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Division of Workers' Compensation (DWC)

Medical Unit - Elbow problems

(Adopted May 15, 1997)

Introduction

Elbow problems are a common musculoskeletal disorder. Acute "strain" or blunt trauma may precipitate elbow problems such as medial and lateral epicondylitis, bursitis, nerve entrapment, and tendinitis.

Scope of this guideline: This guideline is intended for use in the diagnosis and management of working aged people with a primary complaint of elbow or extensor forearm pain and whose occupational activities put them at risk for elbow problems. The condition of lateral epicondylitis will be used throughout this guideline as an example.

Treatment guidelines are designed to assist providers by providing an analytical framework for the evaluation and treatment of the more common problems of injured workers. These guidelines are educational and descriptive of generally accepted parameters for the assessment and treatment of elbow problems. The guidelines are intended to assure appropriate and necessary care for injured workers diagnosed with these types of industrial conditions. Due to the many factors which must be considered when providing quality care, health providers shall not be expected to always provide care within the stated guidelines. Treatment authorization, or payment for treatment, shall not be denied based solely on a health care provider's failure to adhere to the IMC guideline. The guidelines are not intended to be the basis for the imposition of civil liability or professional sanctions. They are not intended to either replace a treating provider's clinical judgment or to establish a protocol for all injured workers with a particular condition. It is understood that some injured workers will not fit the clinical conditions contemplated by a guideline.

Symptom duration is defined as acute (one month), subacute (one to three months) and chronic ( three months).

For the purpose of this document, a provider is defined as any health care provider acting within the scope of his/her practice, including those to whom an injured worker has been referred or whose treatment has been prescribed by a treating physician. This guideline does not address the evaluation and management of chronic elbow problems including chronic pain syndrome.

All health care providers acting within the scope of their practice, including those to whom an injured worker has been referred or whose treatment has been prescribed by a treating physician, shall be allowed to bill and be reimbursed in accordance with the usual practices.

A provider may vary from these guidelines, if in his or her judgment, variance is warranted to meet the health care needs of the injured worker and that variance remains within the standards of practice generally accepted by the health care community, and the provider documents the need for the variance in the evaluation report or the medical treatment record in the manner that is generally accepted by the health care community.

Not every medical situation can be addressed in these regulations and medical standards change constantly. The documentation required of the provider is necessary to monitor and explain the use of variances.

In all cases, the provider shall document no later than six months from the date of injury, whether further treatment is warranted and whether the injured worker has significant subjective and objective evidence of the condition not having plateaued.

1.0 Initial assessments (first month)

1.1 Purpose

The purpose of the initial assessment is to establish a specific diagnosis. For the diagnosis of occupational elbow problems, a work-related etiology should be established, and relevant non-occupational home, hobby and sports activities should be ruled out as contributing or causative factors. When considering diagnoses other than those involving the elbow, the provider should refer to the appropriate treatment guideline.

1.2 Appropriate initial assessment methods

1.2.1 History and physical examination

A detailed history addressing all pertinent complaints should be obtained including the characteristics of the pain, its onset and location, radiation, provocative and relieving factors. Hand dominance should be recorded. Any antecedent symptoms, trauma, fall, or new activities should be documented.

Typical symptoms of lateral epicondylitis include pain in the lateral aspect of the elbow with pain or burning radiating to the forearm (and occasionally proximal radiation). There may be loss of grip strength due to forearm pain with hand grip. Pain is usually insidious in onset but may be provoked by an acute trauma or strain. Initial complaints may be vague, such as a dull forearm ache. Any history of similar symptoms in the past, including diagnosis and treatment strategies should be recorded.

Documentation of probable work-relatedness should be made, including the injured worker's job title and occupational tasks. Specific attention should be directed towards confirming occupational risk factors such as repetitive, sustained or forceful wrist dorsiflexion, power grip, exposure to vibration, repetitive extended elbow reach with forceful pulling, and repetitive pronation and supination of the forearm against resistance. Record any recent changes in work duties, overtime, and work station or process design. Document any relationship of the symptoms to the work day, work week, particular task, and the use of any specific tools and equipment. A history of lost work days due to these symptoms, and other work-related musculoskeletal diagnoses should be recorded. Any functional impairment or current activity or work modifications should be noted.

Rule out nonoccupational activities that could be causing or aggravating the condition, such as activities that require gripping or hyperextending the wrist.

Olecranon bursitis may be secondary to systemic illness.

Past medical history and current health status should be documented. Routine screening questions for cervical or shoulder pain or injury should be asked.

A physical examination should be performed with documentation of the following findings:

Inspection for: deformity, swelling or erythema.

Provocative maneuvers-Such as the presence or absence of pain with resisted dorsiflexion of the wrist, passive wrist flexion with the elbow in full extension, resisted supination of the forearm, and Tinel's sign.

Range of motion: elbow flexion and extension, pronation and supination, wrist flexion and extension. Note any flexion contracture deformity of the elbow.

Palpation-Document the presence or absence of the following: elbow deformity, tenderness, heat or crepitus (including olecranon process and medial epicondyle). Also check the forearm for deformity, heat or tenderness.

Muscle strength testing of the entire upper extremity should be performed as relevant.

Appropriate distal extremity exam should include neurological testing. A routine examination of the shoulder, neck, and wrist, and hand (palpation, range of motion, strength testing) should be performed.

A differential diagnosis should be considered at this point-such as radiculopathy, or shoulder pathology with referred pain.

1.2.2 Diagnostic imaging (M=4) [ 4]

Radiographic studies of the elbow and forearm should be obtained when clinically indicated.

As a rule, the diagnosis of elbow problems does not require an imaging study.

1.2.3 Laboratory studies

Appropriate laboratory studies should be considered if there is evidence of an infectious or diffuse inflammatory process as a contributing or causative factor. (M=4) [ 4]

1.2.4 Electromyography/Nerve conduction studies (EMG/NCS)

Nerve conduction studies may be indicated for elbow problems associated with neurological deficits. (M=4) [ 4]

1.2.5 Aspiration of the olecranon bursa is not routinely indicated unless there is suspicion of infection or metabolic disease.

1.3 Inappropriate initial assessment methods

1.3.1 Routine diagnostic imaging (M=2) (C=1) [ 1]

1.3.2 Routine laboratory studies (M=2) (C=1) [ 1]

1.3.3 Routine nerve conduction studies (M=2) (C=1) [ 1]

1.3.4 Arthroscopy, arthrogram (M=1) [ 1]]

1.3.5 Ultrasound (M=1) [ 1]

1.3.6 MRI scan (M=1) [ 1]

2.0 Initial treatment

2.1 Purpose

The purpose of the initial treatment is to reduce, symptoms, optimize healing/function and increase work with appropriate modifications to minimize the risk factors that contributed to the injury.

2.2 Appropriate initial treatments

2.2.1 Education (M=4) [ 4]

All injured workers should receive instruction concerning the nature of their condition, its risk factors, preventive measures and goals of initial therapy.

This information should be provided by the physician or by a physical or occupational therapist as part of a referral for treatment (see physical treatments and passive modalities section). The injured worker should be instructed on how to eliminate or modify any aggravating nonoccupational activities and sports during treatment.

2.2.2 Ergonomic modification (M=4) [ 4]

Work restrictions or modifications which reduce the injured worker's exposure to the etiologic or aggravating activity are of central importance.

Examples of such restrictions include preclusion from or reduction in time performing tasks requiring repetitive, sustained or repetitive forceful wrist or hand activities, repetitive elbow motion, prolonged elbow positioning or prolonged exposure to vibration. Be specific about work preclusions and avoid terms such as "light duty". The physician should discuss with the employer appropriate tasks for the injured worker to perform while undergoing treatment, and to discuss task modification once the injured worker resumes full and unrestricted employment, in order to reduce the chance of recurrence. Initial treatment of elbow problems need not involve lost work time. A job evaluation by an experienced specialist trained in ergonomics may be considered in order to identify appropriate modifications to the tasks, tools, or workstation.

2.2.3 Medications

a. Nonsteroidal antiinflammatory agents can be used. (M=3) (C=4) [ 3]

The choice of specific drug is discretionary. The injured worker should be screened for contraindications to their use and warned of the common potential side-effects.

b. Acetaminophen is an analgesic which may be used as an adjunct or alternative to NSAIDs. (M=3) (C=4) [ 3]

c. Opioids may be necessary if the pain is refractory to treatment with non-opioid analgesics. (M=3) (C=4) [ 3]

2.2.4 Physical treatments and passive modalities

If there is no improvement after two weeks the treatment should be modified.

a. Use of thermal modalities in conjunction with physical treatment may be useful.

b. Physical treatments for pain management splinting and/or functional retraining and instruction in a graded exercise program. (M=4) [ 4 ]

Appropriate exercises may include, but are not limited to: 1) gentle muscle stretching 2) flexibility and 3) graduated strengthening. Care should be taken while incrementing exercises so that the condition is not aggravated.

c. Appropriate manual therapies may include manipulation, or joint or soft tissue mobilization, supplemented by physical modalities and exercise.[3]

d. Acupuncture

Use of acupuncture in the first four weeks of treatment as a part of an overall treatment plan. (C=3) [ 2 ]

2.2.5 Protective devices

The use of an elbow and/or wrist support for immobilization may be indicated for a brief period(M=4)[4]

The use of a splint at work must be carefully considered as it may put the injured worker at risk for further musculoskeletal injury by forcing the adoption of awkward compensatory postures. A forearm strap can be aggravating in the acute stage so its use should be individualized. It is contraindicated in the presence of nerve compression symptoms. Night splinting may be indicated for nerve entrapment syndromes.

2.2.6 Local corticosteroid injection

Local corticosteroid injections of the myofascial areas or bursae may be appropriate, especially if the pain is moderate to severe. (M=4) [ 4]

Before the injection, it is important to be aware that the olecranon bursa may be the site of infection. In such an instance, an steroid injection would be contraindicated.

2.3 Inappropriate initial treatments

1. Medications-Systemic corticosteroids and/or muscle relaxant (M=1)[1]

2. Exclusive use of passive modalities (M=1) (C= 1) [ 1]

3. Surgery is rarely indicated (M=1) [ 1]

2.4 Case management

Management during the first four weeks of treatment will be determined by the clinician's evaluation of the injured worker's response to therapy. Generally, re-evaluation of the problem, determination of treatment effectiveness and work status should be performed every one to two weeks until return to modified or full work is achieved. At each visit, the initial diagnosis should be confirmed or modified and the treatment plan adjusted if necessary. If symptoms continue to increase despite adequate conservative therapy, or if there is significant disability due to pain, referral to a provider trained and experienced in the evaluation and treatment of occupational disorders is warranted in the initial treatment phase. Once the acute pain is controlled, the treatment should focus on progressive rehabilitative exercises to increase strength and endurance, and activity modification. This approach minimizes the chance of recurrence once normal occupational duties are resumed.

3.0 Secondary assessment

3.1 Purpose

Most workers with elbow injuries will respond to initial treatment with reduction of pain and near or full return to occupational duties. The purpose of secondary assessment after conservative treatment is to determine the cause of delayed recovery. This may be due to misdiagnosis, noncompliance with the treatment regimen, inappropriate work modifications or other perpetuating factors. A reconsideration of the initial diagnosis is necessary at this stage and a differential diagnosis should be reviewed: cervical radiculopathy, shoulder pathology with referred pain and nerve entrapment. Work status and disability should be determined.

3.2. Appropriate secondary assessment methods

3.2.1 History and physical examination

An interval history and physical examination should be performed. Particular attention should be paid to compliance with and response to therapy. The development of any new symptoms should be documented as well as side effects of treatment modalities. The appropriateness of the prescribed work restrictions should be reviewed, including how they were accommodated by the employer.

3.2.2 Diagnostic imaging

Radiographic studies of the elbow and forearm may be considered if, on re-evaluation, the physician suspects morphologic pathology. (M=4) [ 4]

The use of MRI and arthrography is rarely indicated except for the evaluation of intraarticular pathology.

3.2.3 Laboratory studies

Laboratory studies may be performed if there is evidence of an infectious or diffuse inflammatory process as a contributing pathology. (M=4) [ 4]

3.2.4 EMG/NCS

Electrodiagnostic studies should be considered if there is clinical evidence of nerve entrapment or cervical radiculopathy as alternative diagnoses. (M=4) [ 4]

3.3 Inappropriate secondary assessment methods

3.3.1 Arthroscopy or arthrogram (M=1) [ 1]

3.3.2 Ultrasound (M=1) [ 1]

4.0 Secondary treatment

4.1 Purpose

Secondary treatment options should be selected on the basis of the injured worker's response to initial conservative treatment for four weeks. If specific causes of delayed recovery are determined, they may be addressed in this phase. The purpose of secondary treatment is to reduce symptoms and optimize the return to normal arm function and a graded resumption of full and unrestricted employment.

4.2 Appropriate secondary treatments

4.2.1 Continued conservative management

a. Occupational activities should be advanced and modifications to the work environment reviewed to prevent exacerbation of symptoms. (M=4) [ 4]

An ergonomic assessment of the workstation may be necessary to facilitate this.

b. The injured worker's progress in the progressive exercise program should be reviewed. (M=4) [ 4]

c. Medication

NSAID's or acetaminophen may be used periodically.

Non steroidal anti-inflammatory agents should be discontinued as soon as possible. (M=4) [ 4]

A trial of 6-8 weeks maximum is recommended. They may be re-instituted briefly for symptom flare. Periodic acetaminophen may be used also.

Opioids may be necessary if the pain is refractory to treatment with non-opioid analgesics. (M=3)(C=4)[3]

Use of thermal modalities in conjunction with physical treatment may be useful.

d. Bracing or supports may be continued if beneficial. (M=4) [ 4]

It may be uncomfortable and exacerbate symptoms, especially if worn inappropriately (i.e. overlying the trigger point).

e. Various manual and/or passive modalities may be used but not standing alone as a sole treatment. [ 3 ]

f. Acupuncture (M=3) (C=3) [ 3]

g. Biofeedback [ 3 ]

4.2.2 Local injection including corticosteroids during the secondary phase may be indicated.

If there is partial or transient relief with the first injection, local injections may be repeated (up to a total of three). (M=3) (C=4) [ 3 ]

Complications of injection include local infection, hematoma, skin discoloration and subcutaneous fat atrophy. Injection must be accompanied by the activity and workplace modifications discussed above.

4.2.3 Surgical referral

Surgical consultation is recommended if any of the following criteria are met: (C=4) [ 4 ]

a. Failure of conservative treatment and indication of a surgically correctable condition

4.3 Inappropriate secondary treatments

4.3.1 Medications

Systemic corticosteroidsand/or delivery of medications by ionto or phonophoresis . (C=1) [ 1]

4.4 Case management

If the injured worker has not resumed near normal work duties after eight weeks of full conservative therapy including adherence to a graded exercise program, a referral to a physician trained and experienced in the evaluation and treatment of occupational disorders or an orthopedic or hand surgeon is recommended. Consultation should include a complete evaluation and recommendations for treatment and return to appropriate work. If psychosocial issues are judged to contribute to the disability, it may be appropriate to have a psychologic evaluation. If the condition becomes chronic or disabling despite full conservative treatment including appropriate medical, rehabilitative, and ergonomic interventions (and surgery if indicated), the injured worker should be evaluated for permanent disability.

5.0 Primary references

1. American Academy of Orthopedic Surgeons: Clinical policies - lateral epicondylitis of the elbow. AAOS 1-3,1992.

2. Day, DE: Preventive and return to work aspects of cumulative trauma disorders in the workplace. Sem in Occ Med 2(1):57-63,1987.

3. Dijs J, Mortier G, Driessens M, DeRidder A, Willems J, De Vroey T: A retrospective study of the conservative treatment of tennis elbow. Medica Physica 13:73-77,1990.

4. Fillion PL: Treatment of lateral epicondylitis. Am J Occ Ther 45:340-343,1991.

5. Kasdan ML: Occupational hand and upper extremity injuries and diseases. Hanley and Belfus Inc., 1991.

6. Kurppa K, Pekka W, Rokkanen P: Tennis elbow; lateral elbow pain syndrome. Scand J Work Environ Health 5(suppl3):15-18,1979.

7. Nirschl RP: Elbow tendinosis/tennis elbow. Clin Sports Med 11(4):851-870,1992.

8. Rempel DM, Harrison RJ, Barnhart S: Work-related cumulative trauma disorders of the upper extremity. JAMA 267(6):838-842,1992.

9. Thorson EP, Szabo RM: Tendonitis of the wrist and elbow. Occ Med State of the Art Rev 4(3):419-431,1989.

10. Wadsworth CT, Nielsen DH, Burns LT, Krull JD, Thompson CG: Effect of the counterforce armband on wrist extension and grip strength and pain in subjects with tennis elbow. JOSPT 11(5):192-197, 1989.

Appendix 6.0

Description of IMC appropriateness levels

Level 4

Level 3

Level 2

Level 1

Good research based evidence


Yes


No


No


No


Clinical evidence


Yes


Yes


Some


No

Consensus of the health care community


Yes


Yes


Partial

No

Clinical utility of appropriateness level for common elbow problems

Appropriate and recommended

Acceptable or appropriate in most cases

Appropriate in uncommon individual cases. Document the case-specific clinical factors or circumstances which make this procedure reasonable and necessary for this injured worker.

Inappropriate

IMC/Elbow/Final (5/15/97)