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Diagnosis and Treatment of Worker-Related Musculoskeletal Disorders of the Upper Extremity

Summary (continued)

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 evidence-based 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 percent 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 evidence-based conclusions about the relationship between symptom duration and other treatment outcomes.

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 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 well-designed. 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 patient-reported pain. However, injections of glucosamines were found to have a high rate of side effects—40 percent of patients experienced pain at the site of injection, and 6 percent 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 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 evidence-based 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 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 evidence-based conclusions from currently available data.

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 evidence-based 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.

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 and 40 percent (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.

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.

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 non-dominant 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.

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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 non-randomized 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.

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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. 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 (AHRQ Publication Number 03-E038).

The Evidence Report is also online on the National Library of Medicine Bookshelf, or can be downloaded as a PDF File (8.8 MB). [PDF Help]

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AHRQ Publication Number 02-E037
Current as of October 2002

Internet Citation:

Diagnosis and Treatment of Worker-Related Musculoskeletal Disorders of the Upper Extremity. Summary, Evidence Report/Technology Assessment: Number 62. AHRQ Publication Number 02-E037, October 2002. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/clinic/epcsums/musclsum.htm