Abstract
Background/objectives
Patients suffering from Worker’s Compensation (WC) injuries typically demonstrate poorer outcomes despite optimal surgical management. In the occupational setting, shoulder pathology is the most implicated musculoskeletal disease. We recently described the Human Disharmony Loop (HDL), a clinical model of chronic, historically intractable pain of the neck, upper back, shoulder, and arm (Sharma and Friedman in Clin Med 14(5):1769, 2025. 10.3390/jcm14051769; Sharma et al. in J Clin Med 14(16):5650, 2025. 10.3390/jcm14165650; Friedman et al. in PLoS ONE 20(10):e0326815, 2025). Specifically, the asymmetric lower trunk innervation to the pectoralis minor (PM) can deform the scapula’s numerous connections and derange the full anatomy of the upper limb girdle, often after trauma. The purpose of this study was to retrospectively review our cohort of Workers’ Compensation patients (WCP) who met HDL diagnostic criteria and underwent treatment consisting of pectoralis minor release with infraclavicular neurolysis (PM + ICN). We hypothesize that WCP evaluated and treated for the HDL would show decreased pain, increased shoulder function, and a high rate of return to work.
Methods
This is a retrospective study of consecutive WCP meeting HDL criteria treated via PM + ICN. 6-month follow-up minimum was required. Outcomes included self-reported pain and headaches, shoulder range of motion, presence of neuropathy on exam, and return to work (RTW).
Results
36 patients were included. Average age was 48, sex was 61% male. Median follow-up was 10 months. Median preoperative pain was 8/10, headache prevalence was 69%, shoulder abduction was 90 degrees. Following treatment, median postoperative pain was 3/10, headache prevalence was 14%, and shoulder abduction was 180 degrees. 86% of patients returned to work. 25% required secondary neurolysis of the axillary, radial, cubital, and/or median nerves for persistent neuropathy.
Conclusions
In WCP who meet HDL criteria, PM + ICN provides significant clinical improvement in terms of dramatic reductions in pain and high rates of RTW. WCP with refractory pain preventing RTW should be evaluated and treated for the HDL.
Keywords: Shoulder, Workers, Compensation, Neuropathy, Pectoralis, Minor, Scapular, Dyskinesia, Headache
Introduction
Workers’ Compensation patients (WCP) constitute a notoriously challenging population to successfully treat for shoulder and upper extremity injury [1]. The shoulder is the most common anatomic region implicated in musculoskeletal disease secondary to occupational injury [2]. A recent review by Feeley et al. highlights the occupational risk factors, namely repetitive overhead motion, heavy lifting, and the use of vibrating tools, that may contribute to shoulder injury in the Workers’ Compensation population [3]. WCP presentation of upper extremity pathology is often complex with involvement of multiple anatomic regions and additional symptoms including motor and sensory neuropathy of the affected extremity [4]. Patients commonly present with vague and overlapping diagnoses including occupational shoulder disorder (OSD), work-related musculoskeletal disorder (WRMD), scapular dyskinesia, fibromyalgia, thoracic outlet syndrome (TOS), subacromial pain syndrome (SAPS), or complex regional pain syndrome (CRPS) [4]. Furthermore, multiple studies have shown that WCP achieve far inferior outcomes compared to non-WCP following shoulder surgery [5–7]. These inferior outcomes are associated with a longer return-to-work time when compared to non-WCP [8–11]. Patients often fail to recover despite best attempts at conservative and surgical management, leading to substantial economic and social burden with time lost from work [12].
We recently described the Human Disharmony Loop (HDL), a clinical model of chronic pain of the upper extremity that spans the neck, upper back, shoulder, arm, and hand [4, 13, 14]. The HDL centers on the Pectoralis Minor (PM), the sole ventral stabilizer in scapulothoracic glide, which uniquely carries lower trunk C8-T1 innervation (Fig. 1). While PM release has been previously described for patients with shoulder pain [15–19], in these investigations PM tightness is thought to develop secondarily after another unexplained and often-vague cause—“the cause of PM tightness is not fully understood.” [18] In contrast, the HDL articulates a singular cause for PM tightness—its asymmetric neurologic innervation—along with clear anatomic pathways that explain development of neck, upper back, shoulder, arm, and hand dysfunction [13]. As such, the HDL can account for all chronic pain manifestations exhibited in these patients, including headaches and neck stiffness, upper back tightness, shoulder weakness, and neuropathy, and can better identify patients who will benefit from treatment [13]. Crucially, diagnosis for the HDL is derived entirely from history and physical exam. Specifically, patients must exhibit two anatomic criteria of medial coracoid tenderness and scapular dyskinesis or protraction and at least one symptomatic criterion (Fig. 2). Treatment consists of “breaking the loop” via PM tenotomy with infraclavicular brachial plexus neurolysis (PM + ICN). We recently published a large series demonstrating substantial clinical improvements in pain and function for HDL patients who often had normal or unremarkable MRI or EMG findings [13], but this cohort overwhelmingly included non-WCP [14]. Therefore, the goal of this paper is to analyze diagnosis and treatment for the HDL exclusively in Workers’ Compensation patients. We hypothesize that historically challenging WCP who have failed prior treatments and met HDL criteria would exhibit a significant decrease in pain and a high rate of return to work (RTW).
Fig. 1.
The human disharmony loop centers on a positive feedback loop due to the unique lower trunk innervation to the Pectoralis Minor. Patient can enter the loop via factors (depicted in green) through each of the three central elements. The elements then produce anatomic change which lead to four groups of widespread terminal symptom (depicted in red)
Fig. 2.
Patient must meet all three criteria to be considered within the HDL. Patients present with diffuse and seemingly-unconnected pain that ranges from the head along the entire upper extremity
Methods
We performed a retrospective consecutive case series of WCP who met HDL criteria and underwent PM + ICN at two separate institutions. Patients were evaluated by a fellowship-trained board-certified sports or hand surgeon, both of whom were a part of the patients’ clinical care team and performed the surgical procedure. The specific surgical technique utilized was consistent across all enrolled patients. Pectoralis minor release was performed using an open approach. The patient was placed supine. A horizontal 2-inch incision was made distal to the coracoid extending medially. Skin and subcutaneous tissue was incised to expose the deltopectoral interval. The cephalic vein was identified and protected as the deltopectoral interval was bluntly separated. The underlying coracoid was identified and overlying fascia excised. The pectoralis minor and conjoined tendon were identified. The edges of the pectoralis minor were identified and bluntly separated from the underlying fat pad. The pectoralis minor was then transected and allowed to retract. The underlying fat pad was then bluntly dissected to expose the lateral cord of the brachial plexus. Tissue was then cleared from the nerve both medially and laterally.
Symptomatic patients found to have rotator cuff tears greater than 5 mm underwent primary surgical repair prior to consideration for PM + ICN. All patients completed at least 6 weeks of physical therapy focused on posterior chain strengthening and anterior chain stretching prior to consideration for surgical management. Inclusion criteria included: age > 18 years, meeting diagnostic criteria for the HDL, and receiving care under Workers’ Compensation claims. Exclusion criteria included: follow up < 6-months. Patients were evaluated preoperatively and at post-operative weeks 2, 6, 12, and 24 at minimum. At each visit, patients completed a self-reported pain questionnaire, and the following were assessed: scapular dyskinesis, symptoms and signs of cuff impingement, range of motion (ROM) in shoulder abduction plane, and presence of neuropathic lesions. Other patient variables collected included age, sex, BMI, HDL risk factors, prior surgery, and occupation. Scapular dyskinesis was categorized as follows: I or none (no protraction), II or dynamic (protraction with overhead reach only), III or static reversible (protraction at rest but manually reversible via the examiner), IV or static irreversible (protraction at rest not manually reversible via the examiner). Rotator cuff impingement was defined as having a painful arc-test and a positive Hawkins test. Neuropathic lesions were considered positive via the presence of a positive scratch collapse test [13, 20]. Patients were offered a pre-operative medial coracoid block and a positive response was considered as a self-reported decrease in pain or increase in motion. However, a negative response to injection did not affect ultimate decision for surgery based on our previous findings [14]. Need for secondary neurolysis was assessed at 3-month follow-up. Institutional Review Board (IRB) exemption was obtained for this study by the St. Joseph’s Medical Center Research and Quality (RAQ) Committee. The need for consent was waived as data was anonymous and posed minimal risk to patients as a retrospective chart review. Statistical analysis was performed using STATA v14.0. Student’s t-test and Chi-squared analyses compared continuous and categorical variables of interest, respectively, with p < 0.05 indicating statistical significance in all tests.
Results
N = 36 patients were included. Median age was 48. Sex was 61% male and 39% female. Median BMI was 29. Inciting factors into the HDL were: 3% macromastia, 14% cervical spine disease, 47% history of trauma, 11% bodybuilder, 3% iatrogenic upper trunk regional anesthetic injury, 11% manual labor. 53% of patients underwent prior surgery: 4 distal neurolysis including carpal, radial or cubital tunnel release, 3 cervical fusions, and 14 shoulder surgeries. 11 of the shoulder surgeries included rotator cuff repair (Table 1).
Table 1.
Patient characteristics
| Variable | N = 36 |
|---|---|
| Agea | 48 [38–581] |
| Sex | Male 61% |
| Female 39% | |
| BMIa | 29 [21–31] |
| Inciting factorsb | Macromastia 3% |
| Cervical spine disease 14% | |
| History of trauma 47% | |
| Body builder 11% | |
| iatrogenic upper trunk regional anesthetic injury 3% | |
| Manual labor 11% | |
| Prior surgery | Distal neurolysis 11% |
| Cervical fusion 8% | |
| Rotator cuff repair 31% | |
| Occupation | Police officer 6 |
| Construction 9 | |
| Machine operator 3 | |
| Truck driver 1 | |
| Mechanic 1 | |
| Caretaker 1 | |
| Office work 3 | |
| Retail 3 | |
| Cook 2 | |
| Real estate 2 | |
| Healthcare 3 | |
| Software development 2 | |
| Follow-up duration (months)a | 1 [6–13] |
aMedian [Interquartile Range]
bRisk factors for entering the Human Disharmony Loop (see Fig. 1)
At presentation, median pre-operative pain was 8/10. Scapular dyskinesia on exam was categorized as 3% stage II, 39% stage III, 58% stage IV. On exam, 95% of patients exhibited impingement, and median shoulder abduction ROM was 90 degrees. 69% endorsed occipital headaches. Prevalence of concomitant neuropathic lesions was 63% thoracic outlet, 56% suprascapular notch, 89% quadrilateral space, 74% radial tunnel, 44% cubital tunnel, and 59% carpal tunnel. Of 28 patients who underwent a pre-operative PM injection, 96% reported a positive response. Median follow-up was 10 months. At most recent follow-up, median pain was 3/10. Post-operative scapular dyskinesis redistributed to 100% stage I. Only 19% of patients exhibited continued impingement, and median shoulder abduction ROM increased to 180 degrees. Only 14% of patients endorsed occipital headaches. Prevalence of positive neuropathic lesions decreased to 3% thoracic outlet, 0% suprascapular notch, 19% quadrilateral space, 19% radial tunnel, 25% cubital tunnel, 28% carpal tunnel. All differences were statistically significant (p < 0.01). 25% underwent secondary neurolysis for residual symptoms at the following locations: 6% quadrilateral space, 17% radial tunnel, 14% cubital tunnel, 8% carpal tunnel (Table 2). 86% of patients had returned to work by 6 months. Of the patients who had undergone previous rotator cuff repair, 81% had returned to work by 6 months. One patient (3%) had a postoperative seroma which resolved spontaneously.
Table 2.
Outcomes following HDL treatment
| Outcome | Pre-operative | Post-operative | P-Value |
|---|---|---|---|
| Paina | 8.0 [6.5–9.5] | 3.0 [1.4–4.4] | < 0.01 |
| Headaches | 69% | 14% | < 0.01 |
| Shoulder abduction ROMa,b | 90 [90–120] | 180 [180–180] | < 0.01 |
| Scapular dyskinesia stage | Stage I 0% | Stage I 100% | < 0.01 |
| Stage II 3% | Stage II 0% | ||
| Stage III 39% | Stage III 0% | ||
| Stage IV 58% | Stage IV 0% | ||
| Concomitant neuropathyc | Scalene 63% | Scalene 3% | < 0.01 |
| Suprascapular 56% | Suprascapular 0% | ||
| Quadrilateral 89% | Quadrilateral 19% | ||
| Radial 74% | Radial 19% | ||
| Cubital44% | Cubital 25% | ||
| Carpal 59% | Carpal28% | ||
| Need for secondary neurolysis | N/A | Overall 25% | N/A |
| Quadrilateral space 6% | |||
| Radial tunnel 17% | |||
| Cubital tunnel 14% | |||
| Carpal tunnel 8% | |||
| Return to workd | N/A | Yes 86% | N/A |
| No 14% |
aMedian [Interquartile Range]
bRange of motion, from Oto 180 degrees, in the abduction plane
cNeuropathic lesions identified on clinical exam via the scratch-collapse test
dMedian follow-up 10 months
Discussion
This study supports our hypothesis that WCP meeting HDL criteria experience drastic symptom relief and high rates of RTW following PM + ICN. Following surgery, WCP showed substantial decreases in pain, headaches, concomitant neuropathy, and cuff impingement. WCP also demonstrated increased shoulder ROM and a high RTW of 86% by 6 months (Fig. 3).
Fig. 3.
Outcomes following treatment for HDL via PM+IC in WC patient. Note the high rate of return to work (86%)
Our criteria for PM + ICN derive from the HDL model of upper extremity pain. The HDL describes a self-reinforcing positive feedback loop focused on the unique C8-T1 innervation of the PM. Tightening of the PM results in scapular lateral translation, anterior tilt, and internal rotation, collectively known as protraction. This leads to stretching of the upper trunk of the brachial plexus causing a weakening of the PM antagonists and therefore further unopposed tightening of the PM (Fig. 3). The resulting scapular dyskinesis produces multiple seemingly-unrelated symptoms including occipital headaches, peri-scapular myofascial tightness, rotator cuff impingement and loss of shoulder ROM, proximal upper girdle neuropathy at the scalenes, suprascapular notch and quadrilateral space, and exacerbation of distal neuropathy at the radial, cubital, and carpal tunnels likely from double-crush [21]. We have identified multiple avenues for patients to enter the HDL including deskwork, overhead labor, and trauma, all of which are common among WCP [3]. The release of the PM, followed by physical therapy, allows the scapula to return to normal kinesthesia and reharmonizes the upper limb girdle anatomy therefore relieving patients of their diverse and widespread symptoms. Crucially, the HDL is diagnosed purely on history and physical examination alone (Fig. 2). Objective testing such as MRIs and EMGs may be normal, unremarkable, or only show secondary sequelae such as cuff tendinopathy or distal carpal tunnel [4]. Ultimately, PM tightness disturbing scapular mechanics requires a sound physical exam.
Prior literature on RTW status for patients with shoulder injuries receiving Workers’ Compensation benefits has focused largely on surgical management of rotator cuff injuries. One meta-analysis demonstrated a 50.9% rate of return to work after rotator cuff repair [22]. Another analysis showed manual laborers after rotator cuff repair returned to work at 53.8% in their dominant arm versus 90% in their non-dominant arm [23]. Notably, in our study WCP exhibited a RTW rate of 86%, a significant improvement over other shoulder procedures. For instance, one study exhibited a 56% RTW rate after revision rotator cuff repair [24]. Whereas, in this study, 81% of patients who had persistent symptoms after rotator cuff repair were able to return to work following PM + ICN. This reinforces the key tenet that many patients with refractory upper limb girdle pain may have a surgically treatable anatomic cause that is diagnosed by history and physical alone, consistent with longstanding fundamentals of medicine [25].
WCP have historically reported inferior surgical outcomes to non-WCP for shoulder injuries. One systematic review assessed 28 studies of patients undergoing acromioplasty, arthroplasty, rotator cuff repair, and other shoulder surgeries [26]. Across all interventions, WCP had an OR of 4.72 versus non-WCP for inferior surgical outcomes. However, in this study, WCP outcomes were notably similar to our previous study of 115 HDL patients which included a majority of non-WCP [14]. Both non-WCP and WCP exhibited significant decreases in pain and headaches, resolution of scapular dyskinesia, restoration of shoulder ROM, and large decreases in proximal neuropathy with smaller decreases in distal neuropathy. Furthermore, both non-WCP and WCP HDL patients required a similar rate of secondary neurolysis for full relief. However, WCP show a slightly higher response to preoperative medial coracoid injection (96% vs. 89%) and higher rate of persistent axillary neuropathy following PM + ICN (19% vs. 5%). Practitioners should be aware of both similarities and differences when treating WCP and non-WCP HDL patients.
This study has several limitations. First, our sample size was limited at 36 patients, limiting generalizability. Second, median follow-up was 10 months, though we intend to track these patients longitudinally. Third, the scratch collapse test, while useful clinically, is not universally accepted as formal criterion to diagnose neuropathic compression, although no gold standard yet exists [27]. Future studies should include larger sample sizes with longer follow-up and comparative designs.
Nonetheless, this paper provides evidence that Workers’ Compensation patients meeting HDL criteria, including many who have failed all prior treatments and do not show findings on objective testing that can explain their suffering, achieve high rates of RTW following PM + ICN. Furthermore, WCP exhibited similar outcomes to non-WCP HDL patients. WCP with refractory pain preventing RTW should be screened for the HDL. For those who meet criteria, PM + ICN can be considered first line treatment or as a secondary procedure for WCP who do not respond to standard surgical interventions. Patients should be counseled that secondary neurolysis may be needed following initial PM + ICN.
Conclusion
Evaluation and treatment with PM + ICN for the HDL in WCP produces high rates of return to work when compared to historical norms. Evaluation and treatment for the HDL should be considered in WCP with refractory pain preventing RTW despite optimal surgical repair and normal or unremarkable testing.
Acknowledgements
Not applicable.
Abbreviations
- WC
Worker’s compensation
- HDL
Human disharmony loop
- PM
Pectoralis minor
- WCP
Worker’s compensation patients
- PM + ICN
Pectoralis minor release with infraclavicular neurolysis
- ICN
Infraclavicular neurolysis
- RTW
Return to work
- OSD
Occupational shoulder disorder
- WRMD
Work-related musculoskeletal disorder
- TOS
Thoracic outlet syndrome
- SAPS
Subacromial pain syndrome
- CRPS
Complex regional pain syndrome
- IRB
Institutional review board
- RAQ
Research and quality
Author contributions
All authors contributed to the investigation, data collection, writing, and/or review of this manuscript. KC performed review of the current literature and was a major contributor in preparing the manuscript. KS performed the described procedures, data collection, statistical analysis, and prepared the attached figures. JI contributed to the conceptualization, methodology, and preparation of the manuscript. JF performed the described procedures, data collection, and was a major contributor to the preparation of the manuscript and supervision of the study. All authors read and approved the final manuscript.
Funding
Not applicable.
Data availability
The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request from the editorial board.
Declarations
Ethics approval and consent to participate
Institutional Review Board (IRB) exemption was obtained for this study by the St. Joseph’s Medical Center Research and Quality (RAQ) Committee. The need for consent was waived as data was anonymous and posed minimal risk to patients as a retrospective chart review. The ethical principles for medical research involving human participants defined in the Declaration of Helsinki were reviewed and adhered to throughout this study.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request from the editorial board.