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.

Tenosynovitis


Related Terms

  • de Quervain’s Tenosynovitis of the Wrist
  • Gonococcal Tenosynovitis
  • Infectious Tenosynovitis
  • Tendosynovitis
  • Trigger Digit
  • Trigger Finger

Differential Diagnosis

Specialists

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

Factors Influencing Duration

The individual's response to treatment and the site, severity, and underlying cause of tenosynovitis can affect the length of disability. Injections of corticosteroids sometimes increase pain for several hours to days. Restricted joint motion may limit dexterity and create safety issues at the work site.

Medical Codes

ICD-9-CM:
727.00 - Synovitis and Tenosynovitis, Unspecified; Synovitis NOS; Tenosynovitis NOS
727.01 - Synovitis and Tenosynovitis in Diseases Classified Elsewhere
727.04 - Radial Styloid Tenosynovitis; de Quervains Disease
727.05 - Other Tenosynovitis of Hand and Wrist
727.06 - Tenosynovitis of Foot and Ankle

Overview

Tenosynovitis is the inflammation of the sheath (called the synovium) that surrounds a tendon. Tenosynovitis symptoms include pain, swelling and difficulty moving the joint where the inflammation occurs.

The condition occurs most often in the hands, wrists, and elbows, and has specific diagnoses based on location such as trigger digit, de Quervain's disease (tenosynovitis of the thumb extensor and abductor tendons), and medial or lateral epicondylitis.

In its acute stage, infectious tenosynovitis can create pus (purulent exudate), which compromises the space for the tendon even further. Bacterial causes of tenosynovitis include Neisseria gonorrhoeae, Staphylococcus, Streptococcus, Pasteurella multocida (cat bites), Eikenella corrodens (human bites), and Mycobacterium in immunocompromised individuals.

Source: Medical Disability Advisor



Causation and Known Risk Factors

Individuals at risk for tenosynovitis of the upper extremities include carpenters, painters, welders, swimmers, tennis players, and baseball players. Although wrist tenosynovitis usually occurs in individuals who perform repetitive grasping or pinching motions with the thumb, it sometimes develops spontaneously in pregnant women. Runners, who engage in repetitive movements of the lower extremities, are at risk of tenosynovitis of the knee, ankle, and foot, but this type of tenosynovitis is less common. Women are more prone than men to irritative or frictional tenosynovitis.

Most causes of tenosynovitis are unknown. Irritation to the synovial lining can be related to injury, overuse, repetitive strain, trauma, rheumatoid arthritis (RA), or infection, any of which may increase the symptoms of tenosynovitis.

Gonococcal tenosynovitis, a complication of gonorrhea, typically affects teenagers and young adults. Common sites of infection include the top (dorsum) of the hand, wrist, and ankle. Other types of infectious tenosynovitis may result from puncture wounds or lacerations, usually to the hands.

Source: Medical Disability Advisor



Diagnosis

History: A complete medical history should be obtained including recent trauma, history of sexually transmitted diseases (STDs), prior fractures or orthopedic surgery, underlying medical conditions (especially diabetes mellitus, RA, osteoarthritis, gout), medications, allergies, and occupation. A description of repetitive activities is helpful.

Although specific symptoms vary according to the location of the affected tendon sheath, pain, swelling (edema), and restricted motion in the affected area are common complaints with tenosynovitis. Some individuals may notice a crackling or squeaking noise (crepitus) accompanying tendon use.

Physical exam: Findings on examination are specific to the location of tenosynovitis and include pain, swelling and difficulty moving the particular joint where the inflammation occurs. Careful observation and examination of the entire tendon sheath is crucial since infection can easily spread along tissue planes. The affected area may be fixed in slight flexion and the individual may report pain when touched (palpated) in the area over the involved tendon. In some cases, tendon thickening and nodularity can be palpated. There may also be decreased range of motion. In particularly painful cases, the involved joint may exhibit weakness, and the affected area may show redness (erythema), edema, and warmth to the touch. When tenosynovitis is caused by an infection, there may be additional systemic symptoms including rash and fever.

Tests: Laboratory tests are not necessary for diagnosis, but if differential diagnosis includes gout, uric acid levels may be evaluated. Tests for suspected infectious tenosynovitis may include a complete blood count (CBC), erythrocyte sedimentation rate (ESR), and cultures. In some cases, fluid may be withdrawn (aspirated) from a swollen joint for further diagnostic evaluation.

X-rays are sometimes taken to rule out other pathology or to look for tendon calcifications. Although not usually necessary, magnetic resonance imaging (MRI) may be useful to visualize the irritated tendon. If nerve entrapment is also suspected, electromyography (EMG) and nerve conduction studies may be ordered for clarification.

Source: Medical Disability Advisor



Treatment

Treatment usually begins with modification of the activity that is associated with the pain. Individuals are often advised to wear a splint temporarily to avoid recurrence. Nonsurgical (conservative) treatment for tenosynovitis may utilize ultrasound, iontophoresis, and electrical stimulation, along with heat or ice for local pain control and to reduce swelling and inflammation.

Oral nonsteroidal anti-inflammatory drugs (NSAIDs) may be prescribed to control mild to moderate pain. In some cases, injection of lidocaine or a corticosteroid may be helpful. Repeated injections into tendons can weaken the tendon, so injections are limited to 2 to 3 over a period of several months. Weight-bearing tendons, such as the patellar tendon and Achilles tendon, are at greater risk for rupture from injections.

Surgery to incise part or the entire sheath (release of tendon sheath) may be necessary when conservative measures fail. When tenosynovitis causes swelling in a confined space such as the base of the thumb (de Quervain's disease), the swelling may need to be relieved by surgical incision of the constrictive tendon sheath. Surgery may also be necessary for a painful trigger finger or thumb.

Infectious tenosynovitis may require hospitalization for intravenous antibiotics, drainage if pus is suspected, and/or surgery (irrigation and débridement).

Source: Medical Disability Advisor



Prognosis

Depending on the location and severity of tenosynovitis, symptoms may persist for a few days or for several weeks. Symptoms with activities may persist. Improvement may take several months.

If rest and conservative medical management fail to provide relief, surgery to release the tendon sheath usually is effective.

Source: Medical Disability Advisor



Rehabilitation

The rehabilitation of tenosynovitis aims to control pain and swelling and to allow the tendon, muscle, and joint structures involved to regain motion, flexibility, strength, and endurance. The ultimate goal is to return the individual to full function in work and recreational activities with minimal risk of recurrence.

When pain is intense and disabling, application of ice to the injured tendon, muscle, and joint region may reduce pain. Later, heat treatments may reduce inflammation and pain, especially when stretching the involved tendon and muscle.

Once movement is allowed, passive range of motion exercises begin with the therapist bending and straightening the involved area. In time, the individual begins active assisted range of motion exercises, bending and straightening the affected joint with the help of the therapist. As increased motion of the involved joint improves flexibility, the individual begins to perform all the motions independently. The physical therapist also uses joint mobilization techniques to restore joint motion affected by tenosynovitis, as well as to aid in the stretching of surrounding muscles and tendons.

Early in the strengthening phase, the therapist will instruct the individual in isometric strengthening exercises. Once both range of motion and isometric exercises are tolerated, the individual progresses to isotonic strengthening involving movement at and around the joint.

An occupational therapist may fabricate a splint for the individual to help immobilize and protect the involved area.

Modifications may need to be made by the physical therapist for individuals who have arthritis or other muscle or joint conditions. If the affected tendon requires surgical repair, some restrictions may be placed on range of motion and strengthening exercises, depending on the degree or type of surgery that was performed. If surgery is involved, the physician will guide rehabilitation.

FREQUENCY OF REHABILITATION VISITS
Surgical
SpecialistTenosynovitis
Physical or Occupational Therapist4 visits within 6 weeks

Source: Medical Disability Advisor



Complications

Complications of tenosynovitis include chronic pain, decreased range of motion, and amputation. Tendon rupture is a possible complication of chronic tenosynovitis. Risk of tendon rupture increases with the use of corticosteroid injections that may weaken the tendon.

Untreated, infectious tenosynovitis can develop into septic arthritis or spread into adjacent bone, causing osteomyelitis.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

Tenosynovitis can affect an individual's ability to perform a number of ordinary functions. Restrictions on activities that require gripping, twisting, hammering, lifting, pulling, and pushing are common, even if little force is needed to accomplish these tasks. Adaptive devices or changes in job requirements to decrease stress on the tendons will facilitate earlier return to work. Initial treatment would include alternating repetitive tasks and providing rest periods. Alteration in job requirements may be necessary to prevent exacerbation and recurrence. Company policy on medication usage should be reviewed to determine if pain medication use is compatible with job safety and function.

For more information refer to "Work Ability and Return to Work," pages 189–193 and 201–205.

Risk: The risk for recurrence is rare, as is the risk for tendon rupture. Work guides limiting combination activities (especially repetitive simultaneous wrist flexion and ulnar deviation) may be helpful.

Capacity: Capacity is usually limited only by the tolerance for pain, or may be limited for a short period of time after surgery. Typically, range of motion is normal. Apart from the activity restrictions mentioned above, functional abilities are usually normal.

Tolerance: The decision to stay at work or return to work is primarily based on the symptoms (pain, range of motion loss, and grip weakness). Symptoms tend to be chronic with activities, although often not progressive. Temporary work modifications (but not total absence from aggravating tasks) while undergoing treatment may help to minimize symptoms and speed recovery. Most individuals can return to previous employment levels.

Accommodations: If surgery was required and the individual’s activities at work and home can be modified, most can return to normal activities the next day with a light dressing over the incision site. Traditional wound care should be performed.

Source: Medical Disability Advisor



Maximum Medical Improvement

90 days.

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 individual experienced an injury, RA, gout, infection, or repetitive strain or trauma to the hand, wrist, elbow, or other joint?
  • Does individual complain of pain, swelling, and limited motion in the affected area?
  • On exam, is the area tender to palpation? Swollen? Is crepitus detectable?
  • Did individual undergo x-ray? MRI? EMG and nerve conduction studies?
  • Have conditions with similar symptoms been ruled out?

Regarding treatment:

  • Has individual discontinued or modified the activity that causes pain?
  • Is individual using NSAIDs?
  • Did individual have corticosteroid injection? How many?
  • Is individual using a splint? Using ice? Heat?
  • Were antibiotics necessary?
  • Was surgery necessary?

Regarding prognosis:

  • Does individual actively participate in rehabilitation?
  • Does individual perform exercises at home?
  • Does individual have any conditions that could affect ability to recover?
  • Did individual experience complications such as tendon rupture?
  • Is individual's employer able to accommodate any necessary restrictions?

Source: Medical Disability Advisor



References

General

Foster, Mark R. "Tenosynovitis." eMedicine. 7 Oct. 2013. Medscape. 14 Jul. 2015 <http://emedicine.medscape.com/article/2189339-overview>.

Ma, C. Benjamin. "Tenosynovitis." MedlinePlus. 1 Jul. 2015. National Library of Medicine. 14 Jul. 2015 <http://www.nlm.nih.gov/medlineplus/ency/article/001242.htm>.

Source: Medical Disability Advisor






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