In What Section of the Paper Medical Record Would a Report of Shoulder Xray Beef
All-time Pract Res Clin Rheumatol. Author manuscript; available in PMC 2016 Apr 19.
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PMCID: PMC4836557
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SHOULDER DISORDERS AND OCCUPATION
Abstract
Shoulder pain is very common and causes substantial morbidity. Standardised classification systems based upon presumed patho-anatomical origins accept proved poorly reproducible and hampered epidemiological research. Despite this, there is testify that exposure to combinations of physical workplace strains such every bit overhead working, heavy lifting and forceful work every bit well as working in an bad-mannered posture increase the risk of shoulder disorders. Psychosocial risk factors are also associated. There is currently lilliputian evidence to propose that either chief prevention or handling strategies in the workplace are very effective and more than research is required, especially around the cost-effectiveness of different strategies.
Keywords: Shoulder pain, impingement syndrome, frozen shoulder (adhesive capsulitis), rotator gage
Introduction and Scope
According to population surveys, shoulder pain affects 18-26% of adults at whatever point in time [1–4], making information technology one of the most common regional hurting syndromes. Symptoms can be persistent and disabling in terms of an individual's ability to carry out daily activities both at habitation and in the workplace [five,six]. There are also substantial economic costs involved, with increased demands on wellness care, impaired piece of work performance, substantial sickness absenteeism, and early retirement or task loss [7–10].
The shoulder has evolved to withstand heavy physical demands and to practise so over an unusually wide range of motion. To attain this, it is non a unproblematic 'ball and socket' articulation just rather a complex equanimous of four articulations and a supporting organization of bones, muscles and ligaments within and exterior of the joint capsule. However, its complexity and the nature of the demands on it make it susceptible to a range of articular and peri-articular pathologies. Shoulder pain has a diverse range of causes (Tabular array 1). In improver to local pathologies, shoulder pain may be referred from the cervix causing symptoms that may be difficult to distinguish clinically from those localised to the shoulder. Moreover, pain may be experienced in the shoulder referred from abdominal pathologies affecting the diaphragm, liver or other viscera. Although referred abdominal pathologies are outwith the telescopic of this chapter, the range of specific shoulder disorders and overlap with neck conditions will be considered, particularly in relation to work and workers with specific occupational exposures.
Table 1
Differential Diagnosis of Shoulder Pain
| Referred hurting | |
| Neck | Mechanical cervix pain |
| Cervical spondylosis | |
| Brachialgia | |
| Intra-intestinal | Liver affliction |
| Splenomegaly | |
| Perforated bowel | |
| Pulmonary | Apical lung cancer |
| Pulmonary oedema | |
| Pulmonary embolus | |
| Diaphragmatic | Phrenic nervus palsy |
| Pleural plaques | |
| Cardiovascular | Stroke |
| Acute coronary syndrome (typically left sided) | |
| Systemic disease | Malignancy (primary /secondary) |
| Infection (septic arthritis, Tuberculosis) | |
| Inflammatory rheumatic diseases | Polymyalgia rheumatica |
| Rheumatoid arthritis | |
| Psoriatic arthritis | |
| Crystal arthritis | |
| Articular pathology | Osteoarthritis of gleno-humeral joint |
| Osteoarthritis of acromio-clavicular articulation | |
| Milwaukee shoulder | |
| Bone pathology | Tumour (primary or secondary) |
| Avascular necrosis | |
| Paget'southward affliction | |
| Fracture | |
| Soft tissue local pathology | Rotator cuff tendinopathy /Impingement syndrome |
| Biceps tendinopathy | |
| Adhesive capsulitis | |
| Calcific tendinitis | |
| Sub-acromial bursitis | |
| Shoulder instability | |
| Labral tears | |
| Pain syndromes | Fibromyalgia syndrome |
| Shoulder-paw syndrome |
Shoulder anatomy
The extraordinary flexibility of the shoulder joint is achieved through 4 articulations: gleno-humeral, acromio-clavicular, sterno-clavicular and scapulo-thoracic. Stability is therefore reliant upon a functional system of musculo-tendinous support both within (the rotator cuff) and exterior of the joint sheathing. However, its complex design leaves it decumbent to injury and sprain/strain particularly under conditions in which information technology is excessively overloaded. For case, the physiological move of abduction causes impingement of both the rotator cuff tendon and the long head of biceps between the greater tuberosity of the humerus and the coraco-acromial arch. Non surprisingly therefore, excessive or repetitive activities may precipitate a localised tendinopathy and rotator cuff degeneration or tears that inevitably compromise the part of the tendon in stabilising and depressing the humeral head.
Classification systems for shoulder disorders
There has been a lengthy history of use of patho-anatomical classification systems to attempt to divide sub-types of shoulder weather [eleven,12]. Since the publication of Codman'south volume, 'The Shoulder' in 1934 [13], the following patho-anatomical sub-categories accept been widely employed: rotator cuff disease; biceps tendon disease; acromioclavicular joint abnormalities; and adhesive capsulitis. The next section will briefly discuss these 'specific' causes of shoulder pain and their diagnostic criteria as recommended in clinical practice.
Rotator Gage Tendinopathy
The results of post-mortem studies suggest that it is usual, by the fifth decade of life, to find degenerative changes in the rotator gage tendons, particularly thinning and fibrillation at the 'critical zone' (the hypovascular area) of the gage. These changes are thought to be those of physiological ageing, simply it seems that under some weather, as degeneration increases, repair mechanisms fail and micro-tears develop which can become macro-tears, and epidemiological studies propose that these changes are a frequent cause of painful shoulder symptoms [2,xiv]. There may also be inflammation of the tendons or bursa. Typically, the pain is fabricated worse by sleeping on the affected shoulder and moving the shoulder in sure directions and there can exist pressure level on the tendons by the overlying bone when lifting the arm up, the phenomenon described as 'impingement'. Cyriax wrote that the involved tendon could be differentiated by physical test findings: supraspinatus tendinitis past hurting on resisted abduction, infraspinatus tendinitis by hurting on resisted external rotation and subscapularis tendinitis by pain on resisted internal rotation [12]. However, the prove that these signs perform well in clinical practice, at least in population and workplace studies, is lacking.
Biceps tendinopathy
The biceps tendon is also decumbent to tendinopathy, resulting in anterior shoulder pain. Cyriax described the classical findings of bicipital tendinitis as hurting on resisted elbow flexion (Speed's test) and hurting on resisted supination of the forearm (Yergason'south test) [12]. It is noteworthy that few epidemiological studies accept involved an examination component which specifically attempted to discriminate bicipital tendinitis. Of those that have, virtually have used criteria based upon those of Cyriax: shoulder pain, local tenderness over the tendon, and pain on resisted isometric meridian of the arm and/or resisted isometric flexion of the elbow [15–eighteen]. It is idea that isolated biceps tendinopathy is relatively uncommon and that the status more normally co-exists with rotator gage pathology and impingement.
Adhesive capsulitis (frozen shoulder syndrome)
The term 'frozen shoulder' appears to take been get-go coined by Codman in 1934, for a 'course of cases which are difficult to define, difficult to treat and difficult to explain from the point of view of pathology' [thirteen]. Codman wrote that the principal crusade was a localised supraspinatus tendinitis with subsequent extension to the other components of the rotator cuff, the subacromial bursa, and finally the capsule and extra-capsular ligaments. This view has been disputed [12], and in that location is generally no agreement as to the underlying pathophysiology. One arthroscopic study found histological appearances of the capsule like to those seen in Dupuytren's contracture, suggesting that frozen shoulder may be 1 of the fibromatoses [xix]. Withal, these were in a highly selected group of patients (those with astringent symptoms of sufficient elapsing to warrant referral to orthopaedic clinics and surgical intervention).
Capsulitis has been described as having three feature phases. During the first painful phase, the shoulder complex is severely painful, frequently during rest, and this phase can terminal anything from three to 6 months. Subsequently, during the agglutinative phase, pain resolves simply significant restriction of move, active and passive, occurs in all planes. In the final resolution phase, recovery of function is said to occur. The transition through these stages is idea to take an average of 30 months, but may be considerably longer and it is not articulate that complete recovery occurs: 1 written report found that equally many as 50% of patients failed to regain a normal range of movement, fifty-fifty at follow-up after seven years [xx].
To diagnose capsulitis, Cyriax required restricted passive motion of the shoulder joint in a 'capsular pattern' – i.e. limitation of external rotation more than than abduction, more than than internal rotation. Broadly, the case definitions used in epidemiological surveys accept paralleled this description. Chard et al, for example, used: 'marked restriction of all active and passive movements with external rotation reduced by at to the lowest degree 50% of normal, in the absence of bony restriction' [2]. Other studies accept introduced the element of duration: Ohlsson et al [15], Viikari-Juntura [21] and Waris et al [22] required shoulder pain and progressive stiffness of the shoulder over a 3-4 calendar month period. Although broadly similar, it is noteworthy that none of these classifications included a definition of 'normal range of movement', or the cut-off value beneath which restriction would be diagnosed.
Acromioclavicular joint syndrome
The acromioclavicular joint is a airplane synovial joint between the clavicle and the scapula. Normal function of the articulation is required for full active painless summit of the shoulder to take place, and dysfunction causes localised pain, tenderness and swelling and pain felt maximally on full abduction of the shoulder. Horizontal adduction of the joint with the arm extended is besides said to provoke local pain (the so-called 'scarf exam') [12]. In exercise, studies of shoulder disorders accept rarely included diagnostic tests specific to this condition. Where they have [15,sixteen,22], the classification criteria have been similar but not identical.
Although many of the clinical diagnostic criteria for these specific shoulder disorders have been widely published and taught, perhaps considering of the circuitous anatomical and functional structure, there is prove to advise that these patho-anatomical classification systems do not more often than not perform reliably in practice [23–27]. Their validity, at least in population and workplace studies, has as well been questioned.
Specific shoulder disorders and non-specific hurting
Much of the bachelor prove nigh chance factors for shoulder disorders comes from epidemiological studies. In many of these studies, information were collected using self-completed questionnaires and the issue mensurate has been 'shoulder pain' or 'shoulder pain lasting more a specified time' or 'shoulder hurting causing a specified functional harm', sometimes with inclusion of a mannequin diagram to confirm the pain distribution [28]. Whilst these studies have informed our noesis of the risk of certain activities or exposures, they fail to give specific information as to which component of the shoulder complex is affected and this may accept hampered progress towards identifying strategies for prevention. It is plausible that, as with other anatomical sites such as the low back, shoulder pain may be separable into sub-categories, some of which reflect specific patho-anatomical strains and for which risk factors and prevention strategies could exist identifiable. Moreover, there may besides be a sub-category of 'non-specific shoulder pain', which has dissimilar risk factors and needs other preventive strategies, rather akin to non-specific or "mechanical" low back pain. Given our current limitations in defining sub-types shown to be relevant in terms of prognosis or response to handling, much of the literature currently bachelor provides risk estimates for exposures in relation to shoulder pain. Using a case definition of 'shoulder hurting, discomfort, fatigue, limited movement, loss of muscle power but without a pattern assuasive a specific diagnosis to be fabricated' there is growing evidence that 'not-specific shoulder hurting' is more ofttimes found in general population and workplace studies every bit compared with specific shoulder weather that take clear diagnostic features, such equally rotator cuff syndrome [29]. Information technology has been estimated for case, that non-specific shoulder hurting among workers was six times more frequent than specific shoulder atmospheric condition [thirty].
The lack of a consistent standardised diagnostic approach has possibly hindered our understanding of the extent of the trouble in the workplace and across countries, and consequently the development of effective interventions and preventive tools to reduce the burden of musculoskeletal pain, including shoulder problems [29,31]. With this in mind, there have been a number of initiatives to try to improve diagnostic classification of upper limb disorders. One such endeavor in the UK was instigated past the Health and Condom Executive and involved a multidisciplinary group of experts with an interest in soft tissue upper limb disorders [32]. Using a Delphi technique, this group derived consensus case definitions for, amid other disorders, bicipital tendinitis, rotator cuff tendinitis and adhesive capsulitis [33]. Working from these definitions, and after calculation diagnostic criteria for acromioclavicular joint dysfunction and subacromial bursitis (Table ii), informed past a literature search, our grouping developed and tested an examination protocol suitable for use in population-based epidemiological research [34,35]. We have shown this protocol to take good reliability between observers for the detection of physical signs at the shoulder both amongst patients attending hospital-based soft tissue clinics (kappa coefficients 0.54 – 0.93) [34] and amongst adults of working-age from the general population (kappa coefficients 0.29 -0.66) [35].
Table ii
A comparison of nomenclature and criteria for the diagnosis of specific shoulder disorders
| Diagnostic classification and instance definition | Van der Windt, 1995 | HSE, 1998 | Palmer / Walker-Bone, 2000 | Jia et al, 2009 | Hanchard, 2014 |
|---|---|---|---|---|---|
| Rotator cuff disease: Case definitions | Subacromial syndrome Sub-Classes: Rotator gage tendinitis Chronic bursitis Rotator gage tears | Rotator cuff tendinitis | Rotator cuff tendinitis | Sub-Classes: Tendinosis or bursitis (painful tendon – no tear) Partial-thickness tear Full-thickness tear Subscapularis tear | Sub-Classes: Sub-acromial or internal impingement Rotator cuff tendinopathy or tears |
| Clinical examination /tests: | No restriction of passive movement. Hurting in the C5 dermatome. Pianful arc during top. At least i positive resistance test. Bursitis: variable/piddling pain, normal power Tendinitis: hurting, normal power Cuff tears: little hurting, loss of ability | History of pain in the deltoid region and pain on resisted active motility (abduction – supraspinatus; external rotation – infraspinatus; internal rotation- subscapularis) | History of hurting in the deltoid region and pain on resisted active motion (abduction – supraspinatus; external rotation – infraspinatus; internal rotation- subscapularis) | Neer impingement sign Hawkins-Kennedy impingement sign Neither has high sensitivity nor specificity for full-thickness tears | Many tests but insufficient bear witness of usefulness to recommend whatsoever |
| Acromio- clavicular joint syndrome | N/A | N/A | Acromio-clavicular dysfunction | No Sub-Classes | N/A |
| Clinical test /tests: | Restriction of horizontal adduction. Hurting in the surface area of the acromioclavicular joint and/or C4 dermatome | Pain and tenderness over the acromio-clavicular joint and pain on horizontal adduction of the extended arm (cantankerous-body adduction test) | Local tenderness ACJ Cross-torso adduction test Acromio-clavicular resisted extension exam Active compression test may perform better – no data | ||
| Labral conditions | N/A | Due north/A | N/A | Sub-Classes: Inductive and posterior of the superior labrum | Glenoid labral tears |
| Clinical exam /tests: | Not possible to diagnose on clinical exam solitary | Many tests but insufficient bear witness of usefulness to recommend any | |||
| Instability | Remainder (including luxations) | N/A | Due north/A | Sub-Classes: Inductive Posterior Multidirectional | N/A |
| Clinical examination /tests: | ANTERIOR: Reproduction of a symptom of instability: inductive apprehension test, relocation test, surprise test >95% specific but depression sensitivity POSTERIOR: 'Voluntary' subluxation with reproduction of symptoms MULTIDIRECTIONAL: Sulcus sign for junior instability not formally evaluated | ||||
| Biceps tendinopathy | N/A | Bicipital tendinitis | Bicipital tendinitis | Sub-Classes: Biceps tenosynovitis Partial tears Tendon subluxations Biceps entrapment Isolated aberration of biceps tendon relatively rare | Long head of biceps tendinopathy |
| Clinical examination /tests: | History of anterior shoulder pain and hurting on resisted active flexion (Speed test) or supination (Yergason examination) of the forearm | History of anterior shoulder hurting and pain on resisted agile flexion (Speed test) or supination (Yergason test) of the forearm | Speed exam Yergason test Neither clinically diagnostic | Many tests but bereft evidence of usefulness to recommend whatever | |
| Capsular syndrome | Sub-Classes: Capsulitis Arthrosis | ||||
| Clinical examination /tests: | Brake of lateral rotation, abduction and medial rotation, pain in C5 dermatome | History of pain in the deltoid region and equal restriction of active and passive glenohumeral movement with capsular pattern (external rotation>abduction>internal rotation) | History of pain in the deltoid region and equal restriction of agile and passive glenohumeral motility with capsular pattern (external rotation>abduction>internal rotation) | ||
| Acute bursitis | |||||
| Clinical examination /tests: | Restriction of abduction. Astringent pain in C5 dermatome. Acute onset, no preceding trauma |
This examination protocol has been used in a large population written report including 6038 working-aged adults. All 411 people reporting shoulder pain were examined past a trained observer co-ordinate to the Southampton protocol. Diagnoses were assigned past a computerised algorithm co-ordinate to the pre-defined criteria. Marked overlap of all diagnoses was observed inside the same shoulders, such that for case, 205 of the 410 subjects with a diagnosis of adhesive capsulitis also received a diagnosis of rotator cuff tendinitis and amongst 28 people who received a diagnosis of bicipital tendinitis, 23 besides fulfilled diagnostic criteria for adhesive capsulitis. Therefore, it seemed that these criteria had poor specificity at least for the separation of individuals with sub-types of shoulder pain in a general population report [36].
In primary care in the Netherlands, van der Windt and colleagues [37] take shown that simpler clinical nomenclature systems yielded better intra-observer reliability simply the authors concluded that more research was required to demonstrate whether the clinical syndromes that they proposed (Table one) constituted separate disorders requiring different treatment strategies [37]. A contempo (2014) review of this literature past Hanchard et al similarly found insufficient evidence of usefulness to support the utilise of use of many of the diagnostic tests currently taught in clinical practice [38].
Neck/shoulder disorders
Although some researchers endeavour to distinguish pathology at the shoulder from that at the neck, this is not ever possible clinically. In a number of studies therefore, investigators have studied 'cervix and/or shoulder' disorders, even though there may exist important differences in chance factors for hurting in the neck region as opposed to those for the shoulder [39]. Cervix pain is a very mutual symptom, with an estimated annual cumulative incidence of 17.9% [forty] and a lifetime prevalence of 71% [41]. Given their shut anatomical proximity, symptoms arising from the neck are frequently referred to the shoulder region. At its most extreme, acute radiculopathy affecting a specific nerve root equally it exits the cervical spine may cause astringent neck/arm hurting (brachialgia) but the bulk of neck/shoulder symptoms arise from muscular tension and spasm or are associated with cervical spondylosis, without any objective neurological signs. Cervical spondylosis is the term used to describe radiographic changes of osteoarthritis on cervical spine Ten-ray. Neck pain associated with restricted range of neck move, sometimes headaches or dizziness, and possibly referred to the upper limb is a very common clinical syndrome which is variously labelled past different healthcare practitioners every bit 'tension cervix syndrome', 'cervical myalgia', 'trapezius myalgia', 'occupational cervico-brachial disorder', and sometimes, unhelpfully as 'cervical spondylosis'. In general population surveys, radiographic spondylotic changes are common, affecting lx% of people aged >49 years [42]. However, there is poor correlation between radiographic spondylotic changes and symptoms, and information technology is unclear whether common regional neck hurting syndromes are acquired by or exacerbated by degeneration in the cervical spine. Although there is considerably less research on cervix pain, there are strong parallels with 'mechanical dorsum pain'. It is possible that radiographic investigations is as unhelpful in the evaluation of neck hurting equally information technology is in the cess of mechanical low back pain.
One specific occupational neck condition was described by Levy as 'porter's neck' in Rhodesia in 1968, in which porters carrying 90kg sacks of repast on their heads were shown to develop cervical disc compression predisposing them to increased adventure of injury [43]. More by and large, neck pain is more common among workers doing strenuous concrete activities involving their arms than among sedentary workers. When this evidence was systematically reviewed by Palmer and Smedley, most of the studies explored neck pain with tenderness to palpation or mixed neck/shoulder pain and there was 'moderate evidence' for causation past repetitive movements at the shoulder and by neck flexion centrolineal with repetition [44].
In nearly cases of referred cervix/shoulder pain, the underlying status is unknown but the pathophysiology appears to include muscle pain and spasm. The frequency and severity of symptoms vary widely and psychosocial factors, as well as physical factors are important. The severity of radiographic spondylotic changes should non exist used to inform assessment of prognosis or fitness to work. For most people, the prognosis is excellent. Direction past unproblematic analgesia, combined with physiotherapy cess is indicated in people with prolonged or problematic symptoms. Where possible, people should continue to attend work only modification or rotation of job tasks may exist required in the short- to medium-term. For desk-bound-based workers ergonomic review of the workstation may be helpful, and for workers using display screen equipment, at that place are specific regulations from the Health and Safety Executive 1992 (revised 2002) with which employers need to comply [45].
Non-occupational chance factors for shoulder disorders
Individual gamble factors
A number of individual take a chance factors for shoulder pain have been established. These include: female person gender [46], obesity [47] older historic period [48] and co-existing medical disorders (eg inflammatory arthritis, polymyalgia rheumatica, fibromyalgia, multiple sclerosis, diabetes mellitus) [49]. There is growing evidence for a role of individual psychological factors (such every bit distress and depression) in the evolution of shoulder pain [50,51]. Nahit and colleagues found psychological distress was associated with a doubling of the take chances of reported pain [l]. A study of prevalence rates of musculoskeletal symptoms and associated inability in workers suggested that cultural factors such as health behavior and expectations accept an important influence on back, cervix and arm pain [52]. Smoking has also been linked to musculoskeletal hurting in the arm [53] and has been associated with an increased risk of long-term sickness absence (>xiv days) amongst employees with neck-shoulder pain [9]. Possible explanations for such findings include a pharmacological consequence on pain perception, harm to musculoskeletal tissues, or differences in the threshold for reporting symptoms that reverberate differences in personality or illness behaviour [53,54].
Not-occupational mechanical factors and shoulder disorders
Non-occupational mechanical risk factors are not the main focus of this review, but leisure or home activities may be an important source of confounding when investigating occupational adventure factors for shoulder pain [55,56]. Biomechanical features of many sports accept been investigated and findings indicate that both professional and recreational athletes who participate in contact sports (due east.g. water ice hockey) and in sports that involve repetitive overhead actions such as golf, swimming, and javelin, are at increased risk of rotator gage tears [57,58], acromioclavicular joint dysfunction [59], and impingement syndrome [threescore].
Occupational factors and shoulder disorders
Methodological limitations
In addition to the problems of nomenclature discussed earlier in this chapter, there are a number of other important limitations to the available occupational literature which hamper interpretation. For example, studies have adopted widely differing methodological and statistical approaches that brand comparison and interpretation of findings difficult. In that location is considerable heterogeneity betwixt studies with regard to the study setting, and both the characteristics and size of the population under investigation. Additionally, there has been wide variation in methods of exposure assessment. The greatest precision in measurement of workplace exposure can exist accomplished by video recording of an individual worker whilst they carry out each of their usual activities, so detailed ergonomic analyses, but this is expensive and non feasible in most studies. In consequence, surrogate measures are used such as self-completed questionnaires, which are reliant on recollect and accurate estimates of exposure by the private; such estimates are of class less consistent (people tend to over-judge physical demands), even when efforts are fabricated to validate estimates. Similarly, there has been a lack of consistent and unambiguous definitions of psychosocial workplace factors and the need for more rigorous standardised methods for conducting futurity studies has been emphasised [61]. Oft, studies have focussed on particular occupational groups, including butchery workers, meat processing workers, care abode workers, drivers, teachers, and supermarket cashiers. However, this may limit the generalizability of results to other occupational settings [62]. Many occupational studies have been cantankerous-sectional focussing on the prevalence of shoulder pain in a particular workforce. Cross-sectional studies are prone to both call up and selection bias ("the healthy worker effect": those affected tend to become selected out of employment and and then the true risk of shoulder pain associated with occupational exposures is underestimated). These studies provide data regarding the burden of musculoskeletal pain and associations with possible adventure factors, but crucially cannot clearly identify the underlying cause of reported associations between occupational exposures and the development of pain (crusade-effect relationship). The growing number of prospective studies will atomic number 82 to description of the directions of associations.
Occupational mechanical take chances factors
A number of workplace physical exposures have been implicated in the causation or exacerbation of shoulder disorders [56]. Important occupational exposures include: manual treatment (heavy lifting, pushing, pulling, property, conveying [63,64]); working above shoulder height [65]; repetitive work [66,67]; vibration; and working in awkward postures [46]. Interestingly, another review that explored run a risk factors for specific shoulder disorders and not shoulder pain, reported like work exposures as of import: handling of loads frequently or with loftier forcefulness, highly repetitive work, working in awkward postures and also high psychosocial job demand [68]. Amongst the specific conditions, subacromial impingement syndrome was the most ofttimes studied shoulder disorder.
Nevertheless, the show is most convincing for a cumulative effect of multiple mechanical workplace exposures increasing the adventure of shoulder problems [69]. Miranda and colleagues followed upward a cohort of workers in Finland after a twenty year period and found an almost 4-fold increased take chances of a clinically-diagnosed shoulder disorder of at least iii calendar month's duration amongst workers who were exposed to a combination of three physical factors (e.thou. force, posture, overhead piece of work) or more [46]. The take a chance was considerably higher amid female person workers with several exposures when compared to similarly exposed men. Similarly, a higher prevalence of clinically-divers rotator cuff syndrome was observed among US employees from a multifariousness of occupational settings whose work involved a combination of concrete load exposures (long elapsing of shoulder flexion and forceful exertion) compared with those with a unmarried physical exposure [lxx]. The authors noted that the combination of different exposures did not have to be simultaneous and that information technology was the total number of different exposures involved in the job that was critical. A cross-sectional study of manual workers in the Britain by Pope et al identified exposures to both concrete and psychosocial factors that placed groups of employees at "loftier risk" for disabling shoulder pain [62]. The exposures were: duration of lifting weights with 1 hand; duration of working above shoulder level; whether the private institute work stressful; and whether the individual rated their work psychologically enervating (Effigy ane). The authors highlighted the need to consider not only the interaction of the cumulative exposure to mechanical factors, just also other aspects of a particular occupation, including psychosocial factors. Investigators are increasingly adopting such an approach.
In an attempt to minimise the healthy worker upshot, Harkness and colleagues prospectively studied the onset of shoulder pain in newly-employed workers [65]. They concluded that, fifty-fifty at an early phase of employment, exposure to mechanical factors such as lifting heavy weights, working with hands at or above shoulder level, and pushing or pulling heavy loads were independent run a risk factors for new onset shoulder pain.
Miranda and colleagues institute that the determinants of specific shoulder atmospheric condition differed from those of not-specific reports of shoulder pain without clinical findings [30]. They reported that non-specific shoulder pain was related to psychological and psychosocial factors while specific shoulder disorders, such every bit rotator gage tendinitis were associated with piece of work-related mechanical factors, private factors (age and diabetes mellitus). Although this has been hypothesised to exist the case for some time, more bear witness is needed every bit the implication of this finding is that unlike approaches will be needed to prevention of these two types of disorder.
Occupational psychosocial risk factors
There is growing prove that psychosocial aspects of the piece of work environment increment the possibility of job stress and ultimately atomic number 82 to adverse health effects, including musculoskeletal pain [71]. Factors such as high workplace demands, low levels of control over workload and poor support from supervisors and colleagues have been implicated as piece of work stressors [72]. However, the office and extent of the influence of psychosocial workplace factors on the development and prognosis of shoulder pain is not well understood and remains the discipline of much argue. An underlying patho-physiological mechanism has not yet been determined, just a number of possible explanations have been proposed: psychosocial demands at work tin can result in a high level of muscle tension and musculus activeness that in turn causes muscle fatigue; a worker may adopt awkward postures or utilise highly repetitive movements that result in pain; an employee may be unable to relax and to reduce physiological activation to resting levels during a suspension or later on work; and there may be amending in an individual'southward perception of pain and a tendency to report symptoms [72]. Bongers et al conducted a review of the role of psychosocial factors in upper limb disorders, which included shoulder/upper arm issues. The vast bulk of studies reviewed were cross-exclusive in design, only about 3 quarters of the studies that explored the association between work related psychosocial risk factors and shoulder/upper arm bug found at least 1 positive clan [71].
A more recent review of 18 longitudinal studies of psychosocial workplace factors on the development of neck and shoulder disorders plant bear witness for a cumulative effect of loftier job demands, low task command, a lack of social support and job strain on the incidence of symptoms [31]. The authors confined the review to prospective studies that took business relationship of at least i physical workplace exposure because they reasoned that workers are not exposed to psychosocial factors in isolation, but rather a combination of concrete and psychosocial aspects of piece of work simultaneously. Indeed the term "task demand" encompasses a broad range of features (such as working very difficult, very fast, excessive work, long periods of intense concentration, enough fourth dimension to become job done, tasks often interrupted [73]. The term therefore comprises several components including concrete, psychosocial, social and organisational aspects of work that require continuous physiological and psychosocial efforts [74].
In that location is currently uncertainty regarding the influence of other psychosocial factors such every bit task satisfaction, working lonely or individual psychological distress every bit these factors have seldom been studied. Still, a prospective written report of newly employed workers by Nahit et al [50] institute psychological distress to be associated with a doubling of the risk of self-reported shoulder pain. Psychosocial factors such as job demand, poor support from colleagues and piece of work dissatisfaction were also positively associated with musculoskeletal pain, including that at the shoulder. They concluded that unlike occupational sectors are probable to have different psychosocial work environments and that future work should clearly define the workplace setting so that comparisons in terms of relevant exposures to the specific occupational sector tin exist made.
A review of largely cantankerous-sectional studies of specific shoulder disorders and work-related factors observed an association betwixt high task demand and subacromial impingement syndrome [68]. There is testify that individuals with rotator cuff syndrome are more likely to report low task security and to have high job structural constraints [70]. The authors recommended further study of piece of work organization factors (a wide term encompassing many factors including gender mix, work environs, chore type, work hours, job content) to develop a more holistic assessment of psychosocial and concrete workplace exposures and thus more accurately assess the impact and consequently inform preventive policies in the workplace.
Investigation of shoulder pain
For many people who present in primary care with shoulder pain, no investigation is required. A thorough clinical history is mandatory in exploring for 'ruby-red flags' including neurological symptoms and signs, systemic symptoms suggestive of serious pathology or inflammatory rheumatic diseases or features of intra-abdominal pathology causing referred pain. Other important points in the history include: nature of onset, history of trauma, site of pain, human relationship of symptoms to movement, dominant / non-dominant arm affected, bilateral symptoms, radiation, character, duration and exacerbating/relieving factors, functional impact, and issue on sleep. A conscientious occupational history should include name and nature of the occupation and should inquire virtually exposures involving the shoulder including working overhead, lifting weights, use of forcefulness/repetition, pulling/pushing and any perceived relationship of the current symptoms to these exposures. It can be useful to enquire if symptoms are better or worse when the patient takes time abroad from piece of work e.g. for annual leave or at weekends.
Concrete exam should focus on the cervix to identify principal cervical spine pathology causing referred symptoms and neurological cess of both upper limbs, and should involve examination of the total musculoskeletal system if in that location is any suggestion of an inflammatory rheumatic disease. The shoulders should be examined for posture, swelling anteriorly and posteriorly, redness, scars and any evidence of dislocation. The bony landmarks of the shoulder complex, including the axillae, should be palpated as well as peri-articular structures including the sub-acromial bursa, bicipital groove, and inductive and posterior joint margins. Agile and passive movement throughout the full range of shoulder movement (flexion /extension; abduction/adduction; internal and external rotation) should be tested and normal scapular movement observed from behind. Examine specifically for a painful arc watching the face of the patient. In that location are, as described above, a number of clinical confirmatory tests for suspected pathologies which vary in their sensitivity and specificity. The clinical suspicion of a significant rotator cuff tear may be confirmed by the 'drib arm' exam, in which the patient is unable to support the weight of their arm in 90° of abduction.
Imaging of the shoulder
The shoulder may be imaged using plainly X-ray, ultrasound scanning, MRI or MRA. Although increasingly used in clinical exercise (particularly ultrasound), at that place is currently no bear witness-based or toll-effectiveness guidance to inform the optimal use of these modalities in the investigation of shoulder pain. For about people presenting in primary care, no imaging would be required, particularly in the absenteeism of 'red flags'. Plain X-ray may exist advisable for exclusion of fracture and/or dislocation after trauma. Manifestly Ten-ray may also show degenerative changes of the gleno-humeral or acromio-clavicular joints and calcific tendinopathy. Rotator gage tears are best assessed using ultrasound or MRI. The use of the different techniques for cess of rotator cuff tears prior to surgery was recently evaluated in a systematic review past the Cochrane collaboration [75]. They plant 20 studies involving 1147 shoulders that allowed comparison of MRI, MRA and Ultrasound for assessing rotator gage tears. Unfortunately, they concluded that there were meaning methodological problems in these studies, hampering comparisons. Despite this, they ended that all three techniques were similarly authentic in detecting full-thickness rotator cuff tears but that both MRI and ultrasound may have poor sensitivity for detecting partial thickness tears, and that the sensitivity of ultrasound may exist much lower than that of MRI. Neither MRI nor ultrasound provides images of the extra-capsular ligament or shoulder capsule, the site of agglutinative capsulitis. Only arthrography is idea to exist of value in the assessment of capsulitis.
1 recently-published study compared female person supermarket cashiers (undertaking repetitive work) with the general female working-age population (this comprised customers at the supermarket) [48]. Participants completed a questionnaire about pain in the shoulder which was administered past an orthopaedic specialist, and then underwent ultrasound cess of both shoulders. If the radiologist had any doubts regarding the ultrasound findings, a magnetic resonance imaging (MRI) examination was after performed. Cashiers reported a higher prevalence of shoulder symptoms than controls. However, shoulder radiography of cases and controls revealed more evidence of pathology on ultrasound/MRI amidst controls than cases.
Management of shoulder disorders
The majority of studies that consider treatment of shoulder disorders have been based in main or secondary care and the primary outcome measures are typically shoulder pain and shoulder disability. Workplace outcomes are rarely included and if they are, commonly only as secondary measures. Unfortunately, the same methodological shortcomings in example definition that have hampered interpretation of the risk factor literature apply every bit to the studies of interventions. Table 3 summarises the main conservative treatments for shoulder disorders together with the results of systematic reviews summarising the strength of the show in back up of their efficacy for the handling of shoulder pain/disability [76–86].
Tabular array 3
Summary of selected systematic reviews of the conservative direction of shoulder disorders
| Treatment modality | Case definition | Outcome measures | Summary of evidence | References |
|---|---|---|---|---|
| Physiotherapy interventions | Shoulder pain | Hurting Stiffness Disability | Cochrane review: At that place is no prove of the effect of ultrasound in shoulder hurting (mixed diagnosis) | [76] |
| Physiotherapy interventions | Rotator gage disease | Pain Stiffness Inability | Cochrane review: Practice was demonstrated to be effective in terms of short term recovery (RR 7.74 (i.97, 30.32), and longer term benefit with respect to role (RR 2.45 (1.24, 4.86). Combining mobilisation with do resulted in boosted benefit when compared to exercise alone. Laser therapy was non more effective than placebo for supraspinatus tendinitis (RR 2, 95%CI 0.98 to 4.09). There is no testify of the outcome of ultrasound alone. | [76] |
| Physiotherapy interventions | Adhesive capsulitis | Hurting Stiffness Disability | Cochrane review: Laser therapy was demonstrated to exist more than constructive than placebo (RR 8, 95%CI 2.11 to 30.34). There is no evidence of the upshot of either ultrasound or physiotherapy lonely. | [76] |
| Physiotherapy interventions | Calcific tendinitis | Pain Stiffness Disability | Cochrane review: Both ultrasound and pulsed electromagnetic field therapy resulted in improvement compared to placebo for pain (RR 1.81 (1.26, 2.60) and RR 19 (1.16, 12.43) respectively | [76] |
| Glucocorticoid injections | Rotator gage disease | Pain Stiffness Disability | Cochrane review: Subacromial steroid injection was demonstrated to have a small benefit over placebo in some trials however no do good of subacromial steroid injection over NSAID was demonstrated based upon the pooled results of three trials. | [77] |
| Adhesive capsulitis | Pain Stiffness Disability | Cochrane review: For adhesive capsulitis, two trials suggested a possible early on benefit of intra-articular steroid injection over placebo. One trial suggested short- term benefit of intra-articular corticosteroid injection over physiotherapy in the short-term (success at seven weeks RR=1.66 (one.21, ii.28) Data from two RCTs showed that there may exist benefit from calculation a | [77] [78] | |
| Image-guided vs blind glucocorticoid injections | Rotator gage disease Adhesive capsulitis | Hurting Function Range of motion Proportion of participants with overall comeback | Cochrane review: Based upon moderate bear witness from v trials, our review was unable to establish any advantage in terms of pain, office, shoulder range of motion or safe, of ultrasound-guided glucocorticoid injection for shoulder disorders over either landmark-guided or intramuscular injection. | [79] |
| Oral glucocorticoids | Adhesive capsulitis | Pain Range of motion Function | Cochrane review: 'Silver' evidence that oral steroids provide significant brusque-term benefits in pain, range of movement of the shoulder and function but the event may not be maintained beyond 6 weeks. | [80] |
| Arthrographic distension | Adhesive capsulitis | Hurting Range of motion Function | Cochrane review: At that place is "argent" level bear witness that arthrographic distension with saline and steroid provides curt-term benefits (up to 12 weeks) in pain, range of motility and function. It is uncertain whether this is amend than alternative interventions. | [81]) |
| Acupuncture | Rotator gage illness Adhesive capsulitis Full thickness rotator cuff tear Shoulder pain (mixed diagnoses) | Pain Range of motility Role | Cochrane review: Due to a small number of clinical and methodologically diverse trials, little can exist concluded from this review. There is little prove to back up or refute the employ of acupuncture for shoulder hurting although there may be short-term do good with respect to pain and function. There is a demand for further well designed clinical trials. | [82] |
| Electrotherapy | Agglutinative capsulitis | Pain Role Global handling success | Cochrane review: No comparison with placebo. Based upon low quality show from one trial, low-level laser therapy for half-dozen days may be more effective than placebo on global treatment success at half dozen days. Based upon moderate quality evidence from one trial, light amplification by stimulated emission of radiation therapy plus exercise for eight weeks may be more than effective than practise lone in terms of pain up to four weeks, and part upward to four months. | [83] |
| Manual therapy and practice | Adhesive capsulitis | Pain Function Patient-reported treatment success | Cochrane review: No trials of exercise vs. placebo A combination of manual therapy and exercise may non be every bit effective as glucocorticoid injection in the short-term (6 weeks). It is unclear whether a combination of manual therapy, exercise and electrotherapy is an effective adjunct to glucocorticoid injection or oral NSAID. Post-obit arthrographic joint amplification with glucocorticoid and saline, manual therapy and practice may confer furnishings similar to those of sham ultrasound in terms of overall pain, office and quality of life, but may provide greater patient-reported treatment success and agile range of motion | [84] |
| Multidisciplinary bio-psychosocial rehabilitation | Working-aged adults with cervix and shoulder pain | Hurting | Cochrane review: Insufficient evidence of efficacy. | [85] |
| Conservative interventions | Work-related complaints of the arm, neck or shoulder in adults | Pain Recovery Inability Sick leave | Cochrane review: Very low-quality bear witness that hurting, recovery, inability and sick leave are similar afterwards exercises when compared with no treatment, with small intervention controls or with exercises provided equally boosted treatment to people with work-related complaints of the arm, neck or shoulder. Depression-quality bear witness too showed that ergonomic interventions did not decrease pain at curt-term follow-up only did decrease pain at long-term follow-up. No evidence of an consequence on other outcomes. For behavioural and other interventions, there was no testify of a consistent effect on any of the outcomes. | [86] |
Management of shoulder pain in the workplace
To date, in that location have been no published studies evaluating strategies for the main prevention of shoulder disorders in the workplace. In their systematic review commissioned by Arthritis Research-UK, Palmer and co-workers found niggling show in back up of workplace interventions for musculoskeletal hurting [x]; the benefits observed were small-scale and of doubtful price-effectiveness. The median do good amounted to ten% improved chance of returning to work or avoidance on average of 0.iii-0.v days/month of sickness absence. No intervention was clearly superior, although try-intensive interventions were less effective than simple ones. There were, however, few large well-conducted studies and few reports with extended follow-up or economic evaluation. The literature had methodological limitations (unblinded outcome assessment, failure to analyse by intention to care for, poor randomisation protocols) and the interventions were multifactorial and included physical, psychological, social and environmental interventions aimed at the individual (east.g. exercise therapy), workplace, health care and other services to which he/she had access.
In another systematic review of studies in the workplace, Dick et al similarly found very few studies and the reviewers criticised the quality of the available studies [87]. Here over again, the absence of agreed systems of diagnostic classification had hampered the researchers in developing interventions and showing benefit.
In many workplaces, ergonomic adjustments have been introduced in an attempt to reduce the concrete exposure of a worker in order to prevent or alleviate musculoskeletal pain. However ergonomic interventions lonely may not be sufficient to address this issue and more recently, culling strategies have been developed with the aim of increasing a worker's physical chapters. Such concrete conditioning programmes in the workplace take been developed and investigated, with promising results in terms of reducing chronic pain and disability in the upper limb amongst workers in a variety of occupational settings, including those performing forceful and repetitive transmission tasks [88–90]. Such interventions focus on physical resistance-training using kettlebells/dumbbells and rubberband resistance bands and have been constitute to reduce pain intensity and inability, and amend musculus forcefulness. As part of a Cochrane review of treatments for shoulder pain, Karjalainen and colleagues reviewed the testify for multidisciplinary biopsychosocial management of working-aged adults with neck/shoulder pain [85]. Simply two studies fulfilled the inclusion criteria, both of which were considered to be too weak methodologically to provide convincing evidence of efficacy.
In another Cochrane review, evaluating conservative treatments for treating work-related complaints of the arm, cervix or shoulder in adults, the reviewers included 44 studies from 62 publications involving 6580 participants [86]. However, they reported that together these studies contributed very low-quality bear witness to advise that pain, recovery, disability and sick get out were similar after exercises when compared with no handling. They also reported low-quality evidence that ergonomic interventions did not decrease hurting at short-term follow-up but did decrease pain at long-term follow-upwardly. This was associated with a reduction in sick leave in ii studies. At that place was no evidence of an effect on other outcomes. They establish no show of a consistent upshot on any of the outcomes for behavioural or any other interventions.
The considerable cost implications of sickness absenteeism due to musculoskeletal hurting are a major business concern for many western countries. A contempo study of Danish employees observed that twenty% of workers with neck-shoulder pain recorded at least one episode of sickness absence (of more than 14 consecutive days) during a 2-year follow-upward as compared with 13% in the total population of all employees studied [9]. Forth with physical piece of work risk factors, pain intensity and smoking were found to be important predictors of long-term sickness absence among employees with cervix-shoulder pain. They recommended initiatives such as physical exercise aimed at reducing pain intensity and besides the value of smoking cessation programmes in occupations with loftier prevalence of neck-shoulder pain.
A prediction rule and score nautical chart have been developed that may enable general practitioners and occupational health intendance professionals to identify workers with shoulder hurting who are at high risk for sickness absence [7]. The investigators studied a heterogeneous working population and found that long elapsing of sickness absenteeism prior to the study, loftier intensity of shoulder pain on a 10-point visual analogue scale, perception that the pain was caused by strain or overuse during regular activities and co-existing psychological complaints were of import predictors of ill leave during the 6 month follow-up. However, not all workers with musculoskeletal pain have sick get out, and nether-performance and loss of productivity at work because of presenteeism (reduced productivity among employees who continue working) are also likely to have an affect on piece of work, which is equally all the same extremely hard to quantify accurately.
Conclusion
The shoulder circuitous is highly flexible, capable of lifting heavy loads and functioning in several planes of motility. Unsurprisingly, shoulder pain is common in the general population and at that place are multiple potential causes. At that place is a growing body of evidence to suggest that shoulder disorders may be increased amid some workers, particularly those with jobs involving combinations of exposure to: overhead piece of work; heavy loads; vibration; forceful work and repetition. Psychosocial workplace factors are also importantly associated and then that any preventive workplace initiative will need to consider both types of adventure factors. To date, most of the research on management of shoulder disorders has taken place in primary or secondary care settings and occupational outcomes have rarely been included. The literature on direction of shoulder disorders in the workplace is sparse, just there is some promising evidence for physical conditioning programmes aiming to increase the concrete capacity of the individual. More than workplace research is needed and it is important that trials of new medical and surgical interventions include workplace outcomes.
Footnotes
Conflict of Interest:
The authors declare no conflict of interest
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