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## Complete Summary

#### GUIDELINE TITLE

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.

### \*\* REGULATORY ALERT \*\*

#### FDA WARNING/REGULATORY ALERT

**Note from the National Guideline Clearinghouse**: This guideline
references a drug(s) for which important revised regulatory information
has been released.

-   [June 15, 2005, Non-Steroidal Anti-Inflammatory Drugs
    (NSAIDs)](http://www.fda.gov/medwatch/SAFETY/2005/safety05.htm#NSAID):
    U.S. Food and Drug Administration (FDA) recommended proposed
    labeling for both the prescription and over the counter (OTC) NSAIDs
    and a medication guide for the entire class of prescription
    products.

-   [April 7, 2005, Non-steroidal anti-inflammatory drugs (NSAIDS)
    (prescription and OTC, including ibuprofen and
    naproxen)](http://www.fda.gov/medwatch/SAFETY/2005/safety05.htm#Bextra):
    FDA asked manufacturers of prescription and non-prescription (OTC)
    non-steroidal anti-inflammatory drugs (NSAIDs) to revise their
    labeling to include more specific information about potential
    gastrointestinal (GI) and cardiovascular (CV) risks.

### COMPLETE SUMMARY CONTENT

 \*\* REGULATORY ALERT \*\*\
 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Shoulder complaints

#### GUIDELINE CATEGORY

Diagnosis\
Evaluation\
Management\
Treatment

#### CLINICAL SPECIALTY

Family Practice\
Internal Medicine\
Orthopedic Surgery\
Physical Medicine and Rehabilitation\
Preventive Medicine\
Surgery

#### 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.

1.  History and physical exam

2.  Patient education

3.  Medication

4.  Physical treatment methods, activities and exercise

5.  Injections

6.  Rest and immobilization

7.  Detection of physiologic abnormalities

8.  Radiography

9.  Other imaging procedures

10. Surgical considerations

#### MAJOR OUTCOMES CONSIDERED

Missed work days

### METHODOLOGY

#### 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.

### RECOMMENDATIONS

#### 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       **Recommended**        **Optional**     **Not Recommended**
  Measure**                                                
  ---------------- ---------------------- ---------------- -------------------
  History and      Focused history and                      
  physical exam    exam\                                   
                   \                                       
                   Search for red flags                    
                   (e.g., for tumor,                       
                   infection, angina) (C)                  

  Patient          Patient education                        
  education        regarding condition or                  
                   disorder, expectations                  
                   of treatment, side                      
                   effects, etc. (D)                       

  Medication (See  Acetaminophen (C)\     Opioids, short   Use of opioids for
  Chapter 3 in the \                      course (C)       more than 2 weeks
  original         Non-steroidal                           (C)\
  guideline        anti-inflammatory                       \
  document)        drugs (NSAIDs) (B)                      Muscle relaxants
                                                           (D)

  Physical         Maintain activities of At-home          Passive modalities
  treatment        other parts of body    applications of  by therapist
  methods,         while recovering (D)\  heat or cold     (unless accompanied
  activities and   \                      packs to aid     by teaching the
  exercise         Maintain passive range exercises (D)\   patient exercises
                   of motion of the       \                to be carried out
                   shoulder with pendulum Short course of  at home) (D)
                   exercises and wall     supervised       
                   crawl (D)\             exercise         
                   \                      instruction by a 
                   Treat initially with   therapist (D)    
                   strengthening or                        
                   stabilization                           
                   exercises for                           
                   impingement syndrome,                   
                   rotator cuff tear,                      
                   instability, and                        
                   recurrent dislocation                   
                   (C, D)                                  

  Injections       Two or three                            Prolonged or
                   sub-acromial                            frequent use of
                   injections of local                     cortisone
                   anesthetic and                          injections into the
                   cortisone preparation                   sub-acromial space
                   over an extended                        or the shoulder
                   period as part of an                    joint (D)
                   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)                        

  Rest and         Brief use of a sling                    Prolonged use of a
  immobilization   for severe shoulder                     sling only for
                   pain (1 to 2 days),                     symptom control (D)
                   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)                             

  Detection of     Rarely, nerve                           Electromyography
  physiologic      conduction time of the                  (EMG) or nerve
  abnormalities    suprascapular nerve                     conduction velocity
                   for cases of severe                     (NCV) studies as
                   cuff weakness                           part of a shoulder
                   unaccompanied by signs                  evaluation for
                   of a rotator cuff tear                  usual diagnoses (D)
                   (D)                                     

  Radiography                             For acute AC     Routine radiographs
                                          joint            for shoulder
                                          separations,     complaints before 4
                                          stress films     to 6 weeks of
                                          (views of both   conservative
                                          shoulders, with  treatment (D)\
                                          and without      \
                                          patient holding  Stress films for
                                          15-lb weights)   instability (D)
                                          (D)              

  Other imaging    Magnetic resonance     Arthrography for Routine MRI or
  procedures       imaging (MRI) for      preoperative     arthrography for
                   preoperative           evaluation of    evaluation without
                   evaluation of          small            surgical
                   partial-thickness or   full-thickness   indications (D)\
                   large full-thickness   tears (C)\       \
                   rotator cuff tears (C, \                Ultrasonography for
                   D)                     Bone scan for    evaluation of
                                          detection of AC  rotator cuff (C)
                                          joint arthritis  
                                          (D)              

  Surgical         Anterior repair for                     Anterior repair for
  considerations   recurrent dislocation                   initial shoulder
                   after 2 to 3                            dislocation (C)\
                   dislocations (D)\                       \
                   \                                       Acute repair of AC
                   Resection of outer                      separation (C)\
                   clavicle for chronic                    \
                   disabling AC joint                      Acute repair of
                   pain after                              rotator cuff tears,
                   conservative care of                    except for massive
                   acute separation (C)\                   acute tears (C)\
                   \                                       \
                   Rotator cuff repair                     Surgery for
                   after firm diagnosis                    recurrent
                   is made and                             dislocation of
                   rehabilitation efforts                  instability before
                   have failed (D)\                        rehabilitation
                   \                                       efforts (C)
                   Capsular shift surgery                  
                   for disabling                           
                   instability (D)\                        
                   \                                       
                   Subacromial                             
                   decompression after                     
                   failure of                              
                   non-operative care (C)                  
  ----------------------------------------------------------------------------

**[Definitions]{.underline}**:

**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

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of supporting evidence is identified and graded for each
recommendation (see \"Major Recommendations\").

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE 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

#### 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.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

#### IMPLEMENTATION TOOLS

Clinical Algorithm

For information about
[availability](#identifying-information-and-availability), see the
\"Availability of Companion Documents\" and \"Patient Resources\" fields
below.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Getting Better

#### IOM DOMAIN

Effectiveness\
Patient-centeredness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### 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.

#### DATE RELEASED

1997 (revised 2004)

#### GUIDELINE DEVELOPER(S)

American College of Occupational and Environmental Medicine - Medical
Specialty Society

#### 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.

### DISCLAIMER

#### 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
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Guidelines represented on the NGC Web site are submitted by guideline
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Inclusion Criteria which may be found at
<http://www.guideline.gov/about/inclusion.aspx> .

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concerning the content or clinical efficacy or effectiveness of the
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Readers with questions regarding guideline content are directed to
contact the guideline developer.

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© 1998-2008 National Guideline Clearinghouse

Date Modified: 11/10/2008