startedsince symptoms started

–– SluiterSluiter et al, Criteria document for evaluating et al, Criteria document for evaluating

work relatedness of UEMSD.2001work relatedness of UEMSD.2001

Work relatedness of UEMSDWork relatedness of UEMSD

•• Physical factorsPhysical factors

–– PosturePosture

–– ForceForce

–– MovementMovement

–– Time Time invovedinvoved

–– SluiterSluiter 20012001


•• PosturePosture

–– Proximal muscles postural in natureProximal muscles postural in nature

–– Object further away from body >Object further away from body >

–– Greater muscle moment and Greater muscle moment and ––force >force >

–– More recovery time neededMore recovery time needed



•• ForceForce

–– 20% of max voluntary contraction requires 20% of max voluntary contraction requires

50% recovery time50% recovery time

–– i.e. 2 min requires 1 mini.e. 2 min requires 1 min



•• MovementMovement

–– 2 2 -- 4 repetitions per minute or4 repetitions per minute or

–– Cycles lasting at least 30 Cycles lasting at least 30 secssecs

–– More than half range of motion of jointMore than half range of motion of joint



•• Time involvedTime involved

–– Posture and movement criteria more than 4 Posture and movement criteria more than 4

hours per dayhours per day



•• NonNon--physical factorsphysical factors

–– Work/rest ratioWork/rest ratio

••Work tempoWork tempo

–– Psychological demandPsychological demand

•• Deadlines and mental demandsDeadlines and mental demands

–– Social supportSocial support–– Relationship with colleagues end supervisorsRelationship with colleagues end supervisors


Risk of shoulder and upper arm Risk of shoulder and upper arm

disordersdisorders

•• Hand behind trunk for Hand behind trunk for

•• Hand in front of opposite part of trunkHand in front of opposite part of trunk

•• Sustained external rotation of shoulderSustained external rotation of shoulder

•• Sustained abduction (away from body)Sustained abduction (away from body)

•• Hands moving above shoulder levelHands moving above shoulder level

•• Highly repetitive upper extremity movementsHighly repetitive upper extremity movements

•• Substantial part of daySubstantial part of day

•• SluiterSluiter 20012001

Special investigationsSpecial investigations

•• XX--ray examinationray examination

–– AcromionAcromion



–– calcificationcalcification



–– Degenerative changes Degenerative changes

GHJGHJ



–– Degenerative changes Degenerative changes

ACJACJ


•• UltrasoundUltrasound

–– SubacromialSubacromial fluidfluid

–– TendinosisTendinosis

–– Small calcificationsSmall calcifications

–– TearTear


•• MRIMRI

–– More sensitive and specific for soft tissue More sensitive and specific for soft tissue

changeschanges

–– ExpensiveExpensive

ManagementManagement

•• Physical treatmentPhysical treatment

–– Sling worn constantly 1Sling worn constantly 1--2 weeks2 weeks

–– Taken of Taken of tdstds for mobility and strengthening for mobility and strengthening

exercisesexercises


•• PhysiotherapyPhysiotherapy

–– Mobilize GHJMobilize GHJ

–– Stretch posterior capsuleStretch posterior capsule

–– Strengthen RC, scapula retractors and Strengthen RC, scapula retractors and --

stabilizersstabilizers


•• Work Work

–– Below shoulder levelBelow shoulder level

–– Closer to trunk and centre of gravityCloser to trunk and centre of gravity

–– Reduce repetitive actionReduce repetitive action

–– Objects of lower mass (less than 2 kg)Objects of lower mass (less than 2 kg)

–– Resting periods in betweenResting periods in between


•• MedicalMedical

–– NSAIDSNSAIDS

–– AnalgesicsAnalgesics

•• SubacromialSubacromial cortisonecortisone


•• ReRe--evaluate after 1 monthevaluate after 1 month

–– Reconsider diagnosisReconsider diagnosis

–– Continue exercisesContinue exercises

–– Repeat medication and cortisone Repeat medication and cortisone subacromialsubacromial

–– Continue work adjustmentContinue work adjustment


•• ReRe--evaluate after 3 monthsevaluate after 3 months

–– If symptoms return in original job > work If symptoms return in original job > work

evaluation > permanent job changeevaluation > permanent job change

•• Exclude neck pathologyExclude neck pathology


•• ReRe--evaluate after 3 monthsevaluate after 3 months–– Indications for surgeryIndications for surgery

•• Cuff tearCuff tear

•• Pt > 40yrs + persistent disability + positive Pt > 40yrs + persistent disability + positive lignocainelignocaine infiltration testinfiltration test

•• Refractory stage 2 impingement under 40yrs Refractory stage 2 impingement under 40yrs

•• Pt undergoing surgery for condition in which Pt undergoing surgery for condition in which impingement is likely impingement is likely egeg. fracture. fracture

•• Stiffness must be improved firstStiffness must be improved first

•• AC joint pathologyAC joint pathology


•• ReRe--evaluate at 6 monthsevaluate at 6 months

–– Irreparable/permanent pathological changesIrreparable/permanent pathological changes

–– Secondary gainSecondary gain

–– Emotional factorsEmotional factors

–– Work pressureWork pressure

•• Psychiatric evaluationPsychiatric evaluation


•• 1 yr 1 yr assesmentassesment

–– Condition stabilizedCondition stabilized

–– Permanent work adjustmentPermanent work adjustment

Work ChangesWork Changes

•• ReduceReduce–– Repetitive movementsRepetitive movements

–– Power to complete taskPower to complete task•• AidsAids

•• 22ndnd workerworker

•• ergonomicsergonomics

–– Extremes of reachExtremes of reach

–– Static muscle loadingStatic muscle loading

–– Cold exposureCold exposure


•• Safe zonesSafe zones

–– 30 deg ER in 30 deg ER in

abductionabduction

–– 20 deg IR in abduction20 deg IR in abduction



–– 30 30 -- 90 deg of 90 deg of

shoulder flexionshoulder flexion



–– 10 10 –– 90 deg abduction90 deg abduction

ConclusionConclusion

•• Multidisciplinary approachMultidisciplinary approach

•• Start with good history takingStart with good history taking

•• Sometimes end in psychiatric evaluation Sometimes end in psychiatric evaluation

•• Often involves employerOften involves employer

•• Always requires good communication with Always requires good communication with

patientpatient

Thank youThank you

dr js kirsten louis leipoldt medical centre bellville shoulder... · louis leipoldt medical centre...

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