Treating Shoulder Injuries with Evidence-Based Medicine
Fernando Branco, MD, FAAPM&R
AVP of Claims and Chief Medical Officer, Midwest Employers Casualty
The shoulder joint is a complex area that can be prone to injuries, particularly for employees working in the healthcare, construction and manufacturing industries.
There is no bone connection between the shoulder blade and the humerus, just cartilage, ligaments, and tendons. The area is fragile and susceptible to injury due to repetitive or monotonous work that constantly utilizes the same arm movement, trauma and disease. Other factors that can increase the risk of a shoulder injury include heavy lifting, stress and depression. Because of these variables, it is crucial that treating physicians use evidence-based medicine to make proper care determinations.
With any shoulder pain, the initial diagnosis is most important. Best practice guidelines for occupational-based medical and disability care, like those established by the Official Disabilities Guidelines (ODG) and the American College of Occupational and Environmental Medicine (ACOEM), provide a good starting point.
For someone presenting with a shoulder injury, the physician should return to basics and spend time inspecting, palpating, and comparing both shoulders to understand the bone structure and any types of degenerative changes that may exist, rule out other diagnoses and address fractures and dislocations.
When treating shoulder injuries, keep the P.R.I.C.E. principle in mind. First, Protect the area and use Relative Rest to minimize utilization of the joint for the first 24 to 48 hours. Apply Ice to active injuries to help with swelling. After 48 hours, alternate use of ice and heat. Compression, using supportive wrapping, should be applied to the shoulder area to help with instability. Finally, use Elevation to decrease inflammation. These guidelines are all evidence-based from ODG and ACOEM.
Approximately 90% of shoulder injuries will require mild to moderate treatment. The first physician visit immediately following the injury may involve changing activity a little and using acetaminophen or an anti-inflammatory. During the second visit, typically a week or two later, the physician may recommend physical or occupational therapy, or a combination, at two to three visits a week for two weeks.
On the third visit, about three weeks to a month later, if things have not improved, the physician may recommend some form of an injection to provide limited improvement to the pain and inflammation and continued therapy and home exercises.
At the fourth visit at around six weeks, in 30% of cases, the physician will do some form of imaging to diagnose tendonitis, bursitis or other soft tissue problems. Finally, after three months, if conservative treatment is not proving effective, the physician may recommend a more aggressive treatment such as surgery or arthrograms.
Applying general guidelines rooted in evidence-based medicine can be an effective way to help reduce the risk of having poor outcomes in terms of the diagnosis and treatment of issues involving the shoulder.
*The views and opinions expressed in the Public Risk Management Association (PRIMA) blogs are those of each respective author. The views and opinions do not necessarily reflect the official policy or position of PRIMA.*
By:
Fernando Branco, MD, FAAPM&R
AVP of Claims and Chief Medical Officer, Midwest Employers Casualty
Fernando is chief medical officer at Midwest Employers Casualty (MEC), a Berkley Company. He has over 30 years of experience in clinical practice and is board certified in physical medicine and rehabilitation, pain, and addiction medicine. He is the former medical director of a multi-disciplinary rehabilitation pain center for the treatment of chronic pain cases – a center of excellence recognized by the American Pain Society. In his current role at MEC, Dr. Branco leads a team of medical management consultants handling complex workers’ compensation claims to help employers and injured workers achieve better outcomes.
