Substantive changes in Proposed Medical Treatment Guidelines
January 19, 2010 revision
Note: the language in italics is the new language
- Operative Procedures -Bicipital Tendon Disorders revised
[Basis: The literature suggests better outcomes with surgery than with non-surgical management.]
- Acute Disruption of the Bicipital Tendon: Surgery has been shown to be more effective than conservative care in the treatment of full thickness ruptures of the distal biceps tendon.
- Testing Procedures -Bursitis of the Shoulder-Plain x-rays revised
- Plain x-rays include:
Plain x-rays may be performed to rule out other shoulder pathology.
- Non-operative Treatment Procedures (Bursitis of the Shoulder)-revised
- Intrabursal injection with steroids may be therapeutic.
- Frequency: Not more than 2-3 times annually. Usually 1 or 2 injections adequate. A minimum of 3 weeks interval between injections is recommended.
- Time to produce effect: Within 3 days with corticosteroids.
- Maximum duration: Limited to 3 injections annually to the same site.
- Brachioplexus Injuries-Testing Procedure-EDS revised
- Brachioplexus injuries to the nerves and shoulder girdle region result in loss of motor and sensory function, pain and instability of the shoulder. Signs and symptoms vary with the mechanism of injury. The two modes of injury are: 1) acute direct trauma, and 2) repetitive motion or overuse. Transient compression, stretch or traction (neuropraxia) causes sensory and motor signs lasting days to weeks. Damage to the axon (axonotmesis) without disruption of the nerve framework may cause similar symptoms. The recovery time is delayed and depends upon axon regrowth distally from the site of injury. Laceration or disruption of the entire nerve with complete loss of framework (neurotmesis) is the most severe form of nerve injury. Return of function is dependent upon regrowth of the nerve distal to the injury site.
Electrodiagnostic studies are the most commonly used diagnostic modality to analyze nerve injuries. These studies should be utilized when necessary as an extension of the history and clinical examination. Slowing of motor nerve conduction velocities due to demyelinization localizes regions of entrapment and injury. Denervation demonstrated on the electromyographic portion is indicative of motor axonal or anterior horn cell loss. Studies should be performed 3-4 weeks following injury or description of symptoms. If the symptoms have been present for longer than 3-4 weeks, studies may be performed immediately after the initial evaluation. Serial studies may be indicated if initial studies are negative and may also be useful for gauging prognosis. Limb temperature influences nerve conduction velocities. In cases when significant slowed conduction is recorded, the standard of the American Association of Neuromuscular and Electrodiagnostic Medicine (AANEM)
including temperatures should be followed. It is recommended and preferred that EDS in the out-patient setting be performed and interpreted by physicians board-certified in Neurology or Physical Medicine and Rehabilitation.
- Testing Procedures (Impingement Syndrome)
- Plain x-rays-revised.
May demonstrate calcification or bone spurs.
- Subacromial space injection-revised.
Subacromial space injection can be used as a diagnostic procedure by injecting an anesthetic, such as sensorcaine or xylocaine solutions, into the space. If the pain is alleviated with the injection, the diagnosis is confirmed.