Commentary From CareWorks Medical Director Dr. Chrisanne Gordon, MD
“Healing is a matter of time, but it is also a matter of opportunity”
Today’s 21st century medicine is really amazing, with newer diagnostic techniques and more extensive surgical procedures than ever before. We view joints with conventional X-rays, MRI’s and Arthrograms, searching hard to find out just what we can fix surgically. Yet, as our recent orthopedic and rehabilitation protocols reveal, when it comes to shoulder surgery in “the middle ages,” (55+) we would do better reverting to the medicine of the pre-tech era and allowing the body the opportunity to heal on its own. In other words, research has revealed that extensive shoulder surgery for torn rotator cuffs in women and even men in this older workforce are generally not any better than rehabilitation and time to allow the joint to heal.
This decision is made on a number of observations.
First, post-menopausal women are most prone to a condition referred to as “adhesive capsulitis,” or “frozen shoulder,” which occurs more frequently after rotator cuff repairs in the aging population. Indeed, about 80% of all cases of frozen shoulder occur in this age group. Whether it is a function of lower estrogen levels or age, the truth is that the older shoulder does not heal as well as a younger shoulder, and even those surgeries may require six months for healing and safe return-to-work.
Second, many middle aged workers have chronic torn rotator cuffs, which means that they have adjusted to the tear long ago. If the muscle is atrophied, i.e., shriveled or shrunken with or without fat infiltration, the likelihood of a successful reattachment with full recovery is slim. Since many rotator cuff tears occur with previous degenerative changes, there are really no exercises to prevent such injuries. However, if positions requiring push/pull of carts or articles of weight, or require lifting over the shoulder, these positions may be better filled by younger workforce, if possible, or use assistive devices to decrease the load on the rotator cuff.
Third, so many of these torn rotator cuffs of the aging workforce are accompanied by degenerative changes either in the clavicle (collarbone) or the labrum (joint socket) which may be due to the aging process alone, and actually have no bearing on the mechanism of injury. To debride or attempt to cut out the arthritic process may actually add to the morbidity of the injured worker and results of long term benefits are not currently recognized. Indeed, in a recent article published in the Journal of Bone and Joint Surgery November 2015, outcomes at six months were the same for the group who had undergone surgery as for the group treated conservatively with therapy and anti-inflammatory medications, including an occasional joint injection with a steroid.
The rehabilitation of shoulder injuries is an arduous process. Since conservative treatment in the aging worker is recommended, having light duty available during this process is key. Remember that it may be several months to rehab a shoulder back to the original state of function at the time of injury. Exercises to increase strength and range of motion of the injured shoulder are often painful and tedious, requiring outpatient rehabilitation for several weeks or a rigorous routine at home.
Due to the pain associated with shoulder pathology, it is truly up to the patient to tough it out and participate, as in the old adage “no pain, no gain.” Physical therapy three times a week for six to eight weeks is often necessary to produce results. Of course, the injured worker will be encouraged to continue these exercises at home, between physical therapy visits, and a weaning process can be instituted to transition to a home exercise program.
When an injured worker sustains a “pop” in the shoulder, it may be secondary to work load, or it may be secondary to aging. It is important to assess the exact mechanism of the injury since many claims are accepted for aggravation of preexisting arthritis when, in fact, it was not an aggravation caused specifically by the work process but by the aging process.
If there are multiple chronic changes it is reasonable to assume that either an additive effect occurred, or that there may be family history or past history of events that contributed to the degeneration. Indeed, shoulder arthritis is common in many of us who have not performed manual labor, as activities of daily living provide much wear and tear on this very mobile joint as well, not to mention sports and avocations.
So, the next time you see requests for extensive shoulder procedures, many of which have just appeared on the medical horizon, be sure the physician discusses all the possibilities for treatment, including the most important one in rehabilitation, “providing the opportunity for healing.”
Dr. Chrisanne Gordon, MD
CareWorks Medical Director
Chrisanne Gordon, MD received her Doctor of Medicine in 1977 from The Ohio State University where she graduated with honors, Summa Cum Laude. Dr. Gordon trained at The Ohio State University in the Internal Medicine Department. After her internship and residency, Dr. Gordon practiced for four years as an emergency room physician. In 1983, Dr. Gordon became the Director of the Occupational Health Center for Memorial Hospital of Union County in Marysville, Ohio. She completed her residency in Physical Medicine and Rehabilitation from The Ohio State University Hospitals. Since 1988 she has been the Director of Physical Medicine at Memorial Hospital of Union County.
Dr. Gordon obtained Board Certification in 1989 by the American Board of Physical Medicine and Rehabilitation. She has been in private practice in the area of Physical Medicine and Rehabilitation in Columbus and Marysville Ohio from 1988 to present. She has also served as CareWorks Medical Director since 1997. Due to the majority of injuries in workers’ compensation being musculoskeletal in nature, her area of expertise is invaluable to providing direction on medical treatment for the population that is served. Her role and responsibilities include:
– Assisting with the development and quality assurance of policies and procedures for medical management and return to work services;
– Developing medical policy and utilization review criteria;
– Evaluating utilization and provider practice patterns;
– Overseeing clinical decision-making aspects of the medical management program;
– Overseeing the CareWorks’ Alternative Dispute Resolution (ADR) process and panel of ADR physician reviewers/examiners; and,
– Having periodic consultation with practitioners in the field.