Overview

This report is a systematic evaluation of the

evidence pertaining to a broad range of issues

related to the diagnosis and treatment of

worker-related upper extremity disorders

(WRUEDs). For the purposes of this report,

“worker-related” is defined as a disorder that

affects workers, not as a disorder necessarily

caused by work. Four disorders are the focus of

this report; carpal tunnel syndrome, cubital

tunnel syndrome, epicondylitis, and de

Quervain’s disease.

The first two disorders are the result of nerve

entrapment. Carpal tunnel syndrome is the

result of increased pressure on the median nerve

in the carpal tunnel of the wrist, resulting in

sensory and motor disturbances in the parts of

the hand innervated by this nerve. Cubital

tunnel syndrome results from increased pressure

on the ulnar nerve in the cubital tunnel of the

elbow, resulting in sensory and motor

disturbances in the parts of the forearm and

hand innervated by this nerve. The second two

disorders are the result of stress to the tendons of

the elbow and wrist, respectively. All four

disorders can lead to pain, loss of function, and

long-term disability.

The overall prevalence of carpal tunnel

syndrome in the United States may be as high as

1.9 million people, and each year there are

300,000–500,000 operations for the condition.

Epicondylitis has been reported to affect 4.23

individuals per 1,000 adults per year in the U.S.

The prevalence of cubital tunnel syndrome and

de Quervain’s disease has not been established.

In this evidence report, the Evidence-based

Practice Center (EPC) assessed the published

literature describing the effects of these

disorders, before and after treatment, on

patients, particularly workers. They did this by

examining the literature pertaining to 13 key

questions.

Reporting the Evidence

This report addresses 13 questions regarding

worker-related disorders of the upper extremity.

Eleven of these are condition-specific.

Therefore, the EPC individually addressed them

for each of the four above-mentioned disorders.

Two questions are not condition-specific.

Therefore, the EPC addressed them only once.

The 11 condition-specific Key Questions

addressed in this evidence report are:

Question 1: What are the most effective

methods and approaches for the early

identification and diagnosis of worker-related

musculoskeletal disorders of the upper

extremity? 

Question 2: What are the specific

indications for surgery for worker-related

musculoskeletal disorders of the upper

extremity? 

Question 3: What are the relative benefits

and harms of various surgical and nonsurgical

interventions for persons with worker-related

musculoskeletal disorders of the upper

extremity?

Evidence Report/Technology Assessment

Number 62

Diagnosis and Treatment of Worker-Related

Musculoskeletal Disorders of the Upper Extremity

Summary

Agency for Healthcare Research and Quality

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES • Public Health Service
Question 4: Is there a relationship between specific clinical

findings and specific treatment outcomes among patients with

worker-related musculoskeletal disorders of the upper

extremity? 

Question 5: Is there a relationship between duration of

symptoms and specific treatment outcomes among patients

with worker-related musculoskeletal disorders of the upper

extremity?

Question 6: Is there a relationship between factors such as

patients’ age, gender, socioeconomic status and/or racial or

ethnic grouping and specific treatment outcomes among

patients with worker-related musculoskeletal disorders of the

upper extremity? 

Question 7: What are the surgical and nonsurgical costs or

charges for treatment of worker-related musculoskeletal

disorders of the upper extremity? 

Question 8: For persons who have had surgery for workerrelated musculoskeletal disorders of the upper extremity, what

are the most effective methods for preventing the recurrence of

symptoms, and how does this vary depending on subject

characteristics or other underlying health problems?

Question 9: What instruments, if any, can accurately assess

functional limitations in an individual with a worker-related

disorder of the upper extremity?

Question 10: What are the functional limitations for an

individual with a worker-related musculoskeletal disorder of

the upper extremity before treatment?

Question 11: What are the functional limitations of an

individual with a worker-related musculoskeletal disorder of

the upper extremity after treatment? 

The two Key Questions that are not condition-specific are:

Question 12: What are the cumulative effects on

functional abilities among individuals with more than one

worker-related musculoskeletal disorder of the upper extremity

in the same limb?

Question 13: What level of function can patients achieve

in what period of time when they are required to change hand

dominance as a result of injury to their dominant hand? 

Methodology

A panel of nine Technical Experts was employed to assist in

defining the scope of this evidence report, developing its

questions, and developing the criteria for retrieving and

including articles.

To identify information for this evidence report, the EPC

searched 31 electronic databases, the World Wide Web, and

four U.S. Government databases. In addition to these

searches, researchers also reviewed the bibliographies and

reference lists of all studies included in this evidence report,

searched Current Contents®/Clinical Medicine on a weekly

basis, and routinely reviewed over 1,600 journals and

supplements maintained in ECRI’s collections.

To be included in this evidence report, an article had to

meet a set of a priori retrieval criteria and a set of a priori

question-specific inclusion criteria. The EPC designed broad

retrieval criteria to ensure comprehensive retrieval. They

retrieved an article whenever there was uncertainty about

whether it met the retrieval criteria. They also retrieved

articles when an abstract was not present in the search results,

but when the title of the article suggested that it was relevant.

The criteria for article retrieval are briefly summarized below:

• The patients had to have been diagnosed with a workerrelated disorder of the upper extremity.

• All controlled trials, regardless of whether they were

described as randomized or prospective, were retrieved,

regardless of year of publication.

• Case series and other reports were evaluated only if

published in 1980 or later and included 10 or more

patients.

• Only English-language articles were retrieved.

Once an article was retrieved, it was examined to determine

whether it met the question-specific criteria. The major

criteria are briefly summarized below; additional questionspecific inclusion criteria, which are not listed here, were also

applied:

• The study could not have a serious design flaw that

precluded interpretation of the results.

• The study must have addressed one of the key questions

and have included patients with one of the WRUEDs of

interest.

• For studies addressing Key Question 3, the study must

have been a controlled trial.

• The study must have reported on at least one of the

seven key outcomes addressed in this assessment. The

outcomes are: pain, function, quality of life, ability to

return to work, ability to return to activities of daily

living, harms, and global outcome.

A global outcome is any score that attempts to encompass

the overall success or failure of the treatment. It may be a

numerical rating of overall symptom relief or patient

satisfaction, a categorical rating such as excellent, good, fair or

poor, or a dichotomous rating such as the answer to the

question “Would you undergo this procedure again?”

Data from all articles that met our inclusion criteria were

abstracted using electronic data abstraction forms. Separate

data abstraction forms were designed for entering data about

basic trial design information; patient signs, symptoms,

comorbidities, characteristics, and treatments; reporting of

treatment outcomes; surgical complications; and nerve

conduction measurements.

The EPC employed a variety of statistical methods in this

evidence report. Meta-analyses of studies of treatments were

conducted using Hedges’ d as a measure of each study’s effect

size, and then computing the precision-weighted summary d

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from the combined results of all studies. Hedges’ d is the

difference between the means of any study’s two groups

expressed in standard deviation units. Researchers employed

two tests for heterogeneity, the Q statistic and each study’s

standardized residual. The EPC researchers regarded the data

as heterogeneous if the results of either test were statistically

significant.

Diagnostic test meta-analyses were performed according to

the method of Littenberg and Moses. The researchers took the

mean threshold as the best estimate of a single threshold, and

the values of sensitivity and specificity at the mean threshold

as the single best global estimate of test effectiveness. Before

using the results of a meta-analysis of diagnostics, they verified

that there was no statistically significant heterogeneity among

the results of the included articles using the Q statistic. If

heterogeneity was detected, they removed any subgroups that

caused the heterogeneity from the analysis. If there were no

subgroups in the analysis, or those subgroups did not cause

the heterogeneity, they looked for data points that were

outliers, and reported the meta-analytic results with and

without exclusion of these outliers.

The EPC performed numerous other statistical

computations in addition to those involved in performing

meta-analyses. Briefly, these were:

• Corrections for patient attrition. 

• Statistical power analyses. 

• Multiple regression for certain questions when such results

were of interest. 

• Computations of effect sizes for all studies, when possible,

even when no meta-analysis was performed. 

• Determinations of whether there were statistically

significant differences between the characteristics of

patients in any given study.

• Computation of pretreatment effect sizes. 

• Verification of diagnostic test characteristics.

Findings

Carpal Tunnel Syndrome

Question 1: What are the most effective methods and

approaches for the early identification and diagnosis of

carpal tunnel syndrome?

• The evidence base on most individual diagnostic tests for

carpal tunnel syndrome is small, even though the total

number of articles on CTS diagnosis is large. This is

because many different tests have been described. Nerve

conduction tests are most frequently reported in the

literature, but there is great diversity in their methods.

• The results of our analyses may overestimate the

specificity of nerve conduction measurements in typical

practice. This is because the trials we examined used

healthy, asymptomatic persons as controls. In clinical

practice, the test would be used on workers believed to be

at risk for CTS or persons suspected of having CTS.

Under these conditions, the false positive rate would be

higher, and the specificity correspondingly lower.

• The most frequently reported nerve conduction tests were

distal motor latency and palmar sensory latency. For

both tests, clinicians chose thresholds that yielded high

specificity (a low incidence of false-positive results). The

EPC’s meta-analyses of distal motor latency studies found

the sensitivity of the test to be 57% to 66% and the

specificity to be 98%. Meta-analysis of palmar sensory

latency studies found a sensitivity of 76% and a

specificity of 98%.

• Clinical signs and symptoms are also used in the diagnosis

of CTS. They attempted to use their meta-analysis

techniques to obtain summary values for the sensitivity

and specificity of two such signs: Tinel’s sign and

Phalen’s maneuver. In both cases, there was

heterogeneity in the published results that could not be

explained by differences in patient selection or by single

outlier studies. Therefore, they did not calculate

summary measurements for sensitivity or specificity. The

sensitivity of Phalen’s maneuver was lower than its

specificity, and two trials reported sensitivity of 80% to

90%. All of the studies of Tinel’s sign found that its

sensitivity was lower than its specificity, and none found

a sensitivity of 75 percent or greater. There was too

much heterogeneity in the results for them to conclude

that one test was superior to the other, or to compare

these tests to nerve conduction testing.

• Regarding sensory tests, composite nerve conduction tests,

and imaging tests, there was insufficient evidence for the

EPC to perform meta-analyses of clinical trial results.

• Their well-designed study suggests that nerve conduction

measurement may be able to identify some workers at

risk of developing CTS in the future. By itself, this

evidence is not sufficient for the EPC to conclude that

nerve conduction screening for CTS is effective.

Question 2: What are the specific indications for

surgery for carpal tunnel syndrome?

• Patients who have undergone surgery for carpal tunnel

syndrome are predominantly middle aged and female.

• Because of underreporting, no firm evidence-based

conclusions can be drawn regarding the signs, symptoms,

neuroelectrical characteristics, and comorbidities of these

patients.

Question 3: What are the relative benefits and harms of

various surgical and nonsurgical interventions for persons

with carpal tunnel syndrome?

• Meta-analysis of studies comparing open and endoscopic

carpal tunnel release show a small but statistically

significant advantage to endoscopic release in global

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treatment outcome. In addition, the data show a trend

toward faster return to work and to activities of daily

living among patients receiving endoscopic release.

However, these findings must be viewed only as trends in

currently available data. This is because they are based on

a meta-analysis that contained a number of nonrandomized, non-blinded studies. Data from these

studies also suggests that endoscopic release has a higher

complication rate and a higher rate of reoperation

compared to open release. The higher reoperation rates

likely arise because of incomplete transection of the

transverse carpal ligament. Exact complication rates

cannot be determined from presently available data.

Presently available data also do not allow one to reach

firm evidence-based conclusions about the relative effects

of open and endoscopic surgery on the ability of patients

to perform daily functions.

• Meta-analysis of global outcomes demonstrates a potential

benefit from not performing neurolysis. Available return

to work data also shows a trend toward an advantage to

not performing neurolysis. There is insufficient data to

determine the effect of neurolysis on pain and function.

The available evidence suggests there is little or no benefit

from performing neurolysis along with surgical release of

the carpal tunnel. The possibility remains that neurolysis

may be helpful in special cases, such as in the presence of

marked scarring or neural adhesion, but no available

evidence specifically documents the benefits and harms of

neurolysis among such patients.

• Results of four studies suggest that injection of steroid

into the carpal tunnel yields superior global outcomes

compared to no treatment, placebo, or oral steroids.

However, relief from steroid treatments is not complete.

Carpal tunnel injection was significantly better than

intramuscular injection at a 1 month followup time.

Because no further time points were reported, researchers

are unable to determine whether this difference persists

beyond this time. There are no data available that

indicate whether any type of steroid may be superior to

any other, or whether any particular dose is optimum.

Although the effects of steroid injection may wear off

over time, there is no information indicating the

expected duration of relief for the average patient, or

whether any patients can expect to experience permanent

relief.

• Two double-blinded randomized controlled trials suggest

that oral steroids may lead to a reduction in symptoms of

CTS. However, the effects of oral steroids are short-lived

and may not be sufficient for patient satisfaction. The

effects of higher steroid doses or longer treatment

regimens have not been examined in published controlled

trials.

• A single published randomized controlled trial indicates

that oral tenoxicam (a NSAID) and trichlormethiazide 

(a diuretic) do not reduce the symptoms of CTS under

the dosing regimens described. Further trials are needed

to confirm this observation, and to test the effects of

additional drugs and dosing regimens.

• Results of a single study suggest that manual therapy may

have some use in the treatment of carpal tunnel

syndrome. This study suggests that carpal bone

mobilization provides pain relief, improves function, and

delays or eliminates the need for surgery among patients

with carpal tunnel syndrome. However, this small study

was unblinded. Results from neurodynamic mobilization

show a similar trend, but because of a lack of statistical

power one cannot conclude that this trend is real. For

the same reason, differences in effectiveness between these

two treatment groups cannot be determined. A large,

blinded, randomized controlled trial is necessary to

confirm these results.

• A larger, more statistically powerful study found no

difference between the effects of a physical therapy

program and home exercise instructions on pain or

function. However, patients receiving physical therapy

returned to work faster than those instructed to exercise

at home.

• Although these studies indicate a trend toward some

forms of physical therapy having an effect on carpal

tunnel syndrome, their small size and design difficulties

make it difficult to arrive at a firm evidence-based

conclusion.

• Only one study meeting inclusion criteria addresses the

use of ultrasound for carpal tunnel syndrome. Because of

this, and because of its associated design and analysis

difficulties, one cannot reach a firm evidence-based

conclusion.

• Splint use was addressed only by a single trial that had

design difficulties. Because of this, one cannot reach a

firm evidence-based conclusion about splint use. There

may be conditions under which splints offer an advantage

and conditions under which they do not, but this is not

addressed by available evidence.

• The results of one study suggest that suboptimal

outcomes are obtained when patients receive ligament

reconstruction. However, this trial was neither

randomized nor blinded, so one cannot draw firm

evidence-based conclusions from it.

• Although the low statistical power of the one relevant

study prevents any solid conclusion from being drawn,

this study does not support the therapeutic effectiveness

of Vitamin B6. This is because it showed a trend toward

a greater percentage of improved patients in the placebo

group.

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Question 4: Is there a relationship between specific

clinical findings and specific treatment outcomes among

patients with carpal tunnel syndrome?

• The only clinical finding variable shown by more than

one study to significantly predict treatment outcomes was

electrodiagnostic testing. Patients with mildly impaired

or normal results of electrodiagnostic tests had longer

sick leaves and were less likely to be satisfied with the

results of treatment. This finding was statistically

significant in three of the four studies examining this

relationship.

• This apparent lack of consistency of results could indicate

that, although the relationship between electrodiagnostic

tests and treatment outcomes is statistically significant, it

may not be substantial. The possibility that this

relationship is small is supported by the results of

stratified studies that examined the relationship between

electrodiagnostic test results and global outcomes. Six of

seven studies did not find a statistically significant

relationship.

Question 5: Is there a relationship between duration of

symptoms and specific treatment outcomes among patients

with carpal tunnel syndrome?

• The majority of available evidence is less than optimal

because it consists primarily of retrospective studies. The

highest quality study (prospective with multiple

regression analysis) suggested that there was no

statistically significant correlation between duration of

symptoms and global outcome after surgery. One

prospective and two retrospective stratified studies found

similar results. Two retrospective studies (one performing

multiple regressions, one stratified) found a statistically

significant relationship between shorter duration of

symptoms and symptom resolution or patient satisfaction

after surgery. The retrospective nature of these trials

could have created bias that influenced these findings.

An additional high quality prospective study is needed

before firm conclusions can be reached.

Question 6: Is there a relationship between factors such

as patients’ age, gender, socioeconomic status and/or racial

or ethnic grouping and specific treatment outcomes among

patients with carpal tunnel syndrome?

• The available evidence suggests that patients who are not

receiving workers’ compensation tend to return to work

faster than those receiving such compensation. This is

suggested by one of two “multiple regression” studies of

this relationship and by a combination of 10 prospective

and retrospective stratified studies. Evidence of a

relationship does not constitute evidence of causality.

• Some evidence also suggests that patients who are not

receiving workers’ compensation have better global

outcomes, but this evidence is derived exclusively from

retrospective studies. Therefore, these latter findings

require confirmation.

• Available evidence suggests that there is no strong

relationship between gender, employment status, or hand

dominance and return to work or global outcomes.

• There is insufficient evidence to arrive at a firm evidencebased conclusion on the relationship between type of

work, presence of diabetes, or age and patient outcomes.

Question 7: What are the surgical and nonsurgical costs

or charges for treatment of carpal tunnel syndrome?

• According to the Medicare Provider Analysis and Review

(MEDPAR) database, which covers hospital inpatient

services, average total charges per patient for the DRG

(diagnosis-related group) of carpal tunnel release are

$8,185.24 (calculated by dividing total charges by

number of discharges). This DRG includes open and

endoscopic release.

• The Median Costs for Hospital Outpatient Services

Dataset contains median costs for services that are

reimbursed under Medicare for the hospital outpatient

prospective payment system. The reported median cost

for endoscopic release of the transverse carpal ligament is

$849.84 (cost of open release was not reported by this

database). The reported median cost for application of a

short arm static splint is $72.69.

Question 8: For persons who have had surgery for

carpal tunnel syndrome, what are the most effective

methods for preventing the recurrence of symptoms, and

how does this vary depending on subject characteristics or

other underlying health problems?

• No controlled trials have been published that report on

the efficacy or effectiveness of any technique for the

prevention of recurrence of carpal tunnel syndrome. In

the absence of controlled trials, no analysis may be

performed and no evidence-based conclusions may be

drawn.

Question 9: What instruments, if any, can accurately

assess functional limitations in an individual with carpal

tunnel syndrome?

• Three prospective cohort trials have indicated that the SF36 is not a useful instrument for assessing functional

limitations in individuals with carpal tunnel syndrome.

The SF-36 was reported to be unresponsive to treatment

and unable to predict ability to work.

• Four prospective cohort trials have indicated that the

Levine CTS-I may be a useful instrument for assessing

functional limitations in individuals with carpal tunnel

syndrome. This instrument was reported to be

responsive to treatment, and to have concurrent validity

as measured by grip and pinch strength. However, the

studies that addressed the Levine CTS-I did not examine

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its internal reliability, content validity, or its ability to

predict how well patients could perform activities of daily

living. In addition, the Levine CTS-I has been reported

by one study to be unable to predict ability to work.

• No other instrument has been evaluated by more than

one study. It is difficult to reach an evidence-based

conclusion as to the usefulness of the other instruments

evaluated in this report due to the limited evidence base.

Question 10: What are the functional limitations for an

individual with carpal tunnel syndrome before treatment?

• There is some evidence to suggest that most untreated

patients with carpal tunnel syndrome have mild to

moderate functional difficulties before treatment.

However, this evidence is derived from only two studies

comprised of a total of 51 patients. This is too few

patients and too few studies to allow one to reach a firm

evidence-based conclusion.

Question 11: What are the functional limitations of an

individual with carpal tunnel syndrome after treatment?

• Although studies of non-surgical therapies suggested that

most patients experience only mild difficulty with

functional activities after treatment, it is unclear whether

the results of these two studies are generalizable to the

larger patient population.

• Studies with surgical outcomes suggested that most

patients report no-to-moderate difficulty with functional

activities (mean 1.4-2.6 on the Levine CTS-I) after

surgery.

• Although there were no statistically significant differences

between specific patient groups, there was a trend toward

more difficulty with functional activities among workers’

compensation patients in surgical studies. This trend was

based on the results of two studies.

• The available data are insufficient to determine a cutoff

point on measuring scales above which patients are

unable to work.

Cubital Tunnel Syndrome

Question 1: What are the most effective methods and

approaches for the early identification and diagnosis of

cubital tunnel syndrome?

• One test for cubital tunnel syndrome, ulnar motor nerve

conduction velocity at the elbow, was commonly

mentioned by reviewers. Three studies reported high

specificity and low sensitivity for this test. Due to the

small number of studies, however, one cannot draw

quantitative conclusions about the effectiveness of the

test. There are insufficient data to permit firm evidencebased conclusions about the effectiveness of this or any

other tests for cubital tunnel syndrome.

Question 2: What are the specific indications for

surgery for cubital tunnel syndrome?

• Thirty-two studies of patients who received surgery for

cubital tunnel syndrome were identified. The mean age

of patients who received surgery for cubital tunnel

syndrome was 46 years.

• The patients were slightly more likely to be male (62%

male).

• On average, patients had symptoms 10 to 24 months

before receiving surgical treatment.

Question 3: What are the relative benefits and harms of

various surgical and nonsurgical interventions for persons

with cubital tunnel syndrome?

• One randomized controlled trial of 52 patients found that

medial epicondylectomy was superior to anterior

transposition in relieving pain and in improving global

outcome scores. The results of this study are suggestive,

but one cannot arrive at a strong conclusion from the

results of only one trial. There is insufficient evidence to

determine the relative effectiveness of other surgical

treatments.

• There are insufficient data available to determine the

rates of surgical complications for any of the described

surgical procedures.

Question 4: Is there a relationship between specific

clinical findings and specific treatment outcomes among

patients with cubital tunnel syndrome?

• The only clinical finding variable shown by more than

one study to significantly predict treatment outcomes was

severity of symptoms. This correlation was statistically

significant in four out of seven studies that examined it.

The studies that did not find a statistically significant

correlation may have been underpowered. Therefore,

currently available evidence tentatively suggests that there

is a correlation between having less severe symptoms and

having a higher global outcome score after surgical

treatment for cubital tunnel syndrome.

• There are insufficient data to reach evidence-based

conclusions about the relationships between other clinical

findings and treatment outcomes.

Question 5: Is there a relationship between duration of

symptoms and specific treatment outcomes among patients

with cubital tunnel syndrome?

• Currently available evidence does not suggest a clear-cut

relationship between the duration of symptoms before

treatment and the success of surgery.

• There are insufficient data available to reach evidencebased conclusions about the relationship between

symptom duration and other treatment outcomes.

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Question 6: Is there a relationship between factors such

as patients’ age, gender, socioeconomic status and/or racial

or ethnic grouping and specific treatment outcomes among

patients with cubital tunnel syndrome?

• The available data do not suggest a substantial correlation

between the age, sex, or workers’ compensation status of

the patient and the success of surgery.

• Two studies that used multiple regression to examine

relationships between patient characteristics and

treatment outcomes found that patients whose cubital

tunnel syndrome is caused by an acute trauma have

better outcomes after surgical treatment than patients

with cubital tunnel syndrome from other causes.

However, three studies that stratified by etiology found

no statistically significant relationship between cause and

patient outcomes. The studies that used multiple

regression techniques are of better quality than the

stratified studies. Thus, current data suggest that there

may be a correlation between etiology and patient

outcomes, but this cannot be regarded as definitive.

Question 7: What are the surgical and nonsurgical costs

or charges for treatment of cubital tunnel syndrome?

• According to Medicare Provider Analysis and Review

(MEDPAR), average total charges per patient for the

DRG (diagnosis-related group) of major shoulder/elbow

procedures with comorbidities or complications are

$9,008.94 (calculated by dividing total charges by

number of discharges).

• For the DRG shoulder, elbow or forearm procedures,

except major joint procedures, without comorbidities or

complications, average total charges per patient are

$7729.16.

• For the DRG peripheral and cranial nerve and other

nerve procedures without complications or

comorbidities, the average total per patient charges are

$14,357.65 (with complications or comorbidities the

charges are $24,288.00).

• The Median Costs for Hospital Outpatient Services

Dataset contains median costs for services that are

reimbursed under Medicare for the hospital outpatient

prospective payment system. The reported median cost

for a decompression fasciotomy of the forearm and/or

wrist is $603.85. The reported median cost for

application of a long-arm splint is $80.48.

Question 8: For persons who have had surgery for

cubital tunnel syndrome, what are the most effective

methods for preventing the recurrence of symptoms, and

how does this vary depending on subject characteristics or

other underlying health problems?

• None of the included studies addressed this question.

Question 9: What instruments, if any, can accurately

assess functional limitations in an individual with cubital

tunnel syndrome?

• None of the included studies addressed this question.

Question 10: What are the functional limitations for an

individual with cubital tunnel syndrome before treatment?

• None of the included studies addressed this question.

Question 11: What are the functional limitations of an

individual with cubital tunnel syndrome after treatment?

• None of the included studies addressed this question.

Epicondylitis

Question 1: What are the most effective methods and

approaches for the early identification and diagnosis of

epicondylitis?

• There are insufficient data to permit evidence-based

conclusions about the effectiveness of any tests for

epicondylitis. This is because the evidence base is small

and heterogeneous.

Question 2: What are the specific indications for

surgery for epicondylitis?

• Nineteen studies of patients who received surgery for

epicondylitis were identified. Due to a lack of reported

data, few trends or characteristics of patients who

received surgery could be identified. A typical patient

who received surgery for epicondylitis was middle-aged

and equally likely to be male or female.

Question 3: What are the relative benefits and harms of

various surgical and nonsurgical interventions for persons

with epicondylitis?

• Seven double-blinded randomized controlled trials

compared laser therapy to sham laser therapy as

treatment for epicondylitis. A meta-analysis of the results

of the four studies that reported “success of treatment”

did not reveal a statistically significant difference in

outcome between laser and sham-treated patients.

• The four studies that reported the effect of laser treatment

on pain also did not find a statistically significant

difference in outcome between laser and sham treated

patients. However, EPC researchers were unable to

perform a meta-analysis of the outcome pain and,

because all of these studies were small, their individual

results cannot be taken as definitive proof that laser

therapy has no effect on the pain of epicondylitis.

• Only one study examined work status of patients after

laser treatment. This study was also small, and it failed

to find a statistically significant effect of laser treatment

on work status. The results of all seven small randomized

double-blinded controlled trials are consistent with the

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results of our meta-analysis, and suggest that if there is an

effect of laser therapy on epicondylitis, it is not large.

• Two randomized controlled trials of a total of 62 patients

compared oral naproxen to oral diflunisal. One study

reported no statistically significant difference in outcomes

when comparing patients treated with the two different

drugs, and did not find a consistent trend in favor of one

drug. The other study reported that diflunisal treatment

consistently resulted in better outcomes. For two

outcomes, pain and function, the difference reached

statistical significance. Further studies are necessary to

resolve discrepancies between these studies.

• Two randomized controlled trials of 82 patients in total

compared ultrasound treatment to phonophoresis of

hydrocortisone as a therapy for epicondylitis. Neither

study found a statistically significant difference between

treatment groups for any of the outcomes. When

interpreting these results, it is important to keep in mind

that both studies may have been too small to be able to

detect clinically relevant differences between treatment

groups.

• Three randomized controlled trials of 220 patients in total

compared ultrasound treatment to sham ultrasound

treatment or no treatment as a therapy for epicondylitis.

All three of the studies reported a trend towards better

outcomes in the groups treated with ultrasound.

However, this difference reached statistical significance in

only one of the studies. Although low statistical power

may explain the negative results of the two

“nonsignificant” studies, further research is required to

demonstrate this.

• Simply wearing an elbow brace is reported by two

crossover studies to have no effect on pain. Because these

two studies were of less than optimal design, further

studies are necessary before a conclusion may be reached.

• Two randomized controlled trials of a total of 134

patients evaluated the effect of acupuncture on

epicondylitis. Both studies reported patients treated with

acupuncture had better global outcomes and greater pain

relief than patients treated with sham acupuncture at

relatively short (2 weeks) followup times. Although only

two studies evaluated this treatment, both were welldesigned. It is possible to tentatively conclude that

acupuncture is an effective palliative treatment for

epicondylitis.

• Two randomized controlled trials of a total of 203

patients compared oral NSAIDs to injections of

corticosteroids. One study did not find a statistically

significant difference between the groups. The other

study reported that patients treated with injections of

corticosteroids had better outcomes than the patients

treated with oral NSAIDs. Design differences may

explain the discrepancy between these studies’ results, and

further study is required to resolve this issue.

• One double-blinded randomized controlled trial reported

that patients treated with placebo had a trend towards

better outcomes than patients treated with topical

DMSO; however, this trend did not reach statistical

significance. This study also reported that topical

DMSO application caused clinically significant skin

irritation. However, this trial was based on only 51

patients, so further studies are necessary before a

definitive evidence-based conclusion can be reached.

• One randomized controlled trial of 128 patients

compared oral diclofenac to placebo. The group treated

with diclofenac had statistically significantly less pain

than the placebo group, but the NSAID treatment had

no statistically significant effect on hand/arm function,

number of days of missed work, or global outcome. Oral

NSAIDs were reported to occasionally cause

gastrointestinal side effects. In the absence of a very large

effect, it is difficult to reach a firm evidence-based

conclusion from the results of a single trial of moderate

size.

• One double-blinded randomized controlled trial and one

double blinded randomized crossover trial, of a total of

47 patients, compared topical diclofenac to placebo.

One of the studies reported no statistically significant

differences between the two groups for any of the

outcomes. The other study reported that the group

treated with the NSAID may have had some statistically

significant benefit from the treatment. Researchers were

unable to determine whether the differences in results

between studies were due to differences in statistical

power. Further studies are necessary to resolve

discrepancies between these studies.

• One randomized controlled trial of 40 patients compared

topical diclofenac to topical salicylate, and reported that

diclofenac was more effective for treating epicondylitis.

Topical NSAIDs were reported to occasionally cause mild

skin rashes. Further studies are necessary before a

definitive evidence-based conclusion can be reached.

• One randomized double-blinded study reported that

injections of glucosamines are effective in treating the

symptoms of epicondylitis in the short term (less than 6

months) as measured by global outcome and patientreported pain. However, injections of glucosamines were

found to have a high rate of side effects—40% of

patients experienced pain at the site of injection, and 6%

developed hematomas at the site of injection. Further

studies are necessary before a definitive evidence-based

conclusion about the clinical utility of this treatment can

be reached.

• One randomized double-blinded study reported that

injections of methylprednisolone plus lidocaine were

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statistically significantly more effective at treating pain

than injections of lidocaine. Further studies are necessary

before a definitive evidence-based conclusion can be

reached.

• One randomized double-blinded study reported that

injections of lignocaine plus triamcinolone were

statistically significantly more effective at treating pain

than injections of lignocaine or injections of lignocaine

plus hydrocortisone. Further studies are necessary before

a definitive evidence-based conclusion can be reached.

• One randomized double-blinded study reported that

injections of triamcinolone plus bupivacaine were more

successful at treating epicondylitis than injections of

triamcinolone plus lidocaine. Further studies are

necessary before a definitive evidence-based conclusion

can be reached.

• One study reported a trend towards more successful

treatment of epicondylitis after injections of

methylprednisolone than after injections of

hydrocortisone. However, this study was of less than

optimal design, which makes it problematic to come to a

definitive evidence-based conclusion on the basis of its

results.

• One study reported no difference in rates of successful

treatment or number of work-days missed after treatment

with injections of methylprednisolone as compared to

injections of betamethasone plus lidocaine. This study

had sufficient statistical power to have detected relatively

small differences between treatment groups. However,

design flaws in this study make it problematic to come to

a definitive evidence-based conclusion on the basis of its

results.

• One study reported that wearing a brace regularly over

the course of several months is not as effective in treating

epicondylitis as is physiotherapy, but a different study

reported that wearing a brace regularly in addition to

physiotherapy may be more effective than physiotherapy

alone. Further studies of these therapies are necessary

before one can reach definitive evidence-based

conclusions.

• One retrospective case-controlled study compared

fasciectomy, wide fasciectomy plus anconeus transfer, and

re-operation of failed fasciectomy to include an anconeus

transfer. However, because this was a single study of

suboptimal design, one cannot reach a firm evidencebased conclusion about the relative efficacy of these

procedures.

• One non-parallel historically controlled trial reported that

simple denervation led to statistically significantly better

global outcome and greater pain relief than denervation

plus decompression. However, because this was a single

study of suboptimal design, one cannot reach a firm

evidence-based conclusion about the relative efficacy of

these procedures.

• A single double-blinded randomized controlled trial of 30

patients reported that there were no statistically

significant differences in the signs and symptoms of

epicondylitis between patients treated with pulsed

electromagnetic field therapy and patients receiving sham

treatment. When interpreting the results of this trial, it

must be kept in mind that the small size of the trial may

have prevented the results from reaching statistical

significance.

• One randomized controlled trial reported that patients

treated with extracorporeal shock wave therapy had

statistically significantly greater improvements in pain

and arm function than patients given sham treatment.

However, it is difficult to reach firm evidence-based

conclusions from the results of this trial because the lack

of blinding and lack of intent-to-treat analysis of this trial

may have affected its results.

• One randomized controlled trial reported that patients

treated with injections of corticosteroids had better

outcomes than patients treated with manipulations and

deep friction massage. Incomplete data and methods

reporting from this trial make it problematic to reach any

definitive evidence-based conclusions from its results.

• One randomized controlled trial of 76 patients reported

that patients treated with injections of corticosteroids had

better outcomes than patients treated with braces or

immobilization. Partly because of the small size of this

trial, further studies are necessary before a definitive

evidence-based conclusion can be reached.

• One randomized controlled trial of 63 patients reported

that patients treated with acupuncture had better

outcomes than patients treated with corticosteroid

injections. However, the results of this study may have

been affected by patient selection bias because it enrolled

only patients previously found to be unresponsive to

injections of corticosteroids.

Two randomized controlled trials, one comparing

transcutaneous electrical nerve stimulation, ultrasound,

phonophoresis, and injections of steroids, the other

comparing physical therapy to ultrasound, reported no

statistically significant differences between treatment

groups. However, both trials may have been too small to

be able to have detected clinically meaningful differences

between treatment groups.

• Five randomized controlled trials evaluated various

combinations of therapies for the treatment of

epicondylitis. One trial of 18 patients found that

patients treated with manipulation plus a home exercise

program had fewer difficulties in performing activities of

daily living than patients treated with a combination of

ultrasound, physiotherapy, and home exercise. The other

9
four trials did not find statistically significant differences

between treatment groups. However, these studies were

small, which may have prevented them from detecting

clinically important differences between the treatment

groups.

Question 4: Is there a relationship between specific

clinical findings and specific treatment outcomes among

patients with epicondylitis?

• One study reported that the site of pain could be used to

predict response to treatment, one reported that the

severity of pain could be used to predict response to

treatment, and one reported that the timing of onset of

symptoms (acute vs. gradual) did not correlate with the

response to treatment. Because only one study addressed

each outcome, it is difficult to reach firm evidence-based

conclusions from the available data.

Question 5: Is there a relationship between duration of

symptoms and specific treatment outcomes among patients

with epicondylitis?

• Seven studies examined whether duration of symptoms

correlated with treatment outcomes. Only one of the

four studies that employed multiple regression found a

statistically significant relationship between symptom

duration and outcomes, and this study was retrospective.

One of three studies that stratified patients according to

their duration of symptoms found a statistically

significant correlation with treatment outcomes. As this

study was also retrospective, evidence suggesting a

relationship is contradictory and weak. Two prospective

studies that employed multiple regression did not find

such a relationship. Both were of patients who had

received ultrasound. However, currently available

evidence about use of ultrasound in patients with

epicondylitis or de Quervain’s disease does not allow firm

evidence-based conclusions. A lack of treatment

effectiveness could obscure potential relationships

between symptom duration and treatment-related

outcomes. Therefore, one cannot draw firm evidencebased conclusions from currently available data.

Question 6: Is there a relationship between factors such

as patients’ age, gender, socioeconomic status and/or racial

or ethnic grouping and specific treatment outcomes among

patients with epicondylitis?

• Three studies that used multiple regression found no

statistically significant correlation between gender or age

and response to treatment, suggesting that there is no

strong relationship between these variables and patient

outcomes.

• One study found no statistically significant correlation

between certain hobbies and response to treatment.

However, it is difficult to reach evidence-based

conclusions from the results of a single study.

• The only study that examined co-morbidities reported

that patients with co-existent ulnar neuropathy had

significantly poorer outcomes than patients without ulnar

neuropathy. However, it is difficult to reach evidencebased conclusions from the results of a single study.

Question 7: What are the surgical and nonsurgical costs

or charges for treatment of epicondylitis?

• According to Medicare Provider Analysis and Review

(MEDPAR), average total charges per patient for the

DRG (diagnosis-related group) of major shoulder/elbow

procedures with comorbidities or complications are

$9,008.94 (calculated by dividing total charges by

number of discharges).

• For the DRG shoulder, elbow or forearm procedures,

excepting major joint procedures, without comorbidities

or complications, average total charges per patient are

$7729.16.

• The Median Costs for Hospital Outpatient Services

Dataset contains median costs for services that are

reimbursed under Medicare for the hospital outpatient

prospective payment system. The reported median cost

for strapping of the elbow or wrist is $62.61 (cost of

open release was not reported by this database).

Question 8: For persons who have had surgery for

epicondylitis, what are the most effective methods for

preventing the recurrence of symptoms, and how does this

vary depending on subject characteristics or other

underlying health problems?

• No controlled trials addressed this question. Therefore, it

was not possible to perform a reliable analysis, and one

cannot draw firm evidence-based conclusions from the

available data.

Question 9: What instruments, if any, can accurately

assess functional limitations in an individual with

epicondylitis?

• Three studies evaluated two different instruments

(PRFEQ and F-VAS) as ways to measure functional

limitations of patients with epicondylitis. Neither

assessment instrument has been shown to be a useful

instrument for evaluating functional limitations in

persons with epicondylitis. However, it is difficult to

reach firm evidence-based conclusions about the

instruments evaluated in this report due to the limited

evidence base.

10
Question 10: What are the functional limitations for an

individual with epicondylitis before treatment?

• This question is addressed by only two studies comprised

of a total of 82 patients. Although these studies suggest

that epicondylitis patients have an average level of

functional difficulty between 30% - 40% (mild to

moderate) on functional status scales, the low number of

studies and patients makes it difficult to arrive at an

evidence-based answer to this question.

Question 11: What are the functional limitations of an

individual with epicondylitis after treatment?

• There were no studies that met the inclusion criteria for

this question. Therefore, it cannot be answered in an

evidence-based fashion.

De Quervain’s Disease

Question 1: What are the most effective methods and

approaches for the early identification and diagnosis of de

Quervain’s disease?

• None of the included studies addressed this question.

Question 2: What are the specific indications for

surgery for de Quervain’s disease?

• Two of the three studies that addressed this question

reported that surgery was performed only on patients

who did not benefit from conservative (non-operative)

treatment. However, with so few studies and so many

unreported patient characteristics, one cannot assume

that the present data are representative of the larger

patient population with de Quervain’s disease.

Question 3: What are the relative benefits and harms of

various surgical and nonsurgical interventions for persons

with de Quervain’s disease?

• Although one study found that corticosteroid plus

lidocaine injection produced more treatment success than

immobilization splints among de Quervain’s patients,

there were design problems with this study. Because of

these problems, and because only one study addressed

this question, it is difficult to reach firm evidence-based

conclusions concerning the effectiveness of any treatment

for de Quervain’s disease.

Question 4: Is there a relationship between specific

clinical findings and specific treatment outcomes among

patients with de Quervain’s disease?

• This question was addressed by only one relatively small

retrospective study. This study found no relation

between presence of a septated first dorsal compartment

and treatment outcome. However, it is difficult to reach

evidence-based conclusions from the results of a single

study of suboptimal design.

Question 5: Is there a relationship between duration of

symptoms and specific treatment outcomes among patients

with de Quervain’s disease?

• This question was addressed by only one relatively small

retrospective study. This study found no relation

between duration of symptoms and treatment outcome.

However, it is difficult to reach evidence-based

conclusions from the results of a single study of

suboptimal design.

Question 6: Is there a relationship between factors such

as patients’ age, gender, socioeconomic status and/or racial

or ethnic grouping and specific treatment outcomes among

patients with de Quervain’s disease?

• This question was addressed by only one relatively small

retrospective study. This study found no relation

between age, gender, or occupational status and treatment

outcome. However, it is difficult to reach evidence-based

conclusions from the results of a single study of

suboptimal design.

Question 7: What are the surgical and nonsurgical costs

or charges for treatment of de Quervain’s disease?

• According to the Medicare Provider Analysis and Review

(MEDPAR) database, which covers hospital inpatient

services, average total charges per patient for the DRG

(diagnosis-related group) of hand or wrist procedures

(excepting major joint procedures) without complications

or comorbidities are $7,408.14 (calculated by dividing

total charges by number of discharges).

• The Median Costs for Hospital Outpatient Services

Dataset contains median costs for services that are

reimbursed under Medicare for the hospital outpatient

prospective payment system. The reported median cost

for application of a short arm static splint is $72.69.

Question 8: For persons who have had surgery for 

de Quervain’s disease, what are the most effective methods

for preventing the recurrence of symptoms, and how does

this vary depending on subject characteristics or other

underlying health problems?

• None of the included studies addressed this question.

Question 9: What instruments, if any, can accurately

assess functional limitations in an individual with de

Quervain’s disease?

• None of the included studies addressed this question.

Question 10: What are the functional limitations for an

individual with de Quervain’s disease before treatment?

• None of the included studies addressed this question.

Question 11: What are the functional limitations of an

individual with de Quervain’s disease after treatment?

• None of the included studies addressed this question.

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Non-Treatment-Specific Questions

Question 12: What are the cumulative effects on

functional abilities among individuals with more than one

worker-related musculoskeletal disorder of the upper

extremity in the same limb?

• There were no studies that met the inclusion criteria for

this question. Therefore, it cannot be answered in an

evidence-based fashion.

Question 13: What level of function can patients

achieve in what period of time when they are required to

change hand dominance as a result of injury to their

dominant hand?

• The studies of the ability of training to improve use of

the non-dominant hand do not allow one to determine

the degree to which this training provides the patient

with employment opportunities or allows resumption of

normal activities. These studies also lack long-term

followup data. Evidence from two studies suggests that

some learning and training in the use of the nondominant hand is possible, and statistically significant

improvement can be accomplished in 2 to 6 months of

training. For some activities, statistically significant

improvement can be accomplished within 1 week.

Future Research

In general, the literature addressing WRUEDs is of uneven

quality. Well-designed studies on many aspects of WRUEDs

are needed. Prospective, randomized double-blinded

controlled trials are widely considered to provide the highest

quality of evidence for treatment effectiveness. Results of nonrandomized trials can be affected by differences in the

characteristics of the patient groups, rather than the treatment

applied. Uncontrolled trials do not allow one to ascertain

whether patients improve in the absence of treatment, and

they do not allow one to accurately gauge the magnitude of

any change that occurs after treatment. Blinding of patients

and evaluators to treatments avoids the potential for placebo

effects and previously held beliefs about the effectiveness of

treatments to impact on the results of trials.

Studies of diagnostic tests do not necessarily need not be

randomized or contain control groups. In the absence of a

“gold standard” test, longitudinal studies are the most

desirable for assessing diagnostic tests for WRUEDs. In these

studies, patients are first given the diagnostic test, and then

they are followed for a period of time to determine whether

they develop symptoms of a WRUED. Repeating the tests at

regular intervals during the trial could yield insights into the

etiology of the conditions as well as measure test-retest

variability. If a “gold standard” test were developed, then

single-arm cross-sectional studies that compared the results of

the “gold standard” test to the results of the test under

investigation would be appropriate. In such studies, in order

to obtain the most useful information, it is important to select

a patient population that closely resembles the general

population on whom the diagnostic test would ultimately be

used.

Availability of Full Report

The full evidence report from which this summary was

derived was prepared for AHRQ by ECRI’s Health

Technology Assessment Group under contract number 290-

97-0020. It is expected to be available in the Winter of 2002.

At that time, printed copies may be obtained free of charge

from the AHRQ Publications Clearinghouse by calling 800-

358-9295. Requestors should ask for Evidence

Report/Technology Assessment No. 62, Diagnosis and

Treatment of Worker-Related Musculoskeletal Disorders of the

Upper Extremity.

Internet users will be able to access the report online

through AHRQ’s Web site at: www.ahrq.gov.

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AHRQ Pub. No. 02-E037

October 2002

ISSN 1530-440X