Summary

Musculoskeletal shoulder injuries are frequent among workers. In addition to affecting their quality of life, they lead to increased absenteeism and decreased productivity and can result in early retirement. For 2017, $2.5 billion in benefits related to occupational injuries were recorded in the province of Québec. Approximately 8% of these claims were due to an injury involving the shoulder joint (CNESST, 2018).

Rotator cuff (RC) injuries are the most common shoulder injuries found among workers. Currently, clinicians do not have a standardized approach to assess and care for them. As a result, many clinical decisions arise from intuition and experience rather than on evidence-based data.

Although there are clinical practical guides for shoulder injuries, none of them are specifically focused on the Canadian or Québec context. The objective of this report is to describe the development of a clinical practical guide that presents an up-to-date overview of the evidence regarding the three main factors affecting workers with RC injuries: (1) clinical assessment of the shoulder; (2) treatment of tendinopathy and full-thickness tears of the rotator cuff; and (3) strategies to promote a return to work.

The research team based its approach on the results included in a preliminary scientific report, entitled “Clinical Evaluation, Treatment and Return to Work of Workers Suffering from Rotator Cuff Disorders: A Knowledge Review” (Roy, Desmeules, Frémont, Dionne and MacDermid, 2015). Afterwards, 37 additional systematic reviews were added to the initial update of knowledge on RC injuries, making it possible to draw up clinical recommendations.

This report presents the development of 73 recommendations and three decision-making algorithms for care adapted to the Québec context and based on the best evidence, as well as on a consensus among experts, clinicians and various stakeholders (workers, employers, managers and other parties involved), which were then included in the practical guide. The evidence was reviewed by a committee of experts and validated through the Delphi method. The final content of the practical guide was also examined by an external review committee composed of various experts and clinicians.

The principal clinical recommendations state that the assessment of a painful shoulder should include both subjective and objective evaluations to identify the presence of red and yellow flags, as well as objective measurements of the worker’s condition. Medical imaging tests are generally not required at the first assessment, but are recommended in the presence of trauma, a clinical suspicion of a full-thickness rotator cuff tear or the failure of initial conservative treatment.

For workers with RC tendinopathy, an active rehabilitation program is recommended. Therapeutic modalities such as prescriptions of acetaminophen and/or non-steroidal anti-inflammatory drugs, manual therapy, workplace intervention, a multimodal approach and ergonomic adaptations may also be useful.

If pain is persistent, a corticosteroid injection and/or prescription of opiates could be considered. Workers whose progress is unfavourable should be referred to a specialist.

Workers with a suspected full-thickness rotator cuff tear associated with rapid referral factors should first be referred to orthopaedics. If workers have few or no rapid referral factors, they should only be referred to orthopaedics if they do not progress well with conservative treatment. Conservative treatment for a full-thickness rotator cuff tear is the same as that for rotator cuff tendinopathy and should include an active rehabilitation program.

In order to facilitate the return to work, the identification of a key actor, the description of roles and responsibilities of all stakeholders, early contact with the worker injured in the workplace, reassessment and adjustment of the return-to-work plan and goals, the presence of meaningful and rewarding tasks in the rehabilitation and return-to-work program and the development of realistic goals for the worker’s productivity during the return-to-work process are recommended.