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.

Neuropathy of Radial Nerve (Entrapment)


Related Terms

  • Cheiralgia Paresthetica (radial nerve wrist entrapment)
  • Crutch Palsy
  • Finger or Thumb Extensor Paralysis
  • Posterior Interosseous Nerve Syndrome
  • Radial Nerve Compression
  • Radial Nerve Dysfunction
  • Radial Nerve Entrapment
  • Radial Nerve Palsy
  • Radial Neuritis
  • Radial Neuropathy
  • Radial Tunnel Syndrome
  • Saturday Night Palsy
  • Supinator Syndrome
  • Wartenberg Syndrome
  • Wristdrop Neuropathy

Specialists

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

Comorbid Conditions

Factors Influencing Duration

Duration depends on the severity of condition or injury, response to conservative treatment, ability to modify job requirements, the need for surgery, and any complications.

Medical Codes

ICD-9-CM:
354.3 - Lesion of Radial Nerve; Acute Radial Nerve Palsy

Overview

The radial nerve is located behind the arm (triceps), wraps around the outside of the elbow (lateral epicondyle), and continues down the forearm to end on the top of the thumb and index fingers. The term "neuropathy" refers to abnormal nerve function that may occur when a nerve becomes constricted or compressed (entrapped) anywhere along its path. Neuropathy of the radial nerve (radial neuropathy) may result in pain, weakness, numbness, or tingling (paresthesia). These symptoms may occur at the back (dorsum) of the forearm, as well as the dorsal hand, thumb, or fingers (index, middle, and part of the ring finger), but not usually at the fingertips.

The radial nerve travels from the brachial plexus in the armpit (axilla) and spirals down the back of the arm to the outer elbow, where it passes in front of the elbow near the lateral epicondyle and radial head, dividing into sensory and motor portions in the forearm. The main portion of the radial nerve, the posterior interosseous nerve, supplies motor control to the extensor muscles of the forearm, controlling the wrist, thumb, and fingers. It terminates with sensory fibers to the dorsal wrist capsule.

Radial neuropathy (radial nerve entrapment) typically occurs at the back of the arm, at the elbow, or in the deep muscles of the forearm. The most common site of radial nerve entrapment is in the radial tunnel at the front of the lower elbow/upper forearm. The radial tunnel is about 2 inches long and is bordered by the end of the bone of the upper arm (humerus) and muscles of the elbow and forearm. In the radial tunnel, nerve entrapment may be caused by tight forearm muscles, tendons, or fascia; inflammation of the elbow bursa (bursitis); or space-occupying lesions such as bone tumors, benign fatty tumors (lipomas), or ganglion cysts. In this region, the symptoms of radial tunnel syndrome, although rare, may be similar to those of the more commonly experienced tennis elbow (lateral epicondylitis; elbow tendinopathy). Consequently, lateral epicondylitis that is unresponsive to treatment may be explained by an underlying radial tunnel syndrome.

The most common causes of radial neuropathy are direct trauma to the nerve or prolonged pressure on the nerve from compression, swelling, or injury of nearby structures. The radial nerve is frequently injured during a fracture of the distal 1/3 of the humerus (just above the elbow in the upper arm) or upper forearm (proximal radius just below the elbow). A high radial nerve palsy is a compression of the radial nerve above the elbow, which may occur from inappropriately using crutches (crutch palsy) or from habitually resting the arm over the back of a chair. The radial nerve may also become compressed in its spiral groove along the back of the humerus during a period of immobility such as occurs during deep sleep (Saturday night palsy). Symptoms of aching at the elbow/forearm are often reported with work-related repetitive activity requiring significant pronation or supination of the forearm or ulnar wrist flexion (which stretches and therefore puts additional pressure on the radial nerve). Although these factors have been implicated as contributing to radial tunnel syndrome, clear causation is lacking. Symptoms have also been reported with using a screwdriver, prolonged writing with a pen, and using a typewriter (Dellon; Erlich). Compression of the sensory portion of the radial nerve at the wrist (Wartenberg syndrome) may be caused by wearing a tight watch strap or from the application wrist bands. Individuals with diabetes, rheumatoid arthritis, or hypothyroidism have increased likelihood of developing nerve entrapment syndromes.

Incidence and Prevalence: Two to eighteen percent of humeral shaft fractures result in radial neuropathy (Bodner).

Source: Medical Disability Advisor



Causation and Known Risk Factors

Radial neuropathy is twice as likely to occur in men as in women (Latinovic). There is some evidence to suggest force and repetition or force and posture as occupational risk factors for symptoms, but they are not clear occupational risk factors for causation (van Rijn). Individuals who smoke or abuse alcohol have increased risk for nerve entrapment syndromes.

Source: Medical Disability Advisor



Diagnosis

History: The history of symptoms is dependent on the location (arm, forearm, wrist) of the radial nerve entrapment. Individuals may report sharp, burning, or aching pain in the lateral portion of the elbow, as well as along the back (dorsum) of the hand, thumb, or at the index, middle, and part of the ring fingers. Numbness or tingling may be present between the back of the thumb and index finger (first dorsal web space). Over time, individuals may notice progressive weakness, a lack of dexterity, and a feeling of fatigue with wrist and hand movements, and sometimes wrist drop, where the hand is unable to turn from a pronated (palm down) position to a supinated (palm up) position.

Physical exam: Again, the physical examination is dependent on the location (arm, forearm, wrist) of the radial nerve entrapment. On physical exam, the individual may be unable to extend the elbow, wrist (wrist drop), thumb, or fingers (finger drop), and may have difficulty rotating the palm up. Extension with radial deviation but no finger extension localizes the site of compression to the radial tunnel. There may be tenderness to palpation of the radial tunnel region at the front of the elbow distal to the lateral epicondyle, and there may be pain upon resisted wrist extension, index finger extension, or forearm supination. In mild cases, weakness is most likely to be detected by resisting the extended index finger, or resisting supination in the pronated position.

If symptoms originate from the elbow, tapping (percussion) over the radial nerve at the radial tunnel may reveal a localized Tinel's sign (tingling sensation); however, this does not always occur.

Tests: Electromyography (EMG) and nerve conduction studies may help to establish the diagnosis of nerve entrapment, although results are often inconclusive in early mild cases. X-rays may be performed to rule out bony abnormalities that may contribute to nerve compression. If a mass is suspected as the cause of radial nerve compression, an MRI may be obtained for confirmation. A lidocaine injection (nerve block) may be administered to evaluate the presence of nerve entrapment.

Source: Medical Disability Advisor



Treatment

Treatment of radial neuropathy (radial nerve entrapment) depends upon the underlying cause and location of the nerve compression or entrapment. Application of a neutral position wrist splint can help to rest the affected area and limit irritation to the radial nerve. Symptoms may be controlled by over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDs), or with a corticosteroid injection to reduce local inflammation and swelling around the nerve. Physical therapy may be prescribed to stretch tight soft tissues compressing the nerve and to strengthen surrounding muscles. Other non-pharmaceutical treatments, including transcutaneous electric nerve stimulation and acupuncture, may be considered as adjuvant to medication (Weiss and Weiss). A tennis elbow strap, commonly used for lateral epicondylitis, can sometimes aggravate symptoms of radial tunnel syndrome at the elbow.

For individuals that fail conservative treatment, surgical decompression may be indicated. Examples include progressive weakness in grip strength or wrist/finger extension strength coupled with an abnormal electrodiagnostic study, or if imaging studies reveal that a structure (i.e., bone, tight muscle or tendon, cyst, tumor) is constricting the nerve. Surgery may be performed under a general or regional anesthesia. During surgery, the radial tunnel is enlarged by dividing the forearm fascia and surrounding tight muscle fibers, including division of the supinator muscle, allowing exposure of the posterior interosseous nerve (Carter; Derkash; Hirayama; Sponseller). Any space-occupying lesions are located and removed, and the incision is closed with sutures and allowed to heal.

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.*
 
Radial Nerve Entrapment Elbow (including Radial Tunnel Syndrome)
Radial Nerve Entrapment Hand, Wrist, and Forearm
 
* 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

If the cause of radial neuropathy is found and treated, recovery is possible. Most individuals treated conservatively with activity modification, splinting, and medication will experience some improvement but may require 6 months of activity modification. Since most individuals want a faster recovery time, surgical decompression is becoming more common.

Prognosis is excellent in 90% to 95% of individuals receiving decompressive surgery of the radial nerve (Harrop). However, the prognosis for improvement is not as good for individuals with normal electrodiagnostic studies who are treated surgically.

Source: Medical Disability Advisor



Rehabilitation

The goals of rehabilitation for radial neuropathy are to reduce pain and then to restore full function with a pain-free elbow, wrist, and hand. Protocols for rehabilitation are based upon the underlying cause and location of the neuropathy and whether the condition required surgery. Conservative measures are used initially to determine the individual’s response to treatment and to determine the need for surgery.

Treatment of radial neuropathy (nonsurgical) usually begins with PRICE (protection, rest, ice [and / or heat], compression, elevation) to help decrease swelling and pain. Therapists instruct individuals in range of motion exercises for the elbow, wrist, hand, and fingers to retain flexibility and to stretch tight muscles. Massage (soft tissue release) and modalities such as electrical stimulation or therapeutic ultrasound may also help to relax restrictive muscles. For acute onset of symptoms, emphasis is on protective splinting. Individuals are shown how to use a protective splint and are instructed in modification and pacing of activities, and education regarding proper use of the upper extremity with functional tasks. For chronic symptoms, emphasis is on stretching and nerve gliding. Strengthening exercises may be introduced as tolerated and progressed with an emphasis on avoiding the reproduction of symptoms.

If surgical decompression becomes necessary, postsurgical rehabilitation will be directed by the treating physician. Following surgery, the individual is placed in a splint with a neutral forearm and wrist and the elbow flexed to 90° for several days, followed by early range of motion exercises. Early range of motion activities are indicated to stretch tight muscles and restore flexibility, with progressive strengthening exercises added as tolerated.

As part of treatment and as prevention against recurrent injury, therapists should perform an ergonomic assessment to examine the postures and activities required of the individual at work and suggest alternatives to aggravating positions, tools, and movement patterns.

FREQUENCY OF REHABILITATION VISITS
Nonsurgical
SpecialistNeuropathy of Radial Nerve (Entrapment)
Occupational or Physical Therapist2 visits
Surgical
SpecialistNeuropathy of Radial Nerve (Entrapment)
Occupational or Physical Therapist4 visits

Source: Medical Disability Advisor



Complications

Complications include permanent nerve damage that results in partial or complete loss of wrist and hand movement, sensation loss, muscular atrophy, and chronic pain.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

Activity modification to avoid nerve irritation is the cornerstone of successful treatment for radial neuropathy. Return to work is dependent on the ability to modify the work and home environment to reduce movements or positions that cause radial nerve compression symptoms. If nerve entrapment results from the prolonged use of prosthetic devices, such as crutches, redesign or replacement may prove helpful. Certain individuals may be able to stay at work or return to work in a limited capacity. Company policy on medication usage should be reviewed to determine if pain medication use is compatible with job safety and function. For more information please refer to "Work Ability and Return to Work," pages 193-196, where the discussion about ulnar nerve entrapment of the elbow is also relevant to radial nerve entrapment.

Risk: If nerve function is documented at multiple office visits, and if it is clearly worsening with continued work activity and subsequently improves with temporary work restrictions, it is reasonable to conclude that this work activity is a risk to this patient’s radial nerve. Either permanent work restrictions or surgical treatment would be indicated. Generally the weight lifted at work is not a problem. Restrictions should address sustained posturing with the elbow in flexion of greater than 90 degrees, highly repetitive elbow flexion, and repetitive contusion of or sustained pressure on the nerve.

Capacity: Untreated nerve entrapment may result in loss of muscle which will reduce grip strength and therefore reduce capacity.

Tolerance: Tolerance for symptoms such as pain and paresthesia is the most frequent problem. If tests of nerve function confirm that radial neuropathy with significant nerve function impairment is the correct diagnosis, most physicians would feel the symptoms are believable and the condition is at a level of severity that justifies physician support for work modification.

Accommodations: Accommodations allow the individual to continue in the workplace. If symptoms progress and if the entrapment is diagnosed early and failure of non-surgical treatment results in surgery, most individuals can return to their previous work activities if the risk of recurrence is low; however, symptoms of aching are often permanent.

Source: Medical Disability Advisor



Maximum Medical Improvement

8 to 114 days post surgery.

Continued improvement is possible over 504 days, 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:

  • Has there been a recent fracture of the humerus?
  • Has individual been using crutches? Wearing a cast?
  • Was there weakness with forearm supination? Wrist or index finger extension?
  • Did individual complain of pain and swelling that worsened with activity?
  • Did individual report numbness and tingling on the back of the hand or thumb, or index, middle, and part of the ring fingers?
  • Did individual have increased symptoms with resisted middle finger extension? Resisted supination?
  • Were x-rays taken? MRI performed?
  • Were nerve conduction studies performed?
  • Did EMG and electrodiagnostic studies document permanent nerve damage?
  • Was lidocaine nerve block performed?
  • Was diagnosis of radial nerve entrapment confirmed?

Regarding treatment:

  • Was a protective wrist splint recommended?
  • Were aggravating activities causing nerve compression modified or stopped?
  • Was a corticosteroid injection required to reduce symptoms of nerve inflammation?
  • Were protection, rest, ice and / or heat, and elevation recommended?
  • Were NSAIDs required to control pain and reduce swelling?
  • Was individual compliant with treatment recommendations?
  • Was physical therapy recommended?
  • Did individual comply with rehabilitation regimen?
  • Did splinting, medication, and activity modification resolve symptoms?
  • If symptoms worsened with progressive weakness, was surgical decompression of the radial tunnel performed?
  • Did postsurgical complications occur?

Regarding prognosis:

  • Was conservative treatment effective to resolve the condition or was surgical decompression required?
  • Is the dominant or nondominant arm affected?
  • Did permanent nerve damage (partial or complete loss of wrist and hand extension, muscular atrophy, sensation loss, and / or chronic pain) occur?
  • Is individual compliant with treatment recommendations and physical therapy?
  • Are activities of daily living affected?
  • Has adequate time elapsed for a full recovery?
  • Is employer able to provide appropriate work accommodations to prevent recurrence?

Source: Medical Disability Advisor



References

Cited

Bodner, G., et al. "Sonographic Detection of Radial Nerve Entrapment within a Humerus Fracture." Journal of Ultrasound in Medicine 18 10 (1999): 703-706.

Carter, G. T., et al. "Focal Posterior Interosseous Neuropathy in the Presence of Hereditary Motor and Sensory Neuropathy, Type I." Muscle Nerve 19 (1996): 644-648.

Dellon, A. L., and S. E. Mackinnon. "Radial Sensory Nerve Entrapment in the Forearm." Journal of Hand Surgery 11 (1986): 199-205.

Derkash, R. S., and J. J. Niebauer. "Entrapment of the Posterior Interosseous Nerve by a Fibrous Band in the Dorsal Edge of the Supinator Muscle and Erosion of a Groove in the Proximal Radius." Journal of Hand Surgery 6 (1981): 524-626.

Harrop, James, et al. "Nerve Entrapment Syndromes." eMedicine. Eds. Michael G. Nosko, et al. 7 Dec. 2007. Medscape. 2 Mar. 2009 <http://emedicine.medscape.com/article/249784-overview>.

Hirayama, T., and Y. Takemitsu. "Isolated Paralysis of the Descending Branch of the Posterior Interosseous Nerve." Journal of Bone and Joint Surgery 70 (1988): 1402-1403.

Latinovic, R., and M. C. Guilliford. "Incidence of Common Compressive Neuropathies in Primary Care." Journal of Neurology, Neurosurgery & Psychiatry 77 (2006): 263-265.

Sponseller, P. D., and W. D. Engber. "Double-entrapment Radial Tunnel Syndrome." Journal of Hand Surgery 8 (1983): 420-423.

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.

van Rijn, R. M. , et al. "Associations between work-related factors and specific disorders at the elbow: a systematic literature review." Journal of Rheumatology 48 (5) (2009): 528-536.

Weiss, L., et al. "Neuromuscular Rehabilitation and Electrodiagnosis: Peripheral Neuropathy." Archives of Physical and Medical Rehabilitation 86 Suppl 1 (2005): 511-517.

Source: Medical Disability Advisor






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