ii. Past injury/symptoms involving the upper extremities, trunk and cervical spine. iii. Past work-related injury or occupational disease. iv. Past personal injury or disease that resulted in temporary or permanent job limitation. v. Medical conditions associated with cumulative trauma: The following are examples of medical conditions which have been commonly seen in association with cumulative trauma conditions. These require treatment and may impact the recovery of the work comp injury (). A) Amyloidosis; B) Arthropathies, including connective tissue disorders, rheumatoid arthritis, systemic lupus erythematosus, gout, osteoarthritis and spondyloarthropathy; C) Cancer; D) Diabetes mellitus, including family history or gestational diabetes; E) Hypothyroidism, especially in older females; F) Obesity; G) Pregnancy; H) Depression. vi. History of smoking and alcohol use; history of substance abuse; vii. Medication history including, birth control pills, corticosteroid use, and other prescription and non-prescription medications; and viii. Psychosocial history (including history of hobbies and recreational activities). d. Physical Examination The evaluation of any upper extremity complaint should begin at the neck and upper back and then proceed down to the fingers and include the contralateral region. It should include evaluation of vascular and neurologic status, and
Positive compression test; Thenar atrophy may be present later in course; Weakness of abductor pollicis brevis; Sensory loss to pinprick, light touch, two-point discrimination or Semmes-Weinstein monofilament tests in a median nerve distribution. No loss of sensation in the central palm. DIAGNOSIS SYMPTOMS SIGNS (Required Findings) Cubital Tunnel Syndrome Paresthesias or dull, aching sensations in the 4th and 5th digits (ring and small fingers) and discomfort near the medial aspect of the elbow. Paresthesias or dull, aching in the 4th and 5th digits and at least one of the following exam findings: Diminished sensation of the fifth and ulnar half of the ring fingers, which may sometimes include sensory loss to pinprick, light touch, two-point discrimination or Semmes-Weinstein monofilament tests in an ulnar nerve distribution; Positive elbow flexion/ulnar compression test; Later stages manifested by: intrinsic atrophy and ulnar innervated intrinsic weakness; Wartenberg’s sign; Froment’s sign.
d. Risk Factors Definitions Table Category As a Primary Risk Factor Citations / Comments Secondary Risk Factor Citations / Comments Force and Repetition/Duration 6 hrs. of: use of 2 pounds pinch force or 10 pounds hand force 3 times or more per minute. () (; ) 3 hrs. of: use of 2 pounds pinch force or 10 pounds hand force 3 times or more per minute. (; ) 6 hrs. of: lifting 10 lbs > 60x per hour. () 3 hrs. of: lifting 10 lbs > 60x per hour. Indirect evidence 6 hrs. of: use of hand held tools weighing 2 lbs are greater. (; ) 3 hrs. of: use of hand held tools weighing 2 lbs or greater. () Awkward Posture and Repetition/Duration 4 hrs. of: Wrist flexion > 45 degrees, extension > 30 degrees, or ulnar deviation > 20 degrees. (; ; ; ) Category As a Primary Risk Factor Citations / Comments Secondary Risk Factor Citations / Comments
Carpal Tunnel Syndrome Combination of force, repetition, and vibration (; ).2,4 Combination of repetition and force for 6 hours (). Combination repetition and forceful tool use with awkward posture for 6 hours (). Combination force, repetition, and awkward posture (). Combination of 2 pound pinch or 10 pound hand force 3 times or more per minute for 3 hours (). Wrist bending or awkward posture for 4 hrs (). Mouse use more than 4 hours (). Combination cold and forceful repetition for 6 hours - Frozen food handling (). Good evidence - Keyboarding less than or equal to 7 hrs. in good ergonomic position IS NOT RELATED (; ; ; ; ). Good evidence- Repetition alone less than or equal to 6 hrs. IS NOT RELATED (; ). High repetition defined as task cycle times of less than 30 seconds or performing the same task for more than 50% of the total cycle time ().5 Tasks using a hand grip. Extreme wrist radial/ulnar positions or elbows in awkward postures (). Diagnosis Evidence FOR Specific Risk Factors Evidence AGAINST Specific Risk Factors Non-Evidence-Based Additional Risk Factors to Consider. These factors must be present for at least 4 hours of the work day, and may not overlap evidence risk factors.¹ Strong Multiple high quality studies Good One high quality study or multiple adequate studies Some One adequate study
lifting ().2 Combination force and possible awkward posture – study used repetition and turning and screwing (). Combination forearm pronation 45° or greater with power grip or lifting for 3 hours per day (). forearm for 2 hours (). Combination repetition and awkward posture including static posture (). Epicondylitis Combination – force & repetition ()4, force and wrist and hand repetition (). Combination of wrist bending for 4 hours and rotation the forearm for 2 hours (). Some evidence keyboard use IS NOT RELATED (). Wrist posture in flex and repetitive pronation and/or elbow extension.³ Diagnosis Evidence FOR Specific Risk Factors Evidence AGAINST Specific Risk Factors Non-Evidence-Based Additional Risk Factors to Consider. These factors must be present for at least 4 hours of the work day, and may not overlap evidence risk factors.¹ Strong Multiple high quality studies Good One high quality study or multiple adequate studies Some One adequate study
ii. Pain may also increase with gripping. Swelling, erythema, and warmth are generally not seen in this condition. e. Specific Physical Exam Findings - Medial i. Required elements for the diagnosis of medial epicondylitis are as follows: A) The patient must report tenderness to palpation at/near medial epicondyle; and B) In addition, at least one of the following examiner maneuvers must result in pain over the medial epicondyle and/or flexor mass of the forearm: Active or resisted wrist flexion; Active or resisted long finger flexion; Active or resisted pronation. ii. The exam may include elements for diagnosing cubital tunnel syndrome if appropriate. f. Diagnostic Testing The clinical diagnosis of epicondylitis is made by the combination of patient complaints and required objective physical findings. Additional studies such as plain radiographs, MRI, and sonogram examinations are not routinely ordered to establish the diagnosis of epicondylitis. However, these studies may be used to rule out other conditions that may produce similar symptoms, including radial tunnel syndrome, cervical radiculopathy, osteochondral radiocarpal lesion, posterolateral elbow plica, and posterolateral elbow instability. X-rays may be normal or demonstrate spur formation over the involved epicondyle. Electrodiagnostic studies can be considered to rule out neurological sources of pain, such as radial tunnel syndrome or posterior interosseous nerve entrapment. g. Non-operative Treatment i. Initial Treatment: over-the-counter medications for symptomatic relief, ice, bracing, and restriction of activities. Topical NSAIDs are commonly used, although there is no evidence that topical or oral NSAIDs are effective ([Cochrane] ().
months or longer if needed based on the operative procedure. Refer to Section H.7.f Smoking Cessation Medications and Treatment for further details. g. Operative trigger digit release. h. Post-operative i. An individualized rehabilitation program based upon communication between the surgeon and the therapist using therapies as outlined in Section H Therapeutic Procedures – Non-operative. In all cases, communication between the physician and therapist is important to the timing of exercise progressions. Treatment may include the following: splinting, elevating the hand post-operatively, and active therapy with or without passive therapy. Digital motion per surgeon’s instructions will avoid scar formation. ii. Return to work and restrictions after surgery may be made by an attending physician experienced in occupational medicine in consultation with the surgeon or by the surgeon. Usually no heavy lifting or forceful activity for 2 – 4 weeks post-operatively (). G. SPECIFIC PERIPHERAL NERVE DIAGNOSIS, TESTING &TREATMENT PROCEDURES 1. CARPAL TUNNEL SYNDROME a. The median nerve is vulnerable to compression and injury in the region of the wrist and palm. In this area, the nerve is bound by the wrist bones and the transverse carpal ligament. The most common site of compression is at the proximal edge of the flexor retinaculum (an area near the crease of the wrist). Stenosing tenosynovitis may occur proximal and distal to the carpal tunnel area. There is often a myofascial component in the patient's presentation. This should be considered when proceeding with the diagnostic testing and therapeutic intervention. The following elements are commonly associated with carpal tunnel syndrome: