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.

Sprains and Strains, Elbow


Related Terms

  • Elbow Instability
  • Elbow Joint Laxity
  • Lateral Epicondylitis
  • Tendinitis
  • Tendonitis
  • Tennis Elbow

Differential Diagnosis

Specialists

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

Comorbid Conditions

Factors Influencing Duration

Factors include the location, type, and severity of the injury, whether the dominant arm is affected, the severity of the pain associated with the injury, the method of treatment, the individual's response to treatment and adherence to recommendations, and the individual's job requirements.

Medical Codes

ICD-9-CM:
841.0 - Sprains and Strains of Elbow and Forearm, Radial Collateral Ligament
841.1 - Sprains and Strains of Elbow and Forearm, Ulnar Collateral Ligament
841.2 - Sprains and Strains of Elbow and Forearm, Radiohumeral Joint
841.3 - Sprains and Strains of Elbow and Forearm, Ulnohumeral Joint
841.8 - Sprains and Strains of Elbow and Forearm, Other Specified Sites
841.9 - Sprains and Strains of Elbow and Forearm, Unspecified Site; Elbow NOS

Overview

The elbow can have both sprains and strains.

The elbow joint is formed by the joining (articulation) of the upper arm bone (humerus) with the two bones of the forearm (radius and ulna). The radius is located on the thumb side of the forearm, the ulna on the little finger side.

A sprain is a stretching or tearing of ligaments—the tough bands of fibrous tissue that connect one bone to another in the body's joints, stabilizing and supporting the joints. A sprain can be caused by direct or indirect trauma, such as a fall or a blow that knocks a joint out of position. This results in an overstretching and, in severe cases, a complete tear or rupture of the supporting ligaments. Typically, this injury occurs when an individual lands on an outstretched arm; slides into a base; or a power tool kicks back.

An elbow sprain involves damage to in one or more of the three main ligament complexes that connect the bones of the elbow (radial collateral ligament, ulnar collateral ligament, and annular ligament of radius). An elbow sprain usually follows a sharp twist at the joint that exceeds the stretching capacity of the ligament(s).

Elbow sprains, like sprains elsewhere in the body, are graded according to the severity of ligament damage and the resulting amount of joint separation. Grade I sprains (mild or first-degree sprains) involve stretching of the ligament fibers without joint separation and with no resulting joint instability. Grade II sprains (moderate or second-degree sprains) reflect stretching and tearing of some ligament fibers with minimal joint displacement and some joint instability, usually with marked pain and swelling; there may also be bruising (black and blue) around or in the joint. Grade III sprains (severe or third-degree sprains) involve full thickness tears (rupture) of ligament fibers that result in joint dislocation, with marked pain, swelling and bruising. Most elbow sprains are grade I or grade II sprains. These sprains usually are associated with muscle spasm.

The elbow can also experience a strain: damage to the muscles and / or tendons (lateral epicondyle and medial epicondyle) that traverse the elbow joint. Elbow strains can be the result of overstretching or overuse. Repetitive use of the forearm and wrist may also result in elbow strain.

Acute strains occur immediately following muscle overuse or overstretching. Chronic strains occur after repeated overuse or degeneration of tissue. Usually, strains are not as severe as sprains and may not be felt until the day following the injury. Muscle and tendon strains also are graded according to the severity of muscle or tendon fiber damage. A grade I strain is a mild strain in which muscles or tendons become stretched with few torn fibers and no loss of muscle strength; there may be mild pain with or without swelling. Grade II strains involve a greater number of injured muscle or tendon fibers with noticeable loss of strength, usually with marked pain and swelling. With a grade III strain, the muscle or tendon is completely torn (ruptured), resulting in complete functional loss of the affected muscle or tendon, with marked pain, swelling and bruising.

"Tennis elbow" has been used as a catch-all phrase to describe multiple conditions that cause pain in the elbow, particularly in players of racquet sports. The term currently refers to lateral elbow tendinopathy, or to a chronic strain of the tendon that attaches to the lateral epicondyle of the humerus, often with secondary inflammation of the epicondyle itself (epicondylitis). The less common term "golfer's elbow" refers to medial elbow tendinopathy, or a chronic strain of the muscles that originate at the medial epicondyle (inside edge) of the humerus.

Incidence and Prevalence: Muscle aches and pains are common. Grade I strains and sprains are common. Grade II strains and sprains often require short periods of modified activities. Only the majority of grade III strains and sprains are seen by healthcare providers. Consequently, many strains and sprains are not reported or treated and therefore the precise incidence is not known.

Source: Medical Disability Advisor



Causation and Known Risk Factors

Sprains and strains are common injuries among individuals who participate in racquet sports, golf, or other sports requiring a forceful throwing motion. They also can occur on the job, especially in individuals who work at manual labor, painting, plumbing, or meat cutting ("Tennis Elbow (Lateral Epicondylitis)").

Source: Medical Disability Advisor



Diagnosis

History: In acute sprains and strains, the individual may report localized pain in the elbow that worsens with activity or use. Muscle tenderness and / or loss of mobility may not occur immediately. With a severe elbow sprain, the individual may report a sharp, transient pain, possibly associated with a snapping noise and rapid swelling. With lateral epicondylitis (tennis elbow), pain may worsen with twisting or grasping motions, particularly those motions done when the palm is in a face-down position. With medial epicondylitis (golfer’s elbow), pain may worsen with gripping or lifting activities, particularly those motions done when the palm is in a face-up position. With elbow sprains, such as those to the ulnar collateral ligament, pain may worsen with throwing motions. In acute strains, the individual may report pain in the elbow, edema, muscle tenderness, and stiffness and loss of mobility up to a few days after the strain. In chronic strains from repetitive stress, symptoms of stiffness, soreness, and generalized tenderness may appear gradually and worsen with increased use of the joint.

Physical exam: The exam may reveal tenderness to touch or upon pressure, localized swelling (edema), and sometimes areas of discoloration from bleeding into the muscle (ecchymosis). Range of motion may be limited by pain and muscle spasm, and the involved muscles may be tense. Joint instability may be present. Clinical testing maneuvers that involve the joint, such as resisted wrist extension and the valgus stress test, may be used to confirm the diagnosis. Most elbow strains and sprains do not require additional diagnostic tests.

Tests: An x-ray may be taken to rule out fracture. Advanced imaging techniques such as CT and MRI usually are not indicated and are of limited diagnostic use.

Source: Medical Disability Advisor



Treatment

Treatment for both sprains and strains is similar and usually is nonsurgical (conservative) for grade I and grade II. Pain and swelling may be relieved through the intermittent application of ice during the first 48 to 72 hours following injury. Temporary immobilization with an elastic bandage, splinting, bracing, or, if severe, a soft cast, is typically recommended. The joint may be elevated above the level of the heart using pillows when lying down. Nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly used for relief of pain and inflammation. If pain is severe, a mild narcotic may be prescribed for a short period. In addition, muscle relaxant drugs may be prescribed. Corticosteroid injections are commonly used to relieve medial and lateral tendinopathy.

Activity level should be adjusted according to what the individual can tolerate. The individual should avoid activities that aggravate the pain, such as lifting, bending, twisting, or throwing; activity level can be increased gradually.

Surgery is rarely indicated except for grade III sprains and strains where there is complete rupture of the ligament or tendon. The surgical treatments available are primary repair of ruptured tendons (modified Bunnell technique) or reconstruction of torn ligaments using tendon grafts (Jobe procedure, Andrews procedure). Physical therapy does not begin for several weeks after surgery.

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.*
 
Sprain of the Elbow
 
* 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

Most grade I and grade II sprains and strains heal on their own without significant functional impairment. Severe sprains may result in a permanent flexion contracture of the elbow, which is usually minor and of little functional consequence. There may be an increased potential for injury recurrence, particularly in individuals with more severe injuries or in those who do not allow previous injuries to heal completely.

Occasionally, grade III torn ligaments do not heal properly and allow recurrent dislocation, necessitating surgical repair. Also, muscle ruptures in which a tendon becomes partially or completely detached require surgical repair (modified Bunnell technique). Although repair should ideally be carried out within 2 to 3 days of the injury, delayed repair or reconstruction of older ligament tears generally produces good results. These procedures to reconstruct older ligament tears involve the use of a tendon graft anchored in the bones to replace the torn ligament complex (Jobe procedure, Andrews procedure).

Source: Medical Disability Advisor



Rehabilitation

The focus of rehabilitation for sprains and strains of the elbow is to control pain and restore functional status.

Common clinical practice for grade I and grade II includes immobilization with use of a shoulder sling if the degree of soft tissue damage warrants it for up to 1 week (Hegmann). Therapy should follow the PRICE principle (protection, rest, ice, compression, elevation) for the first 48 to 72 hours or until the swelling is controlled (Aiello; Braddom).

In more severe cases, physical therapy may be warranted after pain and swelling are controlled; heat, massage, or therapeutic ultrasound may be used.

Once acute symptoms resolve, restoration of motion at the shoulder, elbow, forearm, and wrist is the next goal of therapy. Range of motion and active stretching exercises should be started early (Hegmann). Upper extremity strengthening exercises are used to strengthen the muscles supporting the involved joints.

The final goal is returning the individual to full function for work and recreational activities with minimal risk of re-injury. If work tasks expose the individual to risk factors for an elbow sprain or strain, an ergonomic assessment may be indicated. If leisure activities are suspected in causing the initial injury, the individual should be educated in ways to modify the activity and decrease the likelihood of having symptoms (Aiello). (See Epicondylitis Medial and Lateral.)

FREQUENCY OF REHABILITATION VISITS
Nonsurgical
SpecialistSprains and Strains, Elbow
Occupational or Physical TherapistUp to 8 visits within 6 weeks
Surgical
SpecialistSprains and Strains, Elbow
Occupational or Physical TherapistUp to 12 visits within 8 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

Complications are rare with grade I and grade II. Complications of severe injuries include dislocations and avulsion fractures, which involves the tearing away of a piece of bone with a ligament at the point of attachment, and nerve compression or blood vessel injury. Stretch injury to one of the nerves passing by the elbow is common. When repaired surgically, all the standard surgical complications are possible along with some residual functional loss.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

Return to work depends on the grade of sprain or strain and the specific work duties that are required. The individual may benefit from temporary reassignment. Dexterity and use of the affected arm will be limited if an arm sling is worn. The individual with a strain of the elbow muscles / tendons may be temporarily unable to lift and carry heavy objects, operate equipment, or perform other tasks that require lifting, pushing, or pulling against resistance using the injured arm. Individuals whose dominant arm is affected may require more accommodations than those whose non-dominant arm is affected.

Company policy on medication usage should be reviewed to determine if pain medication use is compatible with job safety and function.

Source: Medical Disability Advisor



Maximum Medical Improvement

In the absence of fracture, dislocation, nerve injury, or joint injury, the elbow sprain/strain is considered a “soft tissue injury.” Like other soft tissue injuries, the majority of the healing occurs in the first 90 days. Other than surgery, additional treatment after 90 days from the date of injury is not likely to result in dramatic improvement, so MMI is frequently achieved by 90 days after injury.

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:

  • Have conditions such as elbow joint arthrosis in older persons, radiohumeral arthritis, soft-tissue ectopic calcifications, avulsion injury of the medial epicondyle, and fractures of humerus, radius, or ulna, been ruled out?
  • How has diagnosis of elbow strain or sprain been confirmed?
  • Has individual experienced complications, such as dislocation, avulsion fracture, or stretch injury to one of the nerves passing by the elbow?

Regarding treatment:

  • Were rest and temporary immobilization with an elastic bandage, splint, brace, or, if severe, a soft cast, recommended?
  • Were pain relievers, corticosteroid injections, and muscle relaxants prescribed when appropriate?
  • Was physical therapy prescribed? Was individual compliant with treatment regimen? Were activities such as lifting, bending, or twisting avoided?
  • If acute symptoms resolved, did individual begin stretching and strengthening exercises?
  • Did individual resume activities too soon?
  • Is surgical intervention warranted?

Regarding prognosis:

  • Have all conservative options been explored?
  • Would individual benefit from additional physical therapy, with emphasis on regaining full range of motion and the use of warm-up exercises to prevent recurrent injury?
  • Does individual have underlying conditions, such as osteoarthritis, rheumatoid arthritis, or gout that could affect recovery?
  • Have workplace accommodations made to allow injury to heal completely?
  • Has individual experienced any residual impairment?
  • To what degree does impairment affect function?

Source: Medical Disability Advisor



References

Cited

"Tennis Elbow (Lateral Epicondylitis)." American Academy of Orthopaedic Surgeons. Sep. 2009. American Association of Orthopaedic Surgeons. 8 Aug. 2013 <http://orthoinfo.aaos.org/topic.cfm?topic=A00068>.

Aiello, B. "Epicondylitis." Hand Rehabilitation: A Practical Guide. Eds. Gaylord L. Clark, et al. 2nd ed. New York: Churchill Livingstone, Inc., 1998.

Braddom, Randolph L. Physical Medicine and Rehabilitation. 3rd ed. Philadelphia: W.B. Saunders, 2006.

Hegmann, Kurt T., et al., eds. "Chapter 9 - Shoulder Disorders." Occupational Medicine Practice Guidelines: Evaluation and Management of Common Health Problems and Functional Recovery in Workers. 2008 Revision 2nd ed. ACOEM, 2008. 549-572.

Source: Medical Disability Advisor






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