Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Job Classification

In most duration tables, five job classifications are displayed. These job classifications are based on the amount of physical effort required to perform the work. The classifications correspond to the Strength Factor classifications described in the United States Department of Labor's Dictionary of Occupational Titles. The following definitions are quoted directly from that publication.

Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Epicondylitis, Medial and Lateral


Related Terms

  • Golfer's Elbow
  • Tennis Elbow

Differential Diagnosis

Specialists

  • Hand Surgeon
  • Occupational Therapist
  • Orthopedic (Orthopaedic) Surgeon
  • Physiatrist (Physical Medicine and Rehabilitation Specialist)
  • Physical Therapist
  • Rheumatologist
  • Sports Medicine Physician

Comorbid Conditions

Factors Influencing Duration

Duration of disability depends on job requirements (e.g., use of wrist or forearm, and use of dominant versus nondominant arm), conservative versus surgical treatment, and compliance with rehabilitation program. Disability may be longer for individuals whose job duties require forceful, intensive use of both arms, often with repetition, or when comorbid conditions exist. Duration may also be longer for individuals who have delayed response to initial treatment.

For epicondylitis, risk and capacity are not the issue, and the decision to stay at work or return to work is primarily based on tolerance. There is thus no basis for permanent physician-imposed work restrictions or physician described work limitations. Symptoms (pain) tend to be chronic with activities, although often not progressive. For further information, refer to tables 9-12 and 9-13 in "Disease and Injury Causation," page 167-169.

Medical Codes

ICD-9-CM:
726.31 - Medial Epicondylitis
726.32 - Lateral Epicondylitis; Golfers Elbow; Tennis Elbow

Overview

© Reed Group
Epicondylitis suggests an inflammation of the elbow epicondyle either lateral (outside) or medial (inside). Lateral epicondylitis, commonly called tennis elbow, is a painful disorder that originates at the common extensor origin on the lateral humeral epicondyle. Traditionally, it has been described as lateral epicondylitis, despite the fact that repeated studies of pathologic findings do not show inflammation (Orchard). Histologic studies show an angiofibroblastic dysplasia from microtears on the tendon. Hence, lateral epicondylopathy may be semantically more correct. Runge is usually credited for the first description in 1873 of the condition (Runge), while the term "tennis elbow" was first used in 1883 by Major in his paper "Lawn-tennis elbow" (Major; Kaminsky).

A similar condition can occur in the common flexor tendon origin at the medial elbow and has been labeled as golfer's elbow, medial epicondylitis, or medial epicondylopathy.

Symptoms of epicondylitis often occur with overuse or overexertion of the forearm and wrist muscles. Improper training, poor technique, or improperly sized equipment often contributes to the disorder (Blackwell). Some cases have been described after acute trauma from a blow to the elbow or a sudden maximal muscle contraction.

Incidence and Prevalence: Lateral epicondylitis is at least 5 times more common than medial epicondylitis (Mercier). The exact incidence of lateral epicondylitis is difficult to determine, although among the US population it is estimated at 1% to 3% annually (Bryant; Verhaar). Medial epicondylitis accounts for only about 10% to 20% of all epicondylitis (Young). Approximately 15% of patients experience bilateral symptoms.

Source: Medical Disability Advisor



Causation and Known Risk Factors

The risk for symptoms increases with occupations and sports that require forceful movement of the forearm along with repetition. Golfer’s elbow also may affect bowlers, weight lifters, and archers. Tennis elbow may also affect badminton and squash players.

While lateral epicondylitis is uncommon in tennis players under 38 years of age (Kitai), the incidence increases after age 40 (refer to table 9-13 in "Causality," page 169), typically affecting individuals ages 40 to 50 years (Bryant).

Although men are twice as likely to develop medial epicondylitis as women, lateral epicondylitis affects men and women equally (Bryant).

Source: Medical Disability Advisor



Diagnosis

History: Individuals commonly report elbow pain with forceful gripping, and decreased ability to use the wrist most often in the dominant arm. Swelling may occasionally occur at the elbow. The symptoms may appear suddenly, but more often the onset is gradual and progressive. Over time, the pain may become severe and persist even with rest. Pain is localized to the medial or lateral elbow region initially but may progress to involve the muscle mass of the forearm. Individuals may relate a change in activity or increase in size and weight of tools used for a period immediately preceding the onset of pain. Many cases, however, occur without an obvious cause. Medial epicondylitis can be observed with ulnar nerve dysfunction at the elbow (ulnar neuropathy or cubital tunnel syndrome) resulting in numbness and tingling in the small and ring fingers, or weakness in the hand. The medical history should inquire about previous or current neck, shoulder and / or elbow injuries to rule out other causes for the symptoms.

Physical exam: On physical examination, pain may be localized over either epicondyle and may increase with resisted wrist motion. Bending the wrist forward against resistance (flexion) causes pain for individuals with medial epicondylitis and bending the wrist backward against resistance (extension) causes pain for those with lateral epicondylitis. Passive stretch of the involved muscle/tendon units may also cause pain. As the condition becomes chronic, pain and weakness may involve the forearm as well, especially with resisted wrist and finger motion. Tenderness 4 to 5 cm distal to the lateral epicondyle suggests entrapment of the radial nerve (radial tunnel syndrome). Numbness or weakness in the hand may indicate cubital tunnel syndrome as well as medial epicondylitis.

Tests: The diagnosis generally is made based upon the history and exam as noted above. In cases of medial epicondylitis, a Tinel test may be administered over the ulnar nerve, or the elbow flexion test can be used to rule out ulnar neuropathy. An injection test, in which a local anesthetic is injected into the most tender point of the elbow, may suggest the diagnosis if the elbow pain is relieved by the injection. Injections can help differentiate lateral epicondylitis from radial tunnel syndrome. When the diagnosis is in doubt or if an individual fails to respond to treatment, x-ray done to rule out fractures or bony abnormalities including arthritis about the joint. MRI may reveal abnormalities in the medial or lateral epicondyle consistent with tendinopathy or tear, but MRI imaging usually is not necessary.

Source: Medical Disability Advisor



Treatment

Initial nonsurgical (conservative) treatment consists of modification of activities with a reduction in precipitating or exacerbating activity, systemic nonsteroidal anti-inflammatory drugs (NSAIDs) for pain and inflammation. Although often suggested, a band around the proximal forearm (forearm strap or counter-force brace) may provide some symptom relief but will not correct the condition. The suggested mechanism is that the forearm strap spreads the force of the muscle contraction over a greater area and diminishes tensile stresses on the common extensor tendon (lateral epicondylitis) or common flexor tendon (medial epicondylitis). A time-limited use of a wrist extension (cock-up) splint may be helpful initially in more severe cases. Ice often relieves pain after activity, with or without swelling. Stretching can be started immediately and strengthening exercises begun as the pain subsides. There is a lack of clear literature evidence for the efficacy of massage.

Local anesthetic-corticosteroid injection may be used to treat ongoing pain in individuals who do not improve after a few weeks of treatment, although recurrences can be observed after injection. The injection may not be fully effective for 5 to 7 days and can be repeated if initial injections are transiently beneficial. Splints provide restriction of both the wrist and elbow and can be used in individuals not responding to other methods of treatment.

Autologous blood injections, botulinum toxin injections, and extracorporeal shock wave therapy are alternative treatments investigated in limited or inconclusive studies. They may be requested in some cases, as they continue to be investigated despite the lack of clear literature evidence of efficacy.

Surgery is provided on a case-by-case basis. The majority (90% to 95%) of individuals with epicondylitis will respond to non-operative treatment. Unfortunately most individuals are unwilling to wait 6 to 12 months and want to return to work activities sooner. Surgery is reserved for individuals whose pain persists, interfering with activities, and who have not been helped by appropriate nonoperative treatment. Surgery usually involves open release of the tendon's origin, excision of degenerated tendon tissue, and / or needle to the epicondyle. Needle to the epicondyle is using a needle or knife blade to make small holes in the epicondyle that stimulate blood healing to the area. Rarely is a repair of any tendon gaps or tears required. Any abnormalities in the elbow joint may be addressed concurrently.

Source: Medical Disability Advisor



ACOEM

ACOEM's Practice Guidelines, the gold standard in effective medical treatment of occupational injuries and illnesses, are provided in this section to complement the disability duration guidelines.*
 
Lateral Epicondylalgia (Lateral Epicondylitis)
Medial Epicondylalgia (Medial Epicondylitis)
 
* The relationship between the MDGuidelines (MDA) content and ACOEM's guidelines is approximate and does not always link identical diagnoses. The user should consult the diagnostic codes in both guidelines, as well as the clinical descriptions, before assuming an equivalence.

Source: ACOEM Practice Guidelines



Prognosis

Although recovery may be slow and tedious, most individuals have relief of major symptoms within 18 months from onset. Conservative measures can relieve symptoms in more than 90% to 95% of cases but may require 18 months of limited activities. When surgery is needed, it relieves symptoms for more than 80% of individuals (Young), although some individuals continue to experience pain during aggressive activities. Ulnar nerve involvement may be associated with a less optimal prognosis. Recurrence of epicondylitis later in life is common.

Source: Medical Disability Advisor



Rehabilitation

The primary focus of rehabilitation for medial and lateral epicondylitis is to control pain and restore function. Initially, modalities such as cold packs may be helpful in controlling painful symptoms. Loss of motion is usually not a problem with epicondylitis; however, individuals may avoid full range of motion as a result of excessive pain. During the initial period of acute symptomatology, individuals should be advised to limit any movements that exacerbate pain. An ergonomic assessment may be useful for workplace modifications to reduce any aggravating activities associated with this condition. It is important to identify both work and leisure activities that may have contributed to the symptoms and to educate individuals how to reduce risk factors.

Braces or wraps of the elbow or wrist may be used and have some effectiveness (Hegmann). Elbow bracing is likely to improve short term performance of daily living activities (Buchbinder). However, as no particular brace appears superior, it is most useful to consider the individual’s preference and work situation (Hegmann; Bisset, "Mobilisation with movement"). Stretching and strengthening exercises of the elbow, wrist, and extrinsic hand muscles may be beneficial, and, when performed in conjunction with modalities, may provide relief. Home exercises should be taught as well as pain control measures (heat and cold) (Bisset, "A Systematic review").

Topical nonsteroidal anti-inflammatory agents for epicondylitis (Hegmann) and treatment with iontophoresis (Hegmann) or ultrasound may facilitate recovery. Local corticosteroid injections can provide short term relief. Physical therapy treatment, including manipulation, home exercise instruction, and supervised exercise is likely to decrease pain at 6 weeks but not at 1 year (Bisset, "Mobilisation with movement"). Low level laser is not recommended (Bisset, "A Systematic review"). The use of deep transverse friction massage or manipulation alone is not supported (Bisset, "A Systematic review"; Brousseau). Extracorporeal shock wave therapy is also not thought to be effective (Hegmann; Brousseau). Acupuncture may be useful in some cases.

FREQUENCY OF REHABILITATION VISITS
Nonsurgical
SpecialistEpicondylitis, Medial and Lateral
Occupational or Physical TherapistUp to 8 visits within 4 weeks
The table above represents a range of the usual acceptable number of visits for uncomplicated cases. It provides a framework based on the duration of tissue healing time and standard clinical practice.

Source: Medical Disability Advisor



Complications

Radial neuropathy may co-exist in a small percentage of patients with lateral epicondylitis. Ulnar neuropathy (cubital tunnel syndrome) can occur in cases of medial epicondylitis.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

An ergonomic evaluation of the workplace may be helpful. Limiting precipitating or exacerbating activity may be helpful. The key is to remain physically active in an effort to maintain functional capacity and limit loss of muscle mass. A gradual return to normal work duties is recommended, with an emphasis on improving form to avoid aggravating activities. Change in job duties, sharing or alternating tasks, and limiting time and frequency of repetitive activities are important accommodations to consider. Use of vibrating tools such as impact wrenches or jackhammers should be minimized. Increasing or decreasing the size of tool grips so the wrist can be held in the "ideal" position is also helpful. Use of splints, straps, and casts affect dexterity and the individual may be temporarily unable to lift and carry heavy or bulky objects, operate equipment, or perform other tasks requiring the use of both hands. If the dominant arm was affected, the individual may be unable to write legibly (severe cases), type well, or perform activities that require fine motor skills such as those in a laboratory or assembly line. Company policy on medication usage should be reviewed to determine if pain medication use is compatible with job safety and function. For additional information on risk and capacity, please refer to "Work Ability and Return to Work," pages 190-192.

Risk: This is no significant risk of reinjury for epicondylitis. NIOSH data suggest that most jobs do not pose a substantial risk, and that the common problem is tolerance for symptoms, not risk.

Capacity: Capacity, the ability to do activities, is usually not an issue with epicondylitis. Individuals have the ability but will report pain with activities (tolerance).

Tolerance: Tolerance (pain with activities) for epicondylitis is a frequent reason people choose to do, or not to do, specific activities. Tolerance is affected by how the individual considers the rewards (including salary and fun) versus the cost (including pain).

Accommodations: Temporary modification of activities includes limiting exposure to precipitating or exacerbating activity, but not total absence of activity. A change in job duties, sharing or alternating tasks, and limiting time and frequency of repetitive activities are important accommodations. For chronic cases, temporary work modification is not appropriate.

Surgical treatment may decrease the associated pain. Ultimately, however, the employee will need to choose to take a different job or to continue to endure the pain. In many chronic cases, the pain ultimately decreases, but this progression may take years to occur.

Source: Medical Disability Advisor



Maximum Medical Improvement

60 to 90 days post surgery.

Continued improvement is possible over 540 days (18 months), but the amount of improvement is limited.

Source: Medical Disability Advisor



Failure to Recover

If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case.

Regarding diagnosis:

  • Does individual's occupation or hobby involve forceful of stressful use of the forearm, often in combination with repetition?
  • Does individual report elbow pain, swelling, and the inability to use the wrist and arm?
  • Has pain spread to the forearm?
  • Is the affected elbow on the dominant or nondominant side?
  • Does individual have a history of neck or shoulder injuries?
  • On physical examination, is the pain localized over either epicondyle?
  • Does pain increase with resisted wrist motion?
  • Is weakness noted in the forearm?
  • Has the individual experienced numbness and tingling in the affected arm?
  • Does the individual report occasional locking?
  • Did individual have an injection test done? X-ray? MRI?
  • Have conditions with similar symptoms been ruled out?

Regarding treatment:

  • Has individual responded favorably to treatment consisting of rest from the aggravating activity, ice packs, NSAIDs, and a splint?
  • Has individual received a corticosteroid injection?
  • Has individual allowed enough time for conservative treatments to be effective?
  • Was surgery necessary?

Regarding prognosis:

  • Is individual active in physical therapy? Does individual have a home exercise program?
  • Is individual's employer able to accommodate any necessary restrictions?
  • Has individual had an ergonomic evaluation of his or her work area?
  • Does individual have any conditions that may affect the ability to recover?
  • Does individual experience any complications such as radial or ulnar neuropathy?

Source: Medical Disability Advisor



References

Cited

Bisset, L., et al., eds. "A Systematic review and meta-analysis of clinical trials on physical interventions for lateral epicondylalgia." British Journal of Sports Medicine 39 (2005): 411-422.

Bisset, L., et al., eds. "Mobilisation with movement and exercise, corticosteroid injection, or wait and see for tennis elbow: randomized trial." BMJ Clinical Evidence Handbook. 333 ed. BMJ Publishing Group, 2006. 939.

Blackwell, J. R. , and K. J. Cole. "Wrist kinematics differ in expert and novice tennis players performing the backhand stroke: implications for tennis elbow." Journal of Biomechanics 27 (1994): 509-516.

Brousseau, Lucie, et al., eds. "Deep transverse friction massage for treating tendinitis." Cochrane Database of Systematic Reviews. John. Wiley & Sons, 2002.

Buchbinder, Rachelle, et al., eds. "Tennis Elbow." BMJ Clinical Evidence Handbook. BMJ Publishing Group, 2009. 406-407.

Green, S., et al. "Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) for Treating Lateral Elbow Pain in Adults." Cochrane Database of Systematic Reviews 2 (2002): CD003686. National Center for Biotechnology Information. National Library of Medicine. 7 Nov. 2008 <PMID: 12076503>.

Haahr, J. P., and J. H. Andersen. "Prognostic Factors in Lateral Epicondylitis: A Randomized Trial with One-Year Follow-Up in 266 New Cases Treated with minimal Occupational Intervention or the Usual Approach in General Practice." Rheumatology 42 10 (2003): 1216-1225. National Center for Biotechnology Information. National Library of Medicine. 7 Nov. 2008 <PMID: 12810936>.

Hegmann, Kurt T., et al., eds. "Chapter 11: Hand, Wrist and Forearm Disorders." Occupational Medicine Practice Guidelines: Evaluation and Management of Common Health Problems and Functional Recovery in Workers. 2008 Revision 2nd ed. ACOEM, 2008. 627-652.

Kaminsky, S. B. , and C. L. Baker. "Lateral epicondylitis of the elbow." Techniques in Hand & Upper Limb Surgery 7 (4) (2003): 179-189.

Kitai, E. , et al. "An epidemiological study of lateral epicondylitis (tennis elbow) in amateur male players." Ann Chir Main 5 (2) (1986): 113-121.

Major, H. P. "Lawn-tennis elbow." BMJ 1883 (2) 557.

Melhorn, J. Mark, and William Ackerman, eds. Disease and Injury Causation, Guides to the Evaluation of. AMA Press, 2008.

Orchard, J. , and A. Kountouris. "The management of tennis elbow." BMJ 342 (2011): 2687.

Orchard, J. , and A. Kountouris. "The management of tennis elbow." Ferri's Clinical Advisor 2009. Ed. Fred Ferri. Philadelphia: Mosby, Inc., 2009. 2687.

Runge, F. "Zur Genese und Behandlung des Schreibekrampfes." Berliner Klin Wochenschr 1873 (110) 245-248.

Talmage, J. B. , J. M. Melhorn, and M. H. Hyman, eds. Work Ability and Return to Work, AMA Guides to the Evaluation of. Second ed. Chicago: AMA Press, 2011.

Verhaar, J. A. "Tennis elbow. Anatomical, epidemiological and therapeutic aspects." International Orthopaedics 18 (5) (1994): 263-267.

Walrod, Bryant James , and Craig Young. "Lateral Epicondylitis." eMedicine. Eds. Sherwin SW Ho, et al. 3 Oct. 2012. Medscape. 22 Jan. 2013 <http://emedicine.medscape.com/article/96969-overview>.

Young, Craig C. "Medial Epicondylitis." eMedicine. Eds. Anthony J. Saglimbeni, et al. 3 Oct. 2012. Medscape. 22 Jan. 2012 <http://emedicine.medscape.com/article/97217-overview>.

Source: Medical Disability Advisor






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