Guideline:
Shoulder complaints
Bibliographic Source(s)
- Shoulder complaints. Elk Grove Village (IL): American College of Occupational and Environmental Medicine (ACOEM); 2004. 31 p. [68 references]
Guideline Status
This is the current release of the guideline.
This guideline updates a previous version: Harris J ed. Occupational Medicine Practice Guidelines: American College of Occupational and Environmental Medicine. Beverly Farms MA: OEM Press; 1997.
Guideline Category
Diagnosis
Evaluation
Management
Treatment
Intended Users
Advanced Practice Nurses
Physician Assistants
Physicians
Utilization Management
Guideline Objective(s)
- To provide information and guidance on generally accepted elements of quality care in occupational and environmental medicine
- To improve the efficiency with which the diagnostic process is conducted the specificity of each diagnostic test performed and the effectiveness of each treatment in relieving symptoms and achieving cure
- To present recommendations on assessing and treating adults with potentially work-related shoulder complaints
Target Population
Adults with potentially work-related shoulder complaints seen in primary care settings
Interventions and Practices Considered
Note from the National Guideline Clearinghouse (NGC): The following general clinical measures were considered. Refer to the original guideline document for information regarding which specific interventions and practices under these general headings are recommended optional or not recommended by the American College of Occupational and Environmental Medicine.
- History and physical exam
- Patient education
- Medication
- Physical treatment methods activities and exercise
- Injections
- Rest and immobilization
- Detection of physiologic abnormalities
- Radiography
- Other imaging procedures
- Surgical considerations
Major Outcomes Considered
Missed work days
Methods Used to Collect/Select Evidence
Searches of Electronic Databases
Description of Methods used to Collect/Select the Evidence
Note from the National Guideline Clearinghouse (NGC): The American College of Occupational and Environmental Medicine contracted the Work Loss Data Institute to provide medical library research services.
Disability-Duration Data
This edition includes disability-duration data that have been extracted from National Health Interview Survey data. Only data from interviews with individuals without workers' compensation claims has been included.
Number of Source Documents
Not stated
Methods Used to Assess the Quality and Strength of the Evidence
Expert Consensus
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence
A = Strong research-based evidence (multiple relevant high-quality scientific studies).
B = Moderate research-based evidence (one relevant high-quality scientific study or multiple adequate scientific studies).
C = Limited research-based evidence (at least one adequate scientific study of patients with shoulder disorders).
D = Panel interpretation of information not meeting inclusion criteria for research-based evidence.
Adapted from Bigos SJ Bowyer O Braen G et al. Acute Low Back Problems in Adults. Clinical Practice Guideline No. 14. Rockville MD: U.S. Department of Health and Human Services Public Health Service Agency for Health Care Policy and Research AHCPR Pub. No. 95-0642; 1994.
Methods Used to Analyze the Evidence
Review
Description of the Methods Used to Analyze the Evidence
Contributors reviewed at least one chapter each and reviewed the relevant medical literature that had been published since the creation of the original Guidelines in 1997.
Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations
Not stated
Rating Scheme for the Strength of the Recommendations
Not applicable
Cost Analysis
A formal cost analysis was not performed and published cost analyses were not reviewed.
Method of Guideline Validation
Internal Peer Review
Description of Method of Guideline Validation
Following the chapter and literature review participants provided written or verbal comments to the American College of Occupational and Environmental Medicine's Practice Guidelines Committee.
Verbal comments were in the form of participation in multi-specialty conference calls during which the issues raised in each chapter were extensively discussed. Draft chapters were prepared and distributed by the American College of Occupational and Environmental Medicine to all chapter reviewers. Follow-up multi-specialty teleconferences were then held as appropriate during which time the draft was again reviewed.
Major Recommendations
Recommendations are followed by evidence classification (A-D) identifying the type of supporting evidence. Definitions for the types of evidence are presented at the end of the "Major Recommendations" field.
Summary of Recommendations for Evaluating and Managing Shoulder Complaints (refer to the original guideline document for more detailed information)
| Clinical Measure | Recommended | Optional | Not Recommended |
|---|---|---|---|
| History and physical exam | Focused history and exam Search for red flags (e.g. for tumor infection angina) (C) | ||
| Patient education | Patient education regarding condition or disorder expectations of treatment side effects etc. (D) | ||
| Medication (See Chapter 3 in the original guideline document) | Acetaminophen (C) Non-steroidal anti-inflammatory drugs (NSAIDs) (B) | Opioids short course (C) | Use of opioids for more than 2 weeks (C) Muscle relaxants (D) |
| Physical treatment methods activities and exercise | Maintain activities of other parts of body while recovering (D) Maintain passive range of motion of the shoulder with pendulum exercises and wall crawl (D) Treat initially with strengthening or stabilization exercises for impingement syndrome rotator cuff tear instability and recurrent dislocation (C D) | At-home applications of heat or cold packs to aid exercises (D) Short course of supervised exercise instruction by a therapist (D) | Passive modalities by therapist (unless accompanied by teaching the patient exercises to be carried out at home) (D) |
| Injections | Two or three sub-acromial injections of local anesthetic and cortisone preparation over an extended period as part of an exercise rehabilitation program to treat rotator cuff inflammation impingement syndrome or small tears (C D) Diagnostic lidocaine injections to distinguish pain sources in the shoulder area (e.g. impingement) (D) | Prolonged or frequent use of cortisone injections into the sub-acromial space or the shoulder joint (D) | |
| Rest and immobilization | Brief use of a sling for severe shoulder pain (1 to 2 days) with pendulum exercises to prevent stiffness in cases of rotator cuff conditions (D) Three weeks use or less of a sling after an initial shoulder dislocation and reduction (C) Same for acromioclavicular (AC) separations or severe sprains (D) | Prolonged use of a sling only for symptom control (D) | |
| Detection of physiologic abnormalities | Rarely nerve conduction time of the suprascapular nerve for cases of severe cuff weakness unaccompanied by signs of a rotator cuff tear (D) | Electromyography (EMG) or nerve conduction velocity (NCV) studies as part of a shoulder evaluation for usual diagnoses (D) | |
| Radiography | For acute AC joint separations stress films (views of both shoulders with and without patient holding 15-lb weights) (D) | Routine radiographs for shoulder complaints before 4 to 6 weeks of conservative treatment (D) Stress films for instability (D) | |
| Other imaging procedures | Magnetic resonance imaging (MRI) for preoperative evaluation of partial-thickness or large full-thickness rotator cuff tears (C D) | Arthrography for preoperative evaluation of small full-thickness tears (C) Bone scan for detection of AC joint arthritis (D) | Routine MRI or arthrography for evaluation without surgical indications (D) Ultrasonography for evaluation of rotator cuff (C) |
| Surgical considerations | Anterior repair for recurrent dislocation after 2 to 3 dislocations (D) Resection of outer clavicle for chronic disabling AC joint pain after conservative care of acute separation (C) Rotator cuff repair after firm diagnosis is made and rehabilitation efforts have failed (D) Capsular shift surgery for disabling instability (D) Subacromial decompression after failure of non-operative care (C) | Anterior repair for initial shoulder dislocation (C) Acute repair of AC separation (C) Acute repair of rotator cuff tears except for massive acute tears (C) Surgery for recurrent dislocation of instability before rehabilitation efforts (C) |
Definitions:
Levels of Evidence
A = Strong research-based evidence (multiple relevant high-quality scientific studies).
B = Moderate research-based evidence (one relevant high-quality scientific study or multiple adequate scientific studies).
C = Limited research-based evidence (at least one adequate scientific study of patients with shoulder disorders).
D = Panel interpretation of information not meeting inclusion criteria for research-based evidence.
Clinical Algorithm(s)
The following clinical algorithms are provided in the original guideline document:
- American College of Occupational and Environmental Medicine Guidelines for care of acute and subacute occupational shoulder complaints
- Initial evaluation of occupational shoulder complaints
- Initial and follow-up management of occupational shoulder complaints
- Evaluation of slow-to-recover patients with occupational shoulder complaints (symptoms >4 weeks)
- Surgical considerations for patients with anatomic and physiologic evidence of shoulder instability complete rotator cuff tear or impingement syndrome coupled with persistent complaints
- Further management of occupational shoulder complaints
Type of Evidence supporting the Recommendations
The type of supporting evidence is identified and graded for each recommendation (see "Major Recommendations").
Potential Benefits
- Improved efficiency of the diagnostic process
- Effective treatment resulting in symptom alleviation and cure
Potential Harms
- False-positive or false-negative diagnostic tests
- Risks and complications of surgical procedures and imaging studies (e.g. infection radiation)
Qualifying Statements
- The American College of Occupational and Environmental Medicine (ACOEM) provides this segment of guidelines for practitioners and notes that decisions to adopt particular courses of actions must be made by trained practitioners on the basis of the available resources and the particular circumstances presented by the individual patient. Accordingly the American College of Occupational and Environmental Medicine disclaims responsibility for any injury or damage resulting from actions taken by practitioners after considering these guidelines.
- The guidelines for modification of work activities and disability duration (see original guideline document) are general guidelines based on consensus or population sources and are never meant to be applied to an individual case without consideration of workplace factors concurrent disease or other social or medical factors that can affect recovery. The parameters for disability duration are "consensus optimal" targets as determined by a panel of ACOEM members in 1996 and reaffirmed by a panel of ACOEM members in 2002. In most cases persons with one non-severe extremity injury can return to modified duty immediately. Restrictions should take into consideration the opposite extremity also to prevent strain injuries to the uninjured extremity.
Description of Implementation Strategy
An implementation strategy was not provided.
Implementation Tools
Clinical Algorithm
For information about availability see the "Availability of Companion Documents" and "Patient Resources" fields below.
IOM Care Need
Getting Better
IOM Domain
Effectiveness
Patient-centeredness
Bibliographic Source(s)
- Shoulder complaints. Elk Grove Village (IL): American College of Occupational and Environmental Medicine (ACOEM); 2004. 31 p. [68 references]
Adaptation
Not applicable: The guideline was not adapted from another source.
Source(s) of Funding
American College of Occupational and Environmental Medicine
Guideline Committee
American College of Occupational and Environmental Medicine Practice Guidelines Committee
Composition of Group that Authored the Guideline
Chapter Lead: Harold E. Hoffman MD CCFP FACOEM FRCPC
Committee Members: Jennifer H. Christian MD MPH FACPM; Philip I. Harber MD MPH FACOEM FCCP; John P. Holland MD MPH FACOEM; Kathryn L. Mueller MD MPH FACEP FACOEM; Douglas J. Patron MD MSPH; Bernyce M. Peplowski DO MS; and Jack Richman MD CCFP DOHS FACOEM
Timothy J. Key MD MPH FACOEM as Responsible Officer and ACOEM President Elect and Edward A. Emmett MD MS FACOEM Chair of the ACOEM Council on Occupational and Environmental Medical Practice contributed to the development of the guidelines as well.
Financial Disclosures/Conflicts of Interest
Not stated
Guideline Status
This is the current release of the guideline.
This guideline updates a previous version: Harris J ed. Occupational Medicine Practice Guidelines: American College of Occupational and Environmental Medicine. Beverly Farms MA: OEM Press; 1997.
Guideline Availability
Print copies are available from ACOEM 25 Northwest Point Boulevard Suite 700 Elk Grove Village IL 60007; Phone: 847-818-1800 x399. To order a subscription to the online version call 800-441-9674 or visit http://www.acoempracguides.org/.
Availability of Companion Documents
None available
Patient Resources
None available
NGC STATUS
This NGC summary was completed by ECRI on May 30 2006. The information was verified by the guideline developer on November 3 2006.
COPYRIGHT STATEMENT
The American College of Occupational and Environmental Medicine the signator of this license represent and warrant that they are the publisher of the guidelines and/or possess all rights necessary to grant the license rights to AHRQ and its agents.
NGC Disclaimer
The National Guideline Clearinghouse™ (NGC) does not develop produce approve or endorse the guidelines represented on this site.
All guidelines summarized by NGC and hosted on our site are produced under the auspices of medical specialty societies relevant professional associations public or private organizations other government agencies health care organizations or plans and similar entities.
Guidelines represented on the NGC Web site are submitted by guideline developers and are screened solely to determine that they meet the NGC Inclusion Criteria which may be found at http://www.guideline.gov/about/inclusion.aspx .
NGC AHRQ and its contractor ECRI Institute make no warranties concerning the content or clinical efficacy or effectiveness of the clinical practice guidelines and related materials represented on this site. Moreover the views and opinions of developers or authors of guidelines represented on this site do not necessarily state or reflect those of NGC AHRQ or its contractor ECRI Institute and inclusion or hosting of guidelines in NGC may not be used for advertising or commercial endorsement purposes.
Readers with questions regarding guideline content are directed to contact the guideline developer.
Tools
No Quick Reference tools have been developed.