Orthopedic Doctors Reveal Latest on Shoulder Diagnoses, Treatments
Some of the latest protocols to treat shoulder injuries among Connecticut’s workers’ comp patients are drawing criticism from at least one expert. He says one of the new rules may save money initially but lead to poorer outcomes and more money in the long run.
The state’s revised rules took effect April 1. For acute traumatic or overuse/repetitive shoulder injury at less than four weeks, the state’s Workers’ Compensation Commission recommends X-rays if indicated by amount of trauma or medical suspicion but “no MRI or CT scan.”
“If you don’t get an MRI or ultrasound initially, you have the possibility of missing a full thickness rotator cuff tear, which is best repaired within 10 days of the injury,” said Dr. David Cooper, an orthopedic surgeon and founder of The Knee Center in Wilkes-Barre, Pa. “If you don’t make that diagnosis, not only are you doing a disservice to the worker, but also when he doesn’t get better and four weeks later an MRI shows a tear, it’s very hard to fix, and the guy will come back and blame workers’ comp for not getting a good result.”
While other experts may dispute that exact time frame, they agree the sooner a full thickness rotator cuff tear is repaired, the better chance for an optimal outcome.
Rotator Cuff Tears
Rotator cuff tears are one of the most common shoulder injuries, especially among injured workers. A partial tear involves damage to the soft tissue but does not completely sever it while a full-thickness tear splits the soft tissue into two pieces.
“A partial thickness tear is considered degenerative. You may not want to pick it up as a workers’ comp injury. It may not be your responsibility.”
Partial thickness tears are usually the result of wear and tear as part of the normal aging process. On the other hand, full thickness tears are often caused by traumatic injuries such as falls. Knowing the difference can help workers’ comp practitioners determine causation.
“Workers’ comp has a basis in treatment for an acute tear,” Cooper said. “A partial thickness tear is considered degenerative. You may not want to pick it up as a workers’ comp injury. It may not be your responsibility.”
That’s another reason Cooper suggests getting an early diagnosis of shoulder pain among workers. But he understands the reluctance to perform an MRI at the onset of shoulder pain, especially since they can cost upwards of $600.
“I sort of agree with having no MRI. But an ultrasound would be a good screening test. Studies have shown them equivalent to MRI results,” he said. “A good ultrasound costs about $150.”
Cooper and others point out that it’s important to use an occupational health facility that has experience with ultrasound.
“It can be abused but is very operator dependent,” said Dr. William Ritchie, an orthopedic surgeon who specializes in injuries and conditions of the shoulder and knee, occupational medicine, sports medicine, and trauma at New Mexico Orthopaedics. “MRI is still the gold standard.” However, Ritchie also says he would only do an MRI within the first four weeks if there was a high suspicion of a rotator cuff tear such as significant weakness in the setting of a traumatic injury to the shoulder
Ritchie says there are some additional diagnostic tests that may be overused for injured workers. “You seldom need, for instance, EMG and nerve studies, but I do see them done by physiatrists for shoulder pain,” Ritchie said. “[As far as] MRI scans, that’s a tough call. They probably are done somewhat more often than they need to be. On the other hand, in the workers’ comp population, there have been studies showing if they are done early and get diagnosis and treatment in the long term that can save money.”
Aside from rotator cuff tears, other injuries seen among workers include SLAP tears, or superior labral tear from anterior to posterior; essentially a pulling injury to the shoulder.
“The SLAP tear was much more commonly diagnosed by MRI scans in the past. We’re diagnosing and operating on fewer of these.”
“It’s more common in sports, but it can be from a fall if you try to catch yourself. But that’s changing over time,” Ritchie said. “The SLAP tear was much more commonly diagnosed by MRI scans in the past. We’re diagnosing and operating on fewer of these.”
An additional shoulder ailment seen occasionally among injured workers is instability from a current dislocation. Ritchie says that can occur from a fall, although it is more typical among athletes.
The treatment of shoulder injuries varies depending on the diagnosis. For example, there is debate about the effectiveness of surgery for full thickness rotator cuff tears. The American Academy of Orthopaedic Surgeons’ board of directors recently approved new appropriate use criteria to treat full thickness tears.
“We found that in many patient/treatment combinations nonsurgical treatments or lesser surgeries treatments — partial repair and/or débridement, or repair — might be appropriate,” said Dr. James O. Sanders, who served as section leader and moderator during the appropriate use criteria’s development. “Major surgery such as reconstruction was an option less frequently, and arthroplasty was rarely appropriate.”
In arthroplasty, the joint is replaced, remodeled, or realigned by cutting the bone. One change in recent years is the increased use of arthroscopic surgery versus open surgical procedures.
In terms of recovery from arthroscopic procedures, “there is a small but significant difference but a little less painful,” Ritchie said. “There is faster recovery for arthroscopic [surgery].”
In the future, there may be a variety of procedures to repair shoulder ailments. Included in the Connecticut protocol’s “nonconsensus modalities” are platelet rich injections, acupuncture, hyaluronic acid injections, and stem cell preparations.
Researchers Examine Workplace Cancer Links
Workplace exposures are among the environmental factors believed to be responsible for cancer, say researchers. They estimate between 3 and 6 percent of all cancers worldwide are caused by workplace exposures to carcinogens. That translates to as many as 762,000 new cancers each year from occupational exposure, which they say is likely an underestimate. In the U.S., scientists estimate there were between 43,695 and 87,399 new occupational-related cancers in 2010, the most recent year available.
“Cancers that occur as a result of exposures in the workplace are preventable, if exposures to known or suspected carcinogens can be reduced,” wrote researchers on a blog post for the National Institute for Occupational Safety and Health. The agency is doing studies to identify agents in the workplace associated with the development of cancer.
Recent findings include:
Lung cancer among non-metal miners in which “risk was significantly associated with diesel exhaust exposure.” The results of that study were part of a decision by the International Agency for Research on Cancer to designate diesel exhaust as a Group 1 — known human — carcinogen.
Highly elevated incidence of bladder cancer among rubber manufacturing workers that was strongly associated with workplace ortho-toluidine exposure. The findings influenced the IARC’s recent determination of ortho-toluidine to be a Group 1 carcinogen.
Higher than expected rates of cancers, especially mesothelioma and cancers of the respiratory and digestive tract, among firefighters in Chicago, Philadelphia, and San Francisco. “Recent findings about mesothelioma and lung cancer related to asbestos exposure have shed new light on the importance of size and shape on the carcinogenicity of that well studied agent,” NIOSH said. “These findings may have important implications for future risk assessments of the hazards associated with asbestos exposure.”
The research has helped influence the development of risk-based exposure limit recommendations by national and international organizations. The agency is seeking input from stakeholders on priorities for future epidemiological research of potential occupational carcinogens.
5 & 5: Rewards and Risks of Cloud Computing
Cloud computing lowers costs, increases capacity and provides security that companies would be hard-pressed to deliver on their own. Utilizing the cloud allows companies to “rent” hardware and software as a service and store data on a series of servers with unlimited availability and space. But the risks loom large, such as unforgiving contracts, hidden fees and sophisticated criminal attacks.
ACE’s recently published whitepaper, “Cloud Computing: Is Your Company Weighing Both Benefits and Risks?”, focuses on educating risk managers about the risks and rewards of this ever-evolving technology. Key issues raised in the paper include:
5 benefits of cloud computing
1. Lower infrastructure costs
The days of investing in standalone servers are over. For far less investment, a company can store data in the cloud with much greater capacity. Cloud technology reduces or eliminates management costs associated with IT personnel, data storage and real estate. Cloud providers can also absorb the expenses of software upgrades, hardware upgrades and the replacement of obsolete network and security devices.
2. Capacity when you need it … not when you don’t
Cloud computing enables businesses to ramp up their capacity during peak times, then ramp back down during the year, rather than wastefully buying capacity they don’t need. Take the retail sector, for example. During the holiday season, online traffic increases substantially as consumers shop for gifts. Now, companies in the retail sector can pay for the capacity they need only when they need it.
3. Security and speed increase
Cloud providers invest big dollars in securing data with the latest technology — striving for cutting-edge speed and security. In fact, they provide redundancy data that’s replicated and encrypted so it can be delivered quickly and securely. Companies that utilize the cloud would find it difficult to get such results on their own.
4. Anything, anytime, anywhere
With cloud technology, companies can access data from anywhere, at any time. Take Dropbox for example. Its popularity has grown because people want to share large files that exceed the capacity of their email inboxes. Now it’s expanded the way we share data. As time goes on, other cloud companies will surely be looking to improve upon that technology.
5. Regulatory compliance comes more easily
The data security and technology that regulators require typically come standard from cloud providers. They routinely test their networks and systems. They provide data backups and power redundancy. Some even overtly assist customers with regulatory compliance such as the Health Insurance Portability and Accountability Act (HIPAA) or Payment Card Industry Data Security Standard (PCI DSS).
1. Cloud contracts are unforgiving
Typically, risk managers and legal departments create contracts that mitigate losses caused by service providers. But cloud providers decline such stringent contracts, saying they hinder their ability to keep prices down. Instead, cloud contracts don’t include traditional indemnification or limitations of liability, particularly pertaining to privacy and data security. If a cloud provider suffers a data breach of customer information or sustains a network outage, risk managers are less likely to have the same contractual protection they are accustomed to seeing from traditional service providers.
2. Control is lost
In the cloud, companies are often forced to give up control of data and network availability. This can make staying compliant with regulations a challenge. For example cloud providers use data warehouses located in multiple jurisdictions, often transferring data across servers globally. While a company would be compliant in one location, it could be non-compliant when that data is transferred to a different location — and worst of all, the company may have no idea that it even happened.
3. High-level security threats loom
Higher levels of security attract sophisticated hackers. While a data thief may not be interested in your company’s information by itself, a large collection of data is a prime target. Advanced Persistent Threat (APT) attacks by highly skilled criminals continue to increase — putting your data at increased risk.
4. Hidden costs can hurt
Nobody can dispute the up-front cost savings provided by the cloud. But moving from one cloud to another can be expensive. Plus, one cloud is often not enough because of congestion and outages. More cloud providers equals more cost. Also, regulatory compliance again becomes a challenge since you can never outsource the risk to a third party. That leaves the burden of conducting vendor due diligence in a company’s hands.
5. Data security is actually your responsibility
Yes, security in the cloud is often more sophisticated than what a company can provide on its own. However, many organizations fail to realize that it’s their responsibility to secure their data before sending it to the cloud. In fact, cloud providers often won’t ensure the security of the data in their clouds and, legally, most jurisdictions hold the data owner accountable for security.
Risk managers can’t just take cloud computing at face value. Yes, it’s a great alternative for cost, speed and security, but hidden fees and unexpected threats can make utilization much riskier than anticipated.
Managing the risks requires a deeper understanding of the technology, careful due diligence and constant vigilance — and ACE can help guide an organization through the process.
To learn more about how to manage cloud risks, read the ACE whitepaper: Cloud Computing: Is Your Company Weighing Both Benefits and Risks?