What is the occupational medicine management approach for a patient with subscapularis (subscapularis) tendinosis and bicipital (bicipital) tendinitis, who tests positive for Hawkings (Hawkins) test and cross-arm test, and has undergone injection and physical therapy, with a job requiring lifting?

From the Guidelines

From an occupational medicine perspective, management of this patient should focus on a gradual return to work with modified duties while continuing therapeutic interventions, prioritizing relative rest and reduced activity to prevent further damage and promote healing and pain relief, as recommended by 1 and 1. The patient's job requires lifting, which should be limited to under 10-15 pounds for 2-4 weeks to avoid exacerbating the subscapularis tendinosis and bicipital tendinitis.

• Continue the current treatment plan of corticosteroid injections and physical therapy focusing on rotator cuff strengthening, scapular stabilization, and range of motion exercises 2-3 times weekly, as supported by 1.
• Recommend NSAIDs like naproxen 500mg twice daily or ibuprofen 600mg three times daily with food for pain management, as suggested by 1.
• Gradually increase work capacity through a progressive return-to-work program, increasing weight limits by 5-10 pounds every 1-2 weeks based on symptom response, with weekly reassessments guiding progression.
• Consider advanced imaging (MRI) and orthopedic consultation if symptoms persist beyond 8-12 weeks despite adherence to treatment, as this approach balances workplace productivity with proper healing time, and premature return to full duties risks exacerbating the rotator cuff and biceps tendon inflammation, potentially leading to chronic injury and prolonged disability, as implied by 1 and 1. Key aspects of the management plan include:
• Relative rest and reduced activity to prevent further damage and promote healing and pain relief, as recommended by 1 and 1.
• Gradual return to work with modified duties to balance workplace productivity with proper healing time, as suggested by 1 and 1.
• Continued therapeutic interventions, including corticosteroid injections and physical therapy, to promote healing and pain relief, as supported by 1.

From the Research

Occupational Medicine Management Approach

The patient's condition involves subscapularis tendinosis and bicipital tendinitis, with positive test results for Hawkins and cross-arm tests, and has undergone injection and physical therapy. The job requires lifting, which may exacerbate the condition.

• The management approach should focus on reducing inflammation and promoting healing of the affected tendons, as well as improving shoulder function and strength 2.
• Conservative management, including rest, ice, oral analgesics, physical therapy, and corticosteroid injections, may be effective in managing bicipital tendinitis 2.
• For subscapularis tendinosis, rehabilitation through phased progression can help avoid premature stress on the healing tissue while enabling early return to daily activities 3.
• In cases where conservative measures fail, surgical intervention may be necessary to repair the subscapularis tendon and stabilize the long head of the biceps tendon 4, 5.
• The classification of subscapularis tendon tears is crucial in determining the treatment plan, and a consensus decision-making approach among shoulder and elbow surgeons can help identify the best course of action 4.

Job Modification and Return to Work

• The patient's job requires lifting, which may need to be modified or restricted to avoid exacerbating the condition.
• A gradual return to work program can help the patient gradually increase their lifting activities while minimizing the risk of re-injury.
• The patient may need to undergo regular follow-up appointments with their healthcare provider to monitor their progress and adjust their treatment plan as needed 3, 5.

Diagnostic Challenges

• Subscapularis tendon tears can be difficult to diagnose, and written MRI reports from non-musculoskeletal-specialized radiologists may not be reliable 6.
• A thorough clinical examination and imaging studies, such as ultrasonography or magnetic resonance imaging, may be necessary to accurately diagnose and classify the subscapularis tendon tear 2, 6.