Do patients covered by workmen's compensation get back to work after shoulder arthroplasty?

Anatomic Shoulder Arthroplasty in Workers’ Compensation Patients: Predictors of Success and Return to Work

These authors sought to determine: 1) the extent to which patient-reported outcomes are impacted by WC status in comparison to patients covered by other types of insurance, 2) which factors are predictive of a successful outcome of shoulder arthroplasty as defined by improvement exceeding the minimal clinically important difference (MCID), 3) the ability of WC patients to return to their presurgical occupation after arthroplasty.

They identified 677 patients who underwent primary anatomic shoulder arthroplasty with a minimum 2-year follow-up, 39 of whom had WC insurance. These patients were compared to a matched cohort of 78 patients not having WC insurance. Two non-WC patients were matched to every WC patient based on similar age, sex, ASA class, history of prior surgery, smoking status, type of procedure, preoperative SST, and preoperative SANE scores.

Jobs that required medium (9.1 to 22.7 kilograms or 20 to 50 pounds of force occasionally), heavy (22.7 to 45.4 kilograms or 50 to 100 pounds of force occasionally), or very heavy (>45.4 kilograms or >100 pounds of force occasionally) physical demands were classified as physically-demanding, while jobs that required sedentary (less than 4.5 kilograms or 10 pounds of force occasionally) or light (4.5 to 9.1 kilograms or 10 to 20 pounds of force occasionally) physical demands were classified as non-physically-demanding.

21% of patients covered by WC insurance had lawyer involvement in contrast to 1% of non-WC patients

Success, defined as improvement beyond MCID, occurred in a significantly lower proportion of workers’ compensation patients compared to non-workers’ compensation patients (64% vs. 94%, p<0.001).  WC patients had lower postoperative scores and a higher percentage of revision surgery.

Among WC patients, older age (p=0.010) and a higher preoperative SF-36 role physical domain score (a measure of the patient’s perceived limitations in routine activities) (p=0.007) were associated with improvement beyond the MCID. 

Among WC patients, the patients most likely to achieve significant improvement were more likely to be younger, male, have a diagnosis of osteoarthritis, have a lower preoperative SST score and have higher SF-36 scores in "role physical', "mental component summary" and "physical component summary".

A significantly lower percentage of patients with physically demanding jobs returned to previous occupation compared to patients with non physically demanding jobs (13% vs. 73%, p=0.001).

Comment: This article points out that patients on WC insurance and having shoulder arthroplasty have substantially different preoperative characteristics than those not on WC insurance.

The data suggest that surgeons should be cautious about predicting a successful return to work for patients on WC insurance, especially for those patients with physically demanding jobs and those with low levels of physical function prior to surgery.

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Is workers' compensation a comorbidity - if so what do we do about it?

Inferior outcomes and higher complication rates after shoulder arthroplasty in workers’compensation patients

These authors compared the complication rates and clinical outcomes after shoulder arthroplasty in workers' compensation (WC) patients and control non-WC patients.
They queried their institutional shoulder arthroplasty database for patients with minimum 2-year follow-up who underwent total shoulder arthroplasty, reverse total shoulder arthroplasty, or hemiarthroplasty. 45 WC patients were age and sex matched with 45 non-WC patients and retrospectively evaluated for complication rates, patient-reported outcomes, and range of motion.

The WC group had twice as high rate of prior surgery (82% vs 38%).

The WC group had an eight times higher reoperation rate (16% vs 2%) 

The WC group had three times the rate of persistent pain at final follow-up (33% vs 11%). 

The WC group had half the improvement for the SST (from 3.2 to 5.8) in comparison to the non WC group  (4.3 to 9.7).

On multivariate regression controlling for other variables including number of prior surgical procedures, WC status remained associated with lower improvements in the Simple Shoulder Test  scores, as well as a higher reoperation rate and a higher rate of persistent pain.

Comment: This article demonstrates that patients with workers' compensation insurance are at greater risk for adverse outcomes after shoulder arthroplasty.

From these data it appears that the value of shoulder arthroplasty (improvement measured against cost, reoperations and complications) is less for patients on WC insurance. It appears that WC gets less return on its investment in shoulder arthroplasty than other forms of insurance. This study did not assess the success rate of returning patients to work for patients on WC and those not on WC; if shoulder arthroplasty were successful in getting a substantial number of patients back to work, this fact might tip the value equation.

A number of questions arise:

(1) Should these results influence the decision of WC to fund shoulder arthroplasty? 

(2) Should these results influence the surgeon's decision to perform shoulder arthroplasty on WC funded patients? 

(3) When a patient has chronic osteoarthritis with work-related aggravation, to what degree should WC insurance be fiscally responsible for the total cost of shoulder arthroplasty? 

(4) Does WC insurance coverage of time off work disincent patients from "getting better"?

We do not know for sure how to answer these questions, but we must think about them in each case.

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Be sure to visit "Ream and Run - the state of the art" regarding this radically conservative approach to shoulder arthritis at this link and this link

Use the "Search" box to the right to find other topics of interest to you.

How you can support progress in shoulder surgery

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Workers' compensation insurance is a comorbidity for shoulder arthroplasty

Inferior outcomes and higher complication rates after shoulder arthroplasty in workers’ compensation patients

These authors compared the complication rates and clinical outcomes after shoulder arthroplasty (total shoulder arthroplasty, reverse total shoulder arthroplasty, or hemiarthroplasty)  in workers' compensation patients and control non-WC patients. 

They matched 45 WC and 45 non-WC patients by age and sex, with the WC group having a higher rate of prior surgery (82% vs 38%, P < .001). 

The WC group had inferior 2-year outcomes for all PROs and forward elevation (P ≤ .001 for all), as well as a higher reoperation rate (16% vs 2%, P = .030) and higher rate of persistent pain at final follow-up (33% vs 11%, P = .021). 

On multivariate regression controlling for other variables including number of prior surgical procedures, WC status remained associated with lower improvements in the Simple Shoulder Test (P < .001) scores, as well as a higher reoperation rate (P = .015) and higher rate of persistent pain (P = .027).

Comment: Many reasons have been proposed for the well-documented poorer outcomes in WC patients, including young age, patient sex, higher exceptions, lower motivation, secondary gain, and associated co-morbidities, such as smoking.

This study controls for some of these variables and finds that prior surgery is more frequent in WC patients. 

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We have a new set of shoulder youtubes about the shoulder, check them out at this link.

Be sure to visit "Ream and Run - the state of the art" regarding this radically conservative approach to shoulder arthritis at this link and this link

Use the "Search" box to the right to find other topics of interest to you.

How you can support progress in shoulder surgery

You may be interested in some of our most visited web pages  arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

Rotator cuff surgery in workers - effect of timing

The effect of expedited rotator cuff surgery in injured workers: a case-control study

These authors examined the effect of ‘expedited’ surgery on recovery and work status in injured workers.

Injured workers who had undergone an 'expedited' rotator cuff surgery funded by parallel-pay insurance (study group) were compared with workers who had used the public health insurance (control group) while adjusting for sex, age, severity of pathology, and follow-up period.

The patients in the ‘expedited’ group waited less time to have surgery than the control group, reported less disability after surgery, had a higher number of patients whose improvement exceeded the minimal clinically important improvement in the ASES score, and were more likely to be working at the time of the final follow-up.

Comment: The duration of symptoms was <18 months in 77% of the ‘expedited’ group and in 41% of the control group. In the ‘expedited’ group symptoms had been present for 16±18 months and for 38±51 months in the control group. It is not clear whether the workers were off work for the duration of symptoms. It well known that the longer a worker is off work the more difficulty it is to get them back to work. Thus it is not surprising that only 36% of the ‘expedited’ group was back to regular work at followup and only 19% of the control group was back to regular work at followup.

While the title of this study indicates that it is about ‘rotator cuff surgery’, only 45% of the cases in either group had rotator cuff repairs. Other surgeries included acromioplasty, distal clavicle resection, and biceps surgery. This is not a study of the value of acute repairs of traumatic cuff tears.

It is noted that patients in the ‘expedited’ group had an orthopedic evaluation at a specialty shoulder and elbow clinic and an expedited arthroscopic rotator cuff decompression or repair, or both. In contrast, patients in the control group had an active compensable injury that had undergone a publicly funded operation for rotator cuff decompression or repairs. Who winds up being covered by ‘parallel-pay insurance’ and who winds up being covered by public health insurance? We are not informed if these surgeries were performed at a ‘specialty shoulder and elbow clinic’ or not. Thus it is unclear whether selection bias may have tipped the results in favor of the ‘expedited’ group.

The management of injured workers is complex. Our approach is to do our best at the initial visit to determine whether the patient is likely to return to work without or with surgery. If return to work is likely, we expedite non-operative or operative treatment to minimize the detrimental off work time.

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Shoulder arthroplasty in patients covered by workers' compensation

Anatomic total shoulder arthroplasty for patients receiving workers' compensation.

These authors compared 13 male patients, mean age 56 years covered by worker's compensation (WC) insurance having total shoulder arthroplasty (TSA) to 36 men and 27 women, mean age 63 years without worker's compensation insurance at a minimum of 2 years of follow-up.

The American Shoulder and Elbow Surgeons (ASES) scores at final follow-up were significantly lower in the WC cohort (73.6) compared with the control group (86.6).  Only 4 of the 13 WC patients returned to work.

Comment: While most surgeons recognize coverage by workman's compensation as a factor increasing the chance of a poor result, this study did not provide the reader with preoperative ASES scores, so the amount of improvement for the two groups cannot be compared. Furthermore this study  did not attempt to determine whether it was the insurance, the patient age, or the patient sex that exerted the predominant effect on the outcome.

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Consultation for those who live a distance away from Seattle.

Check out the new Shoulder Arthritis Book - click here.

Click here to see the new Rotator Cuff Book

Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

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Shoulders with job-related injuries and worker's compensation

A concerning thing about many occupational disorders is the ‘grab bag’ of imprecise terms that have been applied to them, such as “Complaints of the Arms, Neck and Shoulders (CANS)”, “Work-related upper extremity musculoskeletal disorders (WRUEMSDS)”, “Occupational shoulder disorders (OSDS)”, “Repetitive Motion Disorder (RMD)”, and “Impingement Syndrome”- these are conditions that do not have either robust diagnostic criteria or specific treatment for a defined anatomic entity. They leave shoulder surgeons in a very subjective and imprecise position. A well respected shoulder surgeon once told me that he always gets MRI’s on patients with work-related claims ‘to prove there’s nothing wrong’. The problem is that we rarely see a normal MRI reading on anyone over the age of 25 – everyone has some ‘findings’. As a result, we often see injured workers that have had acromioplasties, acromioclavicular resections, biceps tenodeses, SLAP repairs and Bankart repairs performed on patients in the absence of supporting evidence from the history and physical exam– the results are predictable.

Occupational disorders usually share some important features. They are thought to be caused by the patient’s job. They keep the patient from doing his or her job properly. They result in health care costs and loss of earnings for the patient. And they bring forth the question of the patient’s entitlement to reimbursement and compensation. For these reasons, occupational disorders create an undeniable conflict between (a) the desire of the patient to emphasize the magnitude of the shoulder disability in order to maximize the support they receive from the employer’s insurance and (b) the desire of the employer and the employer’s insurance to minimize their coverage for time off work, medical expenses and long term disability. The shoulder surgeon is often placed in middle of this conflict and asked to make time-consuming, imponderable, non-medical determinations, such as the “percent of permanent partial impairment” or defining when the patient is ‘fixed and stable” or what percent of the problem was “pre-existing” or whether the problem would have come on in the “absence of the patient’s employment”. While the physician is rarely an expert in making these determinations, each decision carries a major impact for the patient and the employer. Patients may feel threatened that the doctor will ‘cut them off’ resulting in a termination of the disability payments that they depend on for family support. This may drive patients to have surgical procedures as a demonstration of the severity of the problem. Employers often want the injured worker back only if there are ‘no restrictions,’ which is usually a challenge in that we can rarely restore an injured shoulder to normal. Physicians are asked to ‘approve’ various job modifications without detailed knowledge of what the modified job really entails.

In terms of the outcome of treatment, it has been repeatedly demonstrated that workman’s compensation is an important co-morbidity. Patients insured for on-the-job injuries have poorer outcomes than patients with other types of insurance coverage. Another fact must be recognized: if a patient is out of work for a year, the chances of going back to work are slim.

While all of these considerations may disincline surgeons from taking on injured workers, these individuals deserve the same thoughtful care we strive to deliver to all our patients. Our practice is to split the issues into (a) the job and (b) the shoulder. We are up front that no cuff surgery is likely to get a dockworker or carpenter back 100%. Before considering any surgery, we make sure that the Labor and Industries or Worker’s Compensation insurance is formally notified that the injury is likely to prevent full resumption of the pre-injury job – without or with treatment. We encourage the parties to begin the process of vocational rehabilitation, again before any interventional treatment. Once the vocational issues are resolved (‘this individual will not be able to return to work requiring overhead use of the arm’), we can devote our attention to defining expectations of treatment and trying our best to match these expectations with a realistic presentation of the outcomes we have achieved for patients having similar pathology.

Patients and surgeons faced with job related injuries face challenges that are not encountered in the management of conditions unrelated to work. These differences need to be carefully considered in planning their evaluation and management.

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Use the "Search" box to the right to find other topics of interest to you.

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Total shoulder arthroplasty - worker's compensation coverage may be a comorbidity

Anatomic total shoulder arthroplasty for patients receiving workers' compensation.

These authors reviewed 13 patients (all men, mean age 56 years, 12 laborers) insured by workers' compensation having total shoulder arthroplasty (WC TSA) along with 63 patients (36 men, 27 women, mean age 63 years) not insured by worker's compensation (NWC TSA).

At a minimum of two years the American Shoulder and Elbow Surgeons scores at final follow-up were significantly lower in the WC cohort (73.6) compared with the control group (86.6; P = .01). 

Only 4 of the 13 WC patients returned to work, only one to his original job.

Comment: While the authors' refer to the NWC TSA patients as a 'control' group, it is easy to see that the two populations differ in important ways other than their insurance (age, sex, occupation). Thus we cannot say how much of the difference is due to the insurance and how much to other factors - for example it is well known that younger patients do less well after total shoulder arthroplasty. In addition, the 13 WC patients had a total of 20 surgeries prior to their total shoulders - another risk factor for poorer outcome.

Our approach to patients on workers' compensation is to clarify with all parties that the goal of surgery is an improved quality of life for the patient, not a return to their prior job. With this in mind, we encourage vocational rehabilitation before deciding on surgery, in that a job change may lessen the patient's symptoms from their arthritis and delay the need for surgery.

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Consultation for those who live a distance away from Seattle.

Check out the new Shoulder Arthritis Book - click here.

Click here to see the new Rotator Cuff Book

Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

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Rotator cuff repair - workers' compensation

Prospective evaluation of postoperative compliance and outcomes after rotator cuff repair in patients with and without workers' compensation claims.

This study prospectively evaluated compliance and outcomes after rotator cuff repair in 42 consecutive patients with Workers' Compensation claims and 50 consecutive patients without a Workers' Compensation claim who underwent arthroscopic rotator cuff repair (transosseous equivalent suture bridge or margin convergence). There were important differences between the WC and non WC groups with respect to female gender (19% vs 38%), smoking (60% vs 24%) and age (51 vs 63 years). Tear size was similar for the two groups: 32% small, 39% medium, 25% large, and 4% massive.

Post operative rehab prescribed included sling + pendulum X 6 weeks. Compliance was documented in terms of sling wear and attendance at post operative PT appointments. Noncompliance with protocol was documented in 52% in the Work Comp group compared with 4% in the non-Work Comp group (P < .001). The Work Comp group had less improvement in preoperative to postoperative outcome scores for the Simple Shoulder Test (SST) score (3.9 to 6.0) compared with the non-Work Comp group 4.3 to 10.7.  The compliant Work Comp patients had more favorable results in final SST, 7.9  than noncompliant Work Comp patients SST.

Postoperative ultrasounds showed 84% of the non Work Comp group had intact cuffs in comparison to 75% of the compliant Work Comp and 59% of the non compliant Work Comp group.

The authors did not perform a multivariate analysis to explore the relationship between age, smoking, tear size, tendon retraction, repair method, compliance, Work Comp status, and gender with retears or the relationship between age, smoking, tear size, tendon retraction, repair method, compliance, Work Comp status, gender, and post operative cuff integrity with the functional outcome. Such analyses would be helpful in determining the most important predictors of the results of cuff repair surgery.

Some other studies of 'what matters' in cuff repair are highlighted here.

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You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty,  and rotator cuff surgery.

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Prospective evaluation of postoperative compliance and outcomes after rotator cuff repair in patients with and without workers' compensation claims. JSES

Rotator cuff failure - check out this link
Prospective evaluation of postoperative compliance and outcomes after rotator cuff repair in patients with and without workers' compensation claims. JSES

This important study drives home the lesson that important determinants of the outcome of treatment are related to the patient and not to the shoulder (again Osler: it is more important to know what patient the disease has than to know what disease the patient has).  In this study the authors found that individuals having Workman's Compensation Claims are less likely to be compliant with the postoperative protocol for shoulder immobilization and physical therapy than patients without such claims. Furthermore, at a minimum of 12 months after surgery the Simple Shoulder Test scores after treatment were higher for the non-WC group (10.7) than for the WC group (6.0). Among the WC group, compliant patients had higher SSTs (7.9) than non compliant patients (4.3). 

Ultrasound examination of the cuff one year after surgery showed that 28 of 42 patients (66%) in the Work Comp group had an intact and healed repair compared with 42 of 50 patients (84%) in the non-Work Comp group. 75% of compliant WC patients had intact cuffs in comparison to 59% of the non-compliant WC patients.


We previously asked the question, "Do shoulder patients insured by workers' compensation present with worse self-assessed function and health status?" We found that patients covered by worker's compensation had lower SST scores and lower SF 36 scores than similar non WC patients. Other studies have shown that patients with workers' compensation claims have worse outcomes after rotator cuff repair.

The study reported here suggests that, in this population, a primary determinant of the structural and functional results after cuff repair was patient compliance - a feature found more commonly in non-WC patients.

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