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Guideline:

Elbow disorders

National Guideline Clearinghouse (NGC). Guideline summary: Elbow disorders In: National Guideline Clearinghouse (NGC) [Web site]. Rockville (MD): cited 1997 (revised 2007). Available: http://www.guideline.gov.


Bibliographic Source(s)

  • American College of Occupational and Environmental Medicine (ACOEM). Elbow disorders. Elk Grove Village (IL): American College of Occupational and Environmental Medicine (ACOEM); 2007. 67 p. [122 references]

Guideline Status

This is the current release of the guideline.

This guideline updates a previous version: Elbow complaints. Elk Grove Village (IL): American College of Occupational and Environmental Medicine (ACOEM); 2004. 25 p.

The Guidelines are currently being updated on a 3-year rolling process.

Guideline Category

Diagnosis
Evaluation
Management
Treatment

Intended Users

Advanced Practice Nurses
Nurses
Occupational Therapists
Physical Therapists
Physician Assistants
Physicians
Utilization Management

Guideline Objective(s)

  • To update the 2004 American College of Occupational and Environmental Medicine's (ACOEM's) Guidelines on Elbow Complaints
  • To help improve or restore the health of those workers who incur occupationally related illnesses or injuries
  • To present essential evidence-based information to address the injured worker's functional impairment and safely return him or her to work

Target Population

Adults with potentially work-related elbow complaints seen in primary care settings

Interventions and Practices Considered

Note from the National Guideline Clearinghouse (NGC): The following general clinical measures were considered. Refer to the original guideline document for information regarding which specific interventions and practices under these general headings are recommended recommended against or for which there is no recommendation by the American College of Occupational and Environmental Medicine (ACOEM).

  1. History and physical exam
  2. Patient education
  3. Medication
  4. Physical treatment methods
  5. Injections
  6. Orthotics and immobilization
  7. Activity and exercise
  8. Detection of neurologic abnormalities
  9. Radiography and other imaging studies
  10. Surgical considerations

Major Outcomes Considered

  • Validity of diagnostic tests
  • Effectiveness of treatment in terms of pain/symptom relief return of function and return to work
  • Cost of treatment
  • Side effects of treatment

Methods Used to Collect/Select Evidence

Searches of Electronic Databases

Description of Methods used to Collect/Select the Evidence

The process begins with the identification of high-quality original research studies on a topic as well as high- and intermediate-quality systematic reviews and meta-analyses relevant to each topic. Only evidence with the highest available rating (e.g. randomized controlled trials [RCTs]) is selected for critical appraisal.

Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence

Expert Consensus
Weighting According to a Rating Scheme (Scheme Given)

Rating Scheme for the Strength of the Evidence

Strength of Evidence Ratings

A: Strong evidence-base: One or more well-conducted systematic reviews or meta-analyses or two or more high-quality studies.1

B: Moderate evidence-base: At least one high-quality study a well-conducted systematic review or meta-analysis of lower quality studies2 or multiple lower-quality studies relevant to the topic and the working population.

C: Limited evidence-base: At least one study of intermediate quality.

I: Insufficient evidence: Evidence is insufficient or irreconcilable.

1For therapy and prevention - randomized controlled trials (RCTs) with narrow confidence intervals and minimal heterogeneity.

For diagnosis and screening - cross sectional studies using independent gold standards.

For prognosis - etiology or harms prospective cohort studies with minimal heterogeneity.

2For therapy and prevention - a well-conducted review of cohort studies.

For prognosis - etiology or harms a well-conducted review of retrospective cohort studies or untreated control arms of RCTs.

Methods Used to Analyze the Evidence

Review of Published Meta-Analyses
Systematic Review with Evidence Tables

Description of the Methods Used to Analyze the Evidence

As part of the update process American College of Occupational and Environmental Medicine (ACOEM) adopted a new more meticulous strength-of-evidence rating methodology. The enhanced methodology incorporates the highest scientific standards for reviewing evidence-based literature thus ensuring the most rigorous reproducible and transparent occupational health guidelines available.

Each article that meets the inclusion criteria is reviewed and critically appraised. Randomized controlled trials (RCTs) that meet inclusion criteria are scored on 11 criteria (see table below). Each criterion is scored 0.0 0.5 or 1.0. These individual ratings are summed up resulting in an overall rating that ranges from 0 to 11.

CriteriaRating Description
RandomizationAssessment of the degree that randomization was both reported to have been performed and successfully achieved through analyses of comparisons of variables between the two groups.
Treatment Allocation ConcealedConcealment of the allocation scheme from all involved not just the patient.
Baseline ComparabilityMeasurement of how well the baseline groups are comparable (e.g. age gender prior treatment).
Patient BlindedBlinding of the patient/subject to the treatment administered.
Provider BlindedBlinding of the provider to the treatment administered.
Assessor BlindedBlinding of the assessor to the treatment administered.
Controlled for Co-interventionThe degree to which the study design controlled for multiple interventions (e.g. a combination of stretching exercises and anti-inflammatory medication or mention of not using other treatments during the study).
Compliance AcceptableMeasurement of the degree of non-compliance.
Dropout RateMeasurement of the drop-out rate.
Timing of AssessmentsAssessment of whether the timing of measurements of effects is the same between treatment groups.
Analyzed by Intention to TreatAscertainment of whether the study was analyzed with an intent-to-treat analysis.

The rating is then converted into a quality grade—low quality (0-3.5) intermediate quality (4.0-7.5) or high quality (8.0-11.0). Critique of meta-analyses and systematic reviews is based on standardized acceptable techniques; search methods reported; comprehensiveness of the search; reporting of inclusion criteria; intervention; avoidance of selection bias; reporting and appropriate assessment of validity criteria; and for meta-analyses only documentation regarding methods used to combine studies and the degree to which findings are appropriately combined. Studies are abstracted into evidence tables that include details of study methods outcomes and statistical analyses. Panels of experts (Evidence-based Practice Panels) then use the tables to grade the strength of evidence in order to develop the evidence-based guidelines. Evidence is drawn from individual studies systematic reviews and meta-analyses. Strength-of-evidence ratings are categorized as A B C or I (Refer to the Rating Scheme for the Strength of the Evidence field).

Methods Used to Formulate the Recommendations

Expert Consensus

Description of Methods Used to Formulate the Recommendations

Development of Recommendations

In formulating recommendations the expert Panels begin by reviewing the articles and evidence tables followed by discussions to agree on the strength-of-the-evidence ratings (A B C or I). Panels then draft recommendations with citation of references for each recommendation. "First principles" are observed in formulating recommendations as follows:

  • Imaging or testing should generally be done to confirm a clinical impression.
  • Tests should affect the course of treatment.
  • Treatments should improve on the natural history of the disorder which in many cases is recovery without treatment.
  • Invasive treatment should be preceded by adequate conservative treatment and may be performed if conservative treatment does not improve the health problem.
  • The more invasive and permanent the more caution should be exerted in considering invasive tests or treatments and the stronger should be the evidence of efficacy.
  • The more costly the test or intervention the more caution should be generally exerted prior to ordering the test or treatment and the stronger should be the evidence of efficacy.
  • Testing/treatment decisions should be a collaboration between the clinician and patient with full disclosure of benefits and risks.
  • Treatment should not create dependence or functional disability.

Health benefits side effects and risks are explicitly considered and discussed in formulating recommendations. Benefits should significantly exceed risks. Each recommendation specifies to which clinical problem it relates and is linked to the evidence. Recommendations not based on expert consensus are linked to a list of references.

Rating Scheme for the Strength of the Recommendations

The criteria for American College of Occupational and Environmental Medicine (ACOEM) evidence-based recommendations are as follows:

Recommendation CategoryEvidence RatingDescription of Category
Strongly RecommendedAThe intervention is strongly recommended for appropriate patients. The intervention improves important health and functional outcomes based on high quality evidence and the Evidence-based Practice Panel (EBPP) concludes that benefits substantially outweigh harms and costs.
Moderately RecommendedBThe intervention is recommended for appropriate patients. The intervention improves important health and functional outcomes based on intermediate quality evidence that benefits substantially outweigh harms and costs.
RecommendedCThe intervention is recommended for appropriate patients. There is limited evidence that the intervention may improve important health and functional benefits.
Insufficient - Recommended (Consensus-based)IThe intervention is recommended for appropriate patients and has nominal costs and low potential for harm. The EBPP feels that the intervention constitutes best medical practice to acquire or provide information in order to best diagnose and treat a health condition and restore function in an expeditious manner. The EBPP believes based on the body of evidence first principles and/or collective experience that patients are best served by these practices although the evidence is insufficient for an evidence-based recommendation.
Insufficient - No Recommendation (Consensus-based)IThe evidence is insufficient to recommend for or against routinely providing the intervention. The EBPP makes no recommendation. Evidence that the intervention is effective is lacking of poor quality or conflicting and the balance of benefits harms and costs cannot be determined.
Insufficient - Not Recommended (Consensus-based)IThe evidence is insufficient for an evidence-based recommendation. The intervention is not recommended for appropriate patients because of high costs/high potential for harm to the patient.
Not RecommendedCRecommendation against routinely providing the intervention. The EBPP found at least intermediate evidence that harms and costs exceed benefits based on limited evidence.
Moderately Not RecommendedBRecommendation against routinely providing the intervention to eligible patients. The EBPP found at least intermediate evidence that the intervention is ineffective or that harms or costs outweigh benefits.
Strongly Not RecommendedAStrong recommendation against providing the intervention to eligible patients. The EBPP found high quality evidence that the intervention is ineffective or that harms or costs outweigh benefits.

Cost Analysis

A formal cost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation

External Peer Review
Internal Peer Review

Description of Method of Guideline Validation

Several organizations and their representatives served as reviewers of the elbow chapter including the Academy of Organizational & Occupational Psychiatry American Association of Occupational Health Nurses American Occupational Therapy Association American Physical Therapy Association. The chapter was approved by the American College of Occupational and Environmental Medicines' Board of Directors on April 9 2007.

Major Recommendations

Definitions for the strength of evidence ratings (A B C and I) and the criteria for evidence-based recommendations are presented at the end of the "Major Recommendations" field.

General Summary of Recommendation

Recommendations for Assessing and Treating Patients with Elbow Disorders

  • The initial assessment of patients with acute and subacute elbow problems should focus on detecting clinical indications of potentially serious disease termed red flags and determining an accurate diagnosis.
  • In the absence of red flags health care providers can safely and effectively manage work-related elbow disorders. Management should focus on monitoring patients for complications facilitating the healing process and returning the individual to modified alternative or full-duty work.
  • One role of the physician or other health care provider (e.g. physical therapist occupational therapist nurse etc.) is to identify and correct or modify the offending or aggravating activity. Consultation with a qualified professional trained in ergonomic analyses can be helpful. Equipment may need to be serviced or adjusted to reduce the force required to accomplish a job task or to reduce vibration. Posture and work technique may need to be changed to address for example excessive grip force contact pressure or sustained wrist extension. Ergonomic biomechanical advice on the efficient use of the elbow is helpful. For example with lateral epicondylalgia/epicondylitis/tendinosis it is generally correct to lift with palm up and not palm down to reduce stress on the lateral elbow (caused by resisted wrist extension). For medial epicondylalgia/epicondylitis/tendinosis it is generally correct to lift palm down to avoid stress on the medial elbow (caused by resisted wrist flexion).
  • Relieving discomfort can be accomplished most safely by temporarily decreasing or modifying the offending activities and by prescribing systemic or topical non-prescription analgesics along with an adjustable properly fitted elbow support. Patients recovering from acute and subacute elbow problems should be encouraged to continue working. Modified duty may be recommended if appropriate.
  • In general immobilization should be avoided. An exception is immediately after surgery where brief immobilization may be required. Wrist splinting is sometimes utilized. However some experts believe splinting potentially contributes to elbow pain. When immobilization is utilized range-of-motion exercises should involve the elbow wrist as well as the shoulder to avoid frozen shoulder ("adhesive capsulitis").
  • If significant symptoms causing self-limitations or restrictions persist beyond 4 to 6 weeks referral for specialty evaluation (e.g. occupational medicine physical medicine and rehabilitation or orthopaedic surgery) may be indicated to assist in the confirmation of the provisional diagnosis and in the determination of further management.
  • A careful search for regional or systemic symptoms signs and disorders should be undertaken particularly in cases of chronic or persistent problems. As there is not scientific consensus on categorization of symptoms for purposes of discussion acute symptoms are defined as those presenting for less than 1 month; subacute symptoms 1 to 3 months; and chronic symptoms greater than 3 months.
  • Non-physical factors (i.e. psychiatric psychosocial workplace or socioeconomic issues) should be investigated and addressed particularly in cases of delayed recovery or delayed return to work. These factors are often not overt and specific inquiries are required to identify these issues.

It is important to note that many of these conditions particularly lateral epicondylalgia or epicondylitis and other tendinoses tend to resolve spontaneously (e.g. see "wait and see" groups within studies of corticosteroid injections in the original guideline document). Thus in evaluating research studies including prospective studies that do not include a placebo control caution should be exerted as results may be interpreted as showing benefit even when there is not true improvement from the therapy beyond normal spontaneous resolution.

Summary of Recommendations for Evaluating and Managing Elbow Disorders (refer to the original guideline document for more detailed information)

Clinical MeasureTreatment with Evidence Rating/Recommendation Level
RecommendedNo RecommendationNot Recommended
History/physical examOccupational and non-occupational activity history (C)

Basic history and exam --(search for red flags for tumor infection systemic disease) (I)		  
Patient educationPatient education regarding diagnosis prognosis expectations of treatment and return to work. (I).  
MedicationOral nonsteroidal anti-inflammatory drugs (NSAIDs) (Rosenthal 1984; Adelaar Maddy & Emroch 1987; Stull & Jokl 1986; Labelle & Guibert 1997) (B)

Topical NSAIDs (Ritchie 1996; Saggini et al. 1996; Baskurt Ozcan & Algun 2003; Burnham et al. 1998; Schapira Linn & Scharf 1991; Kroll Wiseman Guttadauria 1989; Spacca et al. 2005) (B)

Acetaminophen (I)

Aspirin (I)

Ketamine gel for neuropathic pain (I)

NSAIDs for ulnar neuropathies (I)

Systemic antibiotics and aspiration/drainage for infected bursa (I)		 Opioids are not recommended for routine use. However they may be used in an acute elbow injury or inflammation with redness heat swelling concurrently with an antiinflammatory ice and rest and tapered off after 2 to 3 days (I)
Physical treatment methodsUltrasound treatment for epicondylalgia (Nimgade Sullivan & Goldman 2005; Trudel et al. 2004; Bisset et al. 2005; Pienimaki et al. 1996; Halle Franklin & Karalfa 1986; Klaiman et al. 1998; Lundeberg Abrahamsson & Haker 1988; D'Vaz et al. 2006; Binder et al. 1985; Haker & Lundeberg "Pulsed ultrasound treatment" 1991; Smidt et al. 2003; van der Windt et al. 1999) (B)

Iontophoresis for epicondylalgia with either glucocorticoid or diclofenac (Nirschl et al. 2003; Runeson & Haker 2002; Demirtas & Oner 1998) (C)



At-home applications of heat or cold packs for comfort (I)

Acupuncture for epicondylalgia (I)		Manipulation (I)

Massage (I)

Friction massage (I)

Soft tissue mobilization (I)

TENS (I)

Biofeedback (I)

Electrical stimulation (I)

Magnets (I)

Diathermy (I)		Extracorporeal shock wave therapy (Bisset et al. 2005; Chung & Wiley 2004; Speed et al. 2002; Melikyan et al 2003; Haake et al. 2002; Melegati et al. 2004; Crowther et al. 2002; Rompe et al. 1996; Rompe et al. 2004; Mehra Zaman & Jenkin 2003; Pettrone & McCall 2005; Buchbinder et al. 2005) (A)

Low-level laser therapy (Bisset et al. 2005; Haker & Lundeberg 1990; Haker & Lundeberg "Lateral epicondylalgia" 1991; Krasheninnikiff et al. 1994; Vasseljen et al. 1992; Basford Sheffield & Cieslak 2000; Simunovic Trobonjaca & Trobonjaca 1998; Haker & Lundeberg "Is low-energy laser treatment" 1991; Vasseljen 1992; Stasinopoulos & Johnson 2005) (A)

Phonophoresis (Baskurt Ozcan & Algun 2003; Klaiman et al. 1998; Stratford et al. 1989) (C)
InjectionsLocal corticosteroid injections for medial and lateral epicondylalgia have evidence of short-term efficacy while simultaneously having no demonstrated long-term efficacy. Should only be considered after 3–4 weeks of conservative treatment has failed. (Smidt et al. 2002; Bisset et al. 2006; Price et al. 1991; Lewis et al. 2005; Verhaar et al. 1995; Altay Gunal & Ozturk 2002; Newcomer et al. 2001; Hay et al. 1999; Saartok & Eriksson 1986; Solveborn et al. 1995; Nimgade Sullivan & Goldman 2005; Trudel et al. 2004) (B)

Bupivacaine is superior to lidocaine when combined with corticosteroid in lateral epicondylar injections (Solveborn et al. 1995) (C)		Corticosteroid injection into olecranon bursa only after failure of initial care (I)

Botulinum toxin injection for lateral epicondylalgia (I) 		Autologous blood injection (I)
Orthotics and ImmobilizationProtection rest ice compression elevation and mobilization for contusion (I)

Limited (i.e. sling or posterior elbow splint) and then early mobilization for non-displaced radial head fracture (I)

Epicondylalgia supports for epicondylalgia (I)

Dynamic extensor brace for lateral epicondylalgia (I)

Wrist splinting for epicondylalgia (I)

Wrist splinting for radial tunnel syndrome (I)

Nocturnal elbow splinting for ulnar neuropathy (I)

Daytime padding for ulnar neuropathies at the elbow (I)

Avoidance of leaning on the ulnar nerve at the elbow for ulnar neuropathies (I)

Avoidance of prolonged hyperflexion of the elbow for ulnar neuropathies (I)

Padding the elbow for sterile effusion of the olecranon bursa (I)

Posterior splint for elbow dislocation (I)

Shoulder sling for elbow sprain (I)

Wrist brace for pronator syndrome (I)		 Trial of casting for severe recalcitrant epicondylalgia (I)
Activity/ExerciseExercise instruction by a therapist for epicondylalgia (I)

Physician recommendations for range-of-motion instruction and strengthening exercises in epicondylalgia patients (I)

Stretching (I)

Aerobic exercise (I)

Activity modification (I)

Workstation modifications (I) 		  
Detection of Neurologic AbnormalitiesNerve conduction studies (NCS) to confirm ulnar nerve entrapment if conservative treatment fails (I)

NCS to distinguish radial entrapment from lateral epicondylitis if history and physical exam are equivocal and conservative treatment fails (I)		  
Radiography/Other imaging StudiesMagnetic resonance imaging (MRI) for suspected ulnar collateral ligament tears (C)

Plain-film radiography for red-flag cases (I)		 Repeat plain-film radiography for readings with "fat pad sign" (I)

MRI for suspected epicondylalgia (I)
Surgical ConsiderationsSimple decompression for ulnar nerve entrapment (Nabhan et al. 2005; Bartels et al. 2005; Biggs & Curtis 2006; Gervasio et al. 2005) (C)

Simple ulnar nerve release for patients with significant activity limitation and delayed NCS (C)

Anterior transposition for ulnar nerve entrapment in patients with significant activity limitation and delayed NCS or failed simple release (I)

Excision for infected olecranon bursitis if not responsive to intravenous (IV) antibiotics aspiration and drainage (I)

Radial tunnel decompression for failure of conservative treatment and positive electrodiagnostic studies  (I)

Debridement of inflammatory or scarred tissue for patients with epicondylalgia if conservative treatment fails (I)

Surgery for biceps rupture (I)

Surgery after at least 6 months of conservative treatment with failure to show signs of improvement (at least 3 months in unusual circumstances) (I)		 Submuscular transposition of the ulnar nerve at the elbow (Biggs & Curtis 2006; Gervasio et al. 2005) (C)

Excision of olecranon bursa due to metabolic arthritis before appropriate medical treatment (I)

Medical epicondylectomy for ulnar neuropathy (I)

Ulnar nerve surgery in the presence of normal electrical studies (I)

Summary of Recommendations by Elbow Condition (refer to the original guideline document for more detailed information)

Elbow ConditionTreatment with Evidence Rating/Recommendation Level
 RecommendedNo RecommendationNot Recommended
ContusionProtection rest ice compression elevation and mobilization (I)  
Olecranon Bursitis (Aseptic)Soft padding of the elbow (I)

Modifying activities to avoid direct pressure over the olecranon (I)

Surgery if after at least 6 weeks of conservative treatment with failure to show signs of improvement (I)		Corticosteroid injection for persistent symptoms (I)Corticosteroid injection as part of initial care (I)
Olecranon Bursitis (Septic)Elbow padding (I)

Avoid direct pressure (I)

Aspiration and antibiotics(I)

Surgery (I)		  
Non-displaced Radial Head FractureSling/splint for 7 days followed by gentle range of motion exercises then progressive mobilization. Range-of-motion exercises should involve the elbow but also the shoulder and wrist. A shorter immobilization period of as little as 3 days may be used for non-displaced fractures that are clinically present but not visible on x-ray. (I)  
Dislocation of the ElbowPost-reduction x-rays and examination necessary (I)

Posterior splint for 10 days (I)

Range-of-motion exercises after immobilization. Range-of-motion exercises should involve the elbow but also the shoulder and wrist. (I)

Nonsteroidal antiinflammatory drugs (NSAIDs) (I)		  
Sprain of the ElbowNSAIDs (I)

Shoulder sling may be used for up to 1 week (I)

Gentle range-of-motion exercises of the elbow but including the shoulder and wrist (I)		  
Biceps TendinosisSling for severe cases with gentle range-of-motion exercises of the elbow but including the shoulder and wrist (I)

NSAIDs (I)

Activity limitations (I)		  
Ulnar Nerve Entrapment (including Cubital Tunnel Syndrome)Avoid prolonged hyperflexion of elbow (I)

Elbow padding (I)

Avoid leaning on elbow (I)

NSAIDs (I)

Simple decompression (Nabhan et al. 2005; Bartels et al. 2005; Biggs & Curtis 2006; Gervasio et al. 2005) (C)

Anterior transposition after 3 to 6 months (rare cases) (I)		 Submuscular transposition (Biggs & Curtis 2006; Gervasio et al. 2005) (C)

Medial epicondylectomy for ulnar neuropathy (I)
Radial Nerve Entrapment (including Radial Tunnel Syndrome)NSAIDs (I)

Confirmatory electro-diagnostic study helpful (I)

Wrist splint for periodic daytime use (I)

Surgery after at least 6 months of conservative treatment with failure to show signs of improvement (at least 3 months in unusual circumstances) (I)		  
Pronator SyndromeNSAIDs (I)

Activity modifications (I)

Confirmatory electrodiagnostic study helpful (I)

Wrist brace (I)

Surgery after at least 6 months of conservative treatment with failure to show signs of improvement (at least 3 months in unusual circumstances) (I)		  
Lateral Epicondylalgia (Lateral Epicondylitis)Acetaminophen (I)

Aspirin (I)

Heat or cold packs (I)

Topical NSAIDs (Ritchie 1996; Saggini et al. 1996; Baskurt Ozcan & Algun 2003; Burnham et al. 1998; Schapira Linn & Scharf 1991; Kroll Wiseman & Guttadauria 1989; Spacca et al. 2005) (B)

Oral NSAIDs (Rosenthal 1984; Adelaar Maddy & Emroch 1987; Stull & Jokl 1986; Labelle & Guibert 1997) (B)

Home exercise (I)

Epicondylalgia supports (I)

Activity modification (I)

Workstation modifications (I)

Ultrasound (Nimgade Sullivan & Goldman 2005; Trudel et al. 2004; Bisset et al. 2005; Pienimaki et al. 1996; Halle Franklin & Karalfa 1986; Klaiman et al. 1998; Lundeberg Abrahamsson & Haker 1988; D'Vaz et al. 2006; Binder et al. 1985; Haker & Lundeberg "Pulsed ultrasound treatment" 1991; Smidt et al. 2003; van der Windt et al. 1999) (B)

Iontophoresis (Nirschl et al. 2003; Runeson & Haker 2002; Demirtas & Oner 1998) (C)

Acupuncture (I)

Cortisone with bupivacaine (Solveborn et al. 1995) (C)

Local corticosteroid injections (Smidt et al. 2002; Bisset et al. 2006; Price et al. 1991; Lewis et al. 2005; Verhaar et al. 1995; Altay Gunal & Ozturk 2002; Newcomer et al. 2001; Hay et al. 1999; Saartok & Eriksson 1986; Solveborn et al. 1995; Nimgade Sullivan & Goldman 2005; Trudel et al. 2004) (B)

Surgery after at least 6 months of conservative treatment with failure to show signs of improvement (at least 3 months in unusual circumstances) (I)		Botulinum toxin injection (I)

Massage (I)

Friction massage (I)

Soft tissue mobilization (I)

Biofeedback (I)

Transcutaneous electrical neurostimulation (TENS) (I)

Electrical stimulation (I)

Magnets (I)

Diathermy (I)

Manipulation (I)		Extracorporeal shock wave therapy (Bisset et al. 2005; Chung & Wiley 2004; Speed et al. 2002; Melikyan et al 2003; Haake et al. 2002; Melegati et al. 2004; Crowther et al. 2002; Rompe et al. 1996; Rompe et al. 2004; Mehra Zaman & Jenkin 2003; Pettrone & McCall 2005; Buchbinder et al. 2005) (A)

Low level laser therapy (Bisset et al. 2005; Haker & Lundeberg 1990; Haker & Lundeberg "Lateral epicondylalgia" 1991; Krasheninnikiff et al. 1994; Vasseljen et al. 1992; Basford Sheffield & Cieslak 2000; Simunovic Trobonjaca & Trobonjaca 1998; Haker & Lundeberg "Is low-energy laser treatment" 1991; Vasseljen 1992; Stasinopoulos & Johnson 2005) (A)

Phonophoresis (Baskurt Ozcan & Algun 2003; Klaiman et al. 1998; Stratford et al. 1989) (C)

Autologous blood injections (I)

Opioids (other than acute severe conditions) (I)
Medial Epicondylalgia (Medial Epicondylitis)Same recommendations as lateral epicondylalgia above

Activity modification (I)

Workstation modification (I)

Iontophoresis (Nirschl et al. 2003) (C)

Corticosteroid injections (Stahl & Kaufman 1997) (B)

Surgery after at least 6 months of conservative treatment with failure to show signs of improvement (at least 3 months in unusual circumstances) (I)		Same recommendations as lateral epicondylalgia aboveSame recommendations as lateral epicondylalgia above
Biceps RuptureSurgery (I)  

Definitions:

Strength of Evidence Ratings

A: Strong evidence-base: One or more well-conducted systematic reviews or meta-analyses or two or more high-quality studies.1

B: Moderate evidence-base: At least one high-quality study a well-conducted systematic review or meta-analysis of lower quality studies2 or multiple lower-quality studies relevant to the topic and the working population.

C: Limited evidence-base: At least one study of intermediate quality.

I: Insufficient evidence: Evidence is insufficient or irreconcilable.

1For therapy and prevention - randomized controlled trials (RCTs) with narrow confidence intervals and minimal heterogeneity.

For diagnosis and screening - cross sectional studies using independent gold standards.

For prognosis etiology or harms prospective cohort studies with minimal heterogeneity.

2For therapy and prevention - a well-conducted review of cohort studies.

For prognosis - etiology or harms a well-conducted review of retrospective cohort studies or untreated control arms of RCTs.

Categories of Evidence-based Recommendations

Recommendation CategoryEvidence RatingDescription of Category
Strongly RecommendedAThe intervention is strongly recommended for appropriate patients. The intervention improves important health and functional outcomes based on high quality evidence and the Evidence-based Practice Panel (EBPP) concludes that benefits substantially outweigh harms and costs.
Moderately RecommendedBThe intervention is recommended for appropriate patients. The intervention improves important health and functional outcomes based on intermediate quality evidence that benefits substantially outweigh harms and costs.
RecommendedCThe intervention is recommended for appropriate patients. There is limited evidence that the intervention may improve important health and functional benefits.
Insufficient - Recommended (Consensus-based)IThe intervention is recommended for appropriate patients and has nominal costs and low potential for harm. The EBPP feels that the intervention constitutes best medical practice to acquire or provide information in order to best diagnose and treat a health condition and restore function in an expeditious manner. The EBPP believes based on the body of evidence first principles and/or collective experience that patients are best served by these practices although the evidence is insufficient for an evidence-based recommendation.
Insufficient - No Recommendation (Consensus-based)IThe evidence is insufficient to recommend for or against routinely providing the intervention. The EBPP makes no recommendation. Evidence that the intervention is effective is lacking of poor quality or conflicting and the balance of benefits harms and costs cannot be determined.
Insufficient - Not Recommended (Consensus-based)IThe evidence is insufficient for an evidence-based recommendation. The intervention is not recommended for appropriate patients because of high costs/high potential for harm to the patient.
Not RecommendedCRecommendation against routinely providing the intervention. The EBPP found at least intermediate evidence that harms and costs exceed benefits based on limited evidence.
Moderately Not RecommendedBRecommendation against routinely providing the intervention to eligible patients. The EBPP found at least intermediate evidence that the intervention is ineffective or that harms or costs outweigh benefits.
Strongly Not RecommendedAStrong recommendation against providing the intervention to eligible patients. The EBPP found high quality evidence that the intervention is ineffective or that harms or costs outweigh benefits.

Clinical Algorithm(s)

The following clinical algorithms are provided in the original guideline document:

  • American College of Occupational and Environmental Medicine (ACOEM) Guidelines for care of acute and subacute occupational elbow disorders
  • Initial evaluation of occupational elbow disorders
  • Initial and follow-up management of occupational elbow disorders
  • Evaluation of slow-to-recover patients with occupational elbow disorders (symptoms >4 weeks)
  • Surgical considerations for patients with anatomic and physiologic evidence of nerve compression coupled with persistent elbow disorders
  • Further management of occupational elbow disorders

References Supporting the Recommendations

  • Adelaar RS Maddy L Emroch KS. Diflunisal vs naproxen in the management of mild to moderate pain associated with epicondylitis. Adv Ther 1987;4:317-27.


  • Altay T Gunal I Ozturk H. Local injection treatment for lateral epicondylitis. Clin Orthop Relat Res 2002 May;(398):127-30. PubMed


  • Bartels RH Verhagen WI van der Wilt GJ Meulstee J van Rossum LG Grotenhuis JA. Prospective randomized controlled study comparing simple decompression versus anterior subcutaneous transposition for idiopathic neuropathy of the ulnar nerve at the elbow: Part 1. Neurosurgery 2005 Mar;56(3):522-30; discussion 522-30. PubMed


  • Basford JR Sheffield CG Cieslak KR. Laser therapy: a randomized controlled trial of the effects of low intensity Nd:YAG laser irradiation on lateral epicondylitis . Arch Phys Med Rehabil 2000 Nov;81(11):1504-10. PubMed


  • Baskurt F Ozcan A Algun C. Comparison of effects of phonophoresis and iontophoresis of naproxen in the treatment of lateral epicondylitis. Clin Rehabil 2003 Feb;17(1):96-100. PubMed


  • Biggs M Curtis JA. Randomized prospective study comparing ulnar neurolysis in situ with submuscular transposition. Neurosurgery 2006 Feb;58(2):296-304; discussion 296-3. PubMed


  • Binder A Hodge G Greenwood AM Hazleman BL Page Thomas DP. Is therapeutic ultrasound effective in treating soft tissue lesions?. Br Med J (Clin Res Ed) 1985 Feb 16;290(6467):512-4. PubMed


  • Bisset L Beller E Jull G Brooks P Darnell R Vicenzino B. Mobilisation with movement and exercise corticosteroid injection or wait and see for tennis elbow: randomised trial. BMJ 2006 Nov 4;333(7575):939. PubMed


  • Bisset L Paungmali A Vicenzino B Beller E. A systematic review and meta-analysis of clinical trials on physical interventions for lateral epicondylalgia. Br J Sports Med 2005 Jul;39(7):411-22; discussion 411-22. [106 references] PubMed


  • Buchbinder R Green SE Youd JM Assendelft WJ Barnsley L Smidt N. Shock wave therapy for lateral elbow pain (review). In: Cochrane Database of Systematic Reviews [internet]. Issue 4. Hoboken (NJ): John Wiley & Sons Ltd.; 2005 [Art. No.: CD003524.pub2].


  • Burnham R Gregg R Healy P Steadward R. The effectiveness of topical diclofenac for lateral epicondylitis. Clin J Sport Med 1998 Apr;8(2):78-81. PubMed


  • Chung B Wiley JP. Effectiveness of extracorporeal shock wave therapy in the treatment of previously untreated lateral epicondylitis: a randomized controlled trial. Am J Sports Med 2004 Oct-Nov;32(7):1660-7. PubMed


  • Crowther MA Bannister GC Huma H Rooker GD. A prospective randomised study to compare extracorporeal shock-wave therapy and injection of steroid for the treatment of tennis elbow. J Bone Joint Surg Br 2002 Jul;84(5):678-9. PubMed


  • D'Vaz AP Ostor AJ Speed CA Jenner JR Bradley M Prevost AT Hazleman BL. Pulsed low-intensity ultrasound therapy for chronic lateral epicondylitis: a randomized controlled trial. Rheumatology (Oxford) 2006 May;45(5):566-70. PubMed


  • Demirtas RN Oner C. The treatment of lateral epicondylitis by iontophoresis of sodium salicylate and sodium diclofenac. Clin Rehabil 1998 Feb;12(1):23-9. PubMed


  • Gervasio O Gambardella G Zaccone C Branca D. Simple decompression versus anterior submuscular transposition of the ulnar nerve in severe cubital tunnel syndrome: a prospective randomized study. Neurosurgery 2005;56(1):108-17; discussion 117. PubMed


  • Haake M Konig IR Decker T Riedel C Buch M Muller HH. Extracorporeal shock wave therapy in the treatment of lateral epicondylitis : a randomized multicenter trial. J Bone Joint Surg Am 2002 Nov;84(11):1982-91. PubMed


  • Haker E Lundeberg T. Is low-energy laser treatment effective in lateral epicondylalgia?. J Pain Symptom Manage 1991 May;6(4):241-6. PubMed


  • Haker E Lundeberg T. Laser treatment applied to acupuncture points in lateral humeral epicondylalgia. A double-blind study. Pain 1990 Nov;43(2):243-7. PubMed


  • Haker E Lundeberg T. Pulsed ultrasound treatment in lateral epicondylalgia. Scand J Rehabil Med 1991;23(3):115-8. PubMed


  • Haker EH Lundeberg TC. Lateral epicondylalgia: report of noneffective midlaser treatment. Arch Phys Med Rehabil 1991 Nov;72(12):984-8. PubMed


  • Halle JS Franklin RJ Karalja BL. Comparison of four treatment approaches for lateral epicondylitis of the elbow. J Orthop Sports Phys Ther 1986;8:62-9.


  • Hay EM Paterson SM Lewis M Hosie G Croft P. Pragmatic randomised controlled trial of local corticosteroid injection and naproxen for treatment of lateral epicondylitis of elbow in primary care. BMJ 1999 Oct 9;319(7215):964-8. PubMed


  • Klaiman MD Shrader JA Danoff JV Hicks JE Pesce WJ Ferland J. Phonophoresis versus ultrasound in the treatment of common musculoskeletal conditions. Med Sci Sports Exerc 1998 Sep;30(9):1349-55. PubMed


  • Krasheninnikoff M Ellitsgaard N Rogvi-Hansen B Zeuthen A Harder K Larsen R Gaardbo H. No effect of low power laser in lateral epicondylitis. Scand J Rheumatol 1994;23(5):260-3. PubMed


  • Kroll MP Wiseman RL Guttadauria M. A clinical evaluation of piroxicam gel: an open comparative trial with diclofenac gel in the treatment of acute musculoskeletal disorders. Clin Ther 1989 May-Jun;11:382-91. PubMed


  • Labelle H Guibert R. Efficacy of diclofenac in lateral epicondylitis of the elbow also treated with immobilization. The University of Montreal Orthopaedic Research Group . Arch Fam Med 1997 May-Jun;6(3):257-62. PubMed


  • Lewis M Hay EM Paterson SM Croft P. Local steroid injections for tennis elbow: does the pain get worse before it gets better?: Results from a randomized controlled trial. Clin J Pain 2005 Jul-Aug;21(4):330-4. PubMed


  • Lundeberg T Abrahamsson P Haker E. A comparative study of continuous ultrasound placebo ultrasound and rest in epicondylalgia. Scand J Rehabil Med 1988;20(3):99-101. [10 references] PubMed


  • Mehra A Zaman T Jenkin AI. The use of a mobile lithotripter in the treatment of tennis elbow and plantar fasciitis. Surgeon 2003 Oct;1(5):290-2. PubMed


  • Melegati G Tornese D Bandi M Rubini M. Comparison of two ultrasonographic localization techniques for the treatment of lateral epicondylitis with extracorporeal shock wave therapy: a randomized study. Clin Rehabil 2004 Jun;18(4):366-70. PubMed


  • Melikyan EY Shahin E Miles J Bainbridge LC. Extracorporeal shock-wave treatment for tennis elbow. A randomised double-blind study. J Bone Joint Surg Br 2003 Aug;85(6):852-5. PubMed


  • Nabhan A Ahlhelm F Kelm J Reith W Schwerdtfeger K Steudel WI. Simple decompression or subcutaneous anterior transposition of the ulnar nerve for cubital tunnel syndrome. J Hand Surg [Br] 2005 Oct;30(5):521-4. PubMed


  • Newcomer KL Laskowski ER Idank DM McLean TJ Egan KS. Corticosteroid injection in early treatment of lateral epicondylitis. Clin J Sport Med 2001 Oct;11(4):214-22. PubMed


  • Nimgade A Sullivan M Goldman R. Physiotherapy steroid injections or rest for lateral epicondylosis? What the evidence suggests. Pain Pract 2005 Sep;5(3):203-15. PubMed


  • Nirschl RP Rodin DM Ochiai DH Maartmann-Moe C. Iontophoretic administration of dexamethasone sodium phosphate for acute epicondylitis: a randomized double-blinded placebo-controlled study. Am J Sports Med 2003 Mar-Apr;31(2):189-95. PubMed


  • Pettrone FA McCall BR. Extracorporeal shock wave therapy without local anesthesia for chronic lateral epicondylitis. J Bone Joint Surg Am 2005 Jun;87(6):1297-304. PubMed


  • Pienimaki TT Tarvainen TK Siira PT Vanharanta H. Progressive strengthening and stretching exercises and ultrasound for chronic lateral epicondylitis. Physiotherapy 1996;82(9):522-30.


  • Price R Sinclair H Heinrich I Gibson T. Local injection treatment of tennis elbow - hydrocortisone triamcinolone and lignocaine compared. Br J Rheumatol 1991;30(1):39-44. PubMed


  • Ritchie LD. A clinical evaluation of flurbiprofen LAT and piroxicam gel: a multicentre study in general practice. Clin Rheumatol 1996 May;15(3):243-7. PubMed


  • Rompe JD Decking J Schoellner C Theis C. Repetitive low-energy shock wave treatment for chronic lateral epicondylitis in tennis players. Am J Sports Med 2004 Apr-May;32(3):734-43. PubMed


  • Rompe JD Hope C Kullmer K Heine J Burger R. Analgesic effect of extracorporeal shock-wave therapy on chronic tennis elbow. J Bone Joint Surg Br 1996 Mar;78B(2):233-7. [24 references] PubMed


  • Rosenthal M. The efficacy of flurbiprofen versus piroxicam in the treatment of acute soft tissue rheumatism. Curr Med Res Opin 1984;9(5):304-9. PubMed


  • Runeson L Haker E. Iontophoresis with cortisone in the treatment of lateral epicondylalgia (tennis elbow)--a double-blind study. Scand J Med Sci Sports 2002 Jun;12(3):136-42. PubMed


  • Saartok T Eriksson E. Randomized trial of oral naproxen or local injection of betamethasone in lateral epicondylitis of the humerus. Orthopedics 1986 Feb;9(2):191-4. PubMed


  • Saggini R Zoppi M Vecchiet F Gatteschi L Obletter G Giamberardino MA. Comparison of electromotive drug administration with ketorolac or with placebo in patients with pain from rheumatic disease: a double-masked study. Clin Ther 1996 Nov-Dec;18(6):1169-74. PubMed


  • Schapira D Linn S Scharf Y. A placebo-controlled evaluation of diclofenac diethylamine salt in the treatment of lateral epicondylitis of the elbow. Curr Ther Res Clin Exp 1991;49(2):162-8.


  • Simunovic Z Trobonjaca T Trobonjaca Z. Treatment of medial and lateral epicondylitis--tennis and golfer's elbow--with low level laser therapy: a multicenter double blind placebo-controlled clinical study on 324 patients. J Clin Laser Med Surg 1998 Jun;16(3):145-51. PubMed


  • Smidt N Assendelft WJ Arola H Malmivaara A Greens S Buchbinder R van der Windt DA Bouter LM. Effectiveness of physiotherapy for lateral epicondylitis: a systematic review. Ann Med 2003;35(1):51-62. [57 references] PubMed


  • Smidt N van der Windt DA Assendelft WJ Deville WL Korthals-de Bos IB Bouter LM. Corticosteroid injections physiotherapy or a wait-and-see policy for lateral epicondylitis: a randomised controlled trial. Lancet 2002 Feb 23;359(9307):657-62. PubMed


  • Solveborn SA Buch F Mallmin H Adalberth G. Cortisone injection with anesthetic additives for radial epicondylalgia (tennis elbow). Clin Orthop Relat Res 1995 Jul;(316):99-105. PubMed


  • Spacca G Cacchio A Forgacs A Monteforte P Rovetta G. Analgesic efficacy of a lecithin-vehiculated diclofenac epolamine gel in shoulder periarthritis and lateral epicondylitis: a placebo-controlled multicenter randomized double-blind clinical trial. Drugs Exp Clin Res 2005;31(4):147-54. PubMed


  • Speed CA Nichols D Richards C Humphreys H Wies JT Burnet S Hazleman BL. Extracorporeal shock wave therapy for lateral epicondylitis--a double blind randomised controlled trial. J Orthop Res 2002 Sep;20(5):895-8. PubMed


  • Stahl S Kaufman T. The efficacy of an injection of steroids for medial epicondylitis. A prospective study of sixty elbows. J Bone Joint Surg Am 1997 Nov;79(11):1648-52. PubMed


  • Stasinopoulos DI Johnson MI. Effectiveness of low-level laser therapy for lateral elbow tendinopathy. Photomed Laser Surg 2005 Aug;23(4):425-30. [44 references] PubMed


  • Stratford PW Levy DR Gauldie S Miseferi D Levy K. The evaluation of phonophoresis and friction massage as treatments for extensor carpi radialis tendinitis: a randomized controlled trial. Physiother Can 1989;41:93-9.


  • Stull PA Jokl P. Comparison of diflunisal and naproxen in the treatment of tennis elbow. Clin Ther 1986;9 Suppl C:62-6. PubMed


  • Trudel D Duley J Zastrow I Kerr EW Davidson R MacDermid JC. Rehabilitation for patients with lateral epicondylitis: a systematic review. J Hand Ther 2004 Apr-Jun;17(2):243-66. [53 references] PubMed


  • van der Windt DA van der Heijden GJ van den Berg SG ter Riet G de Winter AF Bouter LM. Ultrasound therapy for musculoskeletal disorders: a systematic review. Pain 1999 Jun;81(3):257-71. PubMed


  • Vasseljen O Jr Hoeg N Kjeldstad B Johnsson A Larsen S. Low level laser versus placebo in the treatment of tennis elbow. Scand J Rehabil Med 1992;24(1):37-42. PubMed


  • Vasseljen O. Low-level laser versus traditional physiotherapy in the treatment of tennis elbow. Physiotherapy 1992;78:329-34.


  • Verhaar JA Walenkamp GH van Mameren H Kester AD van der Linden AJ. Local corticosteroid injection versus Cyriax-type physiotherapy for tennis elbow. J Bone Joint Surg Br 1995 Jan;77B(1):128-32. PubMed

Type of Evidence supporting the Recommendations

The type of supporting evidence is identified and graded for each recommendation (see "Major Recommendations").

Potential Benefits

  • Improved efficiency of the diagnostic process
  • Effective treatment resulting in symptom alleviation and cure
  • Reduced over utilization of unproductive and harmful procedures
  • Timely return of the employee to work usually within 90 days of injury or illness

Potential Harms

  • Risks and complications of surgical procedures and imaging studies (e.g. infection radiation)
  • Adverse effects of medications:
    • Glucocorticoid injections have some risks. For example with a large volume in a small space there is a risk of tendon fraying and even rupture although the underlying pathogenesis is thought to frequently entail those processes. Injections can also cause an inflammatory reaction causing pain lasting for several hours and rarely infection.

Contraindications

Patients with positive findings of non-localized pain non-localized tenderness and psychological or psychiatric issues have relative but not absolute contraindications to invasive testing or procedures.

Qualifying Statements

The American College of Occupational and Environmental Medicine (ACOEM) provides this segment of guidelines for practitioners and notes that decisions to adopt particular courses of actions must be made by trained practitioners on the basis of the available resources and the particular circumstances presented by the individual patient. Accordingly the ACOEM disclaims responsibility for any injury or damage resulting from actions taken by practitioners after considering these guidelines.

Description of Implementation Strategy

An implementation strategy was not provided.

Implementation Tools

Clinical Algorithm

For information about availability see the "Availability of Companion Documents" and "Patient Resources" fields below.

IOM Care Need

Getting Better

IOM Domain

Effectiveness
Patient-centeredness

Bibliographic Source(s)

  • American College of Occupational and Environmental Medicine (ACOEM). Elbow disorders. Elk Grove Village (IL): American College of Occupational and Environmental Medicine (ACOEM); 2007. 67 p. [122 references]

Adaptation

Not applicable: The guideline was not adapted from another source.

Source(s) of Funding

American College of Occupational and Environmental Medicine

Guideline Committee

American College of Occupational and Environmental Medicine Practice Guidelines Committee

Composition of Group that Authored the Guideline

Editor-in-Chief: Kurt T. Hegmann MD MPH FACOEM FACP

Elbow Panel Chair: Harold E. Hoffman MD FACOEM FRCPC

Elbow Panel Members: Roger M. Belcourt MD MPH FACOEM; Kevin Byrne MD MPH FACOEM; Jed Downs MD MPH; Lee S. Glass MD JD; J. Mark Melhorn MD FAAOS FAADEP; Jack Richman MD CCBOM FACOEM FAADEP CIME; Phillip Zinni III DO FAOASM CMRO

Managing Editors: Technical: Bruce Sherman MD FCCP; Production: Marianne Dreger MA; Research: Julie A. Ording MPH; Editorial Assistant: Debra M. Paddack

Financial Disclosures/Conflicts of Interest

Roger Belcourt MD MPH (Panel Member)

Director of Managed Care Services Specialty Health Inc.; and Assistant Clinical Professor of Medicine University of Nevada at Reno

National Regional Local Committee Affiliations#8212;President Nevada Health Professional Assistance Foundation; Diversion Committee and Foundation Board Member; Nevada Institutional Review Board; Board of Directors Western Occupational and Environmental Medical Association (WOEMA); and Chair 2006 Western Occupational Health Conference

Guidelines Related Professional Activities—None

Research Grants/Other Support—None

Financial/Non-Financial Conflict of Interest—None

Kevin Byrne MD MPH (Panel Member)

Associate Area Medical Director USPS

National Regional Local Committee Affiliations—Ergonomics Committee ACOEM; Examiner Corporate Health Achievement Award ACOEM

Guidelines Related Professional Activities—None

Research Grants/Other Support—None

Financial/Non-Financial Conflict of Interest—None

Jed Downs MD MPH (Panel Member)

President Occupational & Manual Medicine of Duluth Ltd.

National Regional Local Committee Affiliations—None

Guidelines Related Professional Activities—None

Research Grants/Other Support—None

Financial/Non-Financial Conflict of Interest—None

Lee Glass MD JD (Panel Member)

Associate Medical Director State of Washington's Department of Labor and Industries

National Regional Local Committee Affiliations—Chair Coding and Classification Committee ACOEM; Member Council on OEM Practice ACOEM; ACOEM Representative to AMA's Relative Value System Update Committee; Committee on Homeland Security State of Washington Department of Emergency Management; Disaster Preparedness Task Force Washington State Medical Association; and Bioterrorism Preparedness and Response Program Advisory Committee Washington State's Department of Health

Guidelines Related Professional Activities—Member APS/ACP Low Back Pain Guideline Project; Immediate Past Chair Guidelines Committee ACOEM; Editor ACOEM's Occupational Medicine Practice Guidelines 2nd Edition; and Past Associate Editor APG Insights

Research Grants/Other Support—None

Financial/Non-Financial Conflict of Interest—None

Kurt Hegmann MD MPH (Editor-in-Chief)

Associate Professor and Center Director Rocky Mountain Center for Occupational and Environmental Health University of Utah

National Regional Local Committee Affiliations—Member Ergonomics Committee (Chair 2001–2005)

ACOEM; American Board of Preventive Medicine (Trustee; Chair Core Examination Committee; Chair Examination Committee); and Chair Federal Motor Carrier Safety Administration's Medical Review Board

Guidelines Related Professional Activities—Chair Evidence Based Practice Committee (update of 2nd Edition) ACOEM; and Member Council on Scientific Affairs ACOEM

Research Grants/Other Support—NIOSH (CDC) research and training grants

Financial/Non-Financial Conflict of Interest—None

Harold Hoffman MD (Chair of Panel)

Specialist in Occupational and Environmental Medicine HE Hoffman Professional Corporation; Adjunct Associate Professor Department of Public Health Sciences Faculty of Medicine and Dentistry University of Alberta; Clinical Consultant Trace Element Laboratory Division of Biochemistry Department of Laboratory Medicine and Pathology University of Alberta Hospital Edmonton; and Consultant: Occupational and Environmental Medicine Clinic University of Alberta; Great West Life Insurance Company; Appeals Commission of Workers' Compensation Board of Alberta; and several industries

National Regional Local Committee Affiliations—Director "Basic Curriculum in Occupational Medicine: A Survey of the Essentials" course ACOEM

Guidelines Related Professional Activities—Member Practice Guidelines Committee ACOEM (2nd Edition); and Medical Advisory Board Member/Contributor Medical Disability Advisor

Research Grants/Other Support—None

Financial/Non-Financial Conflict of Interest—None

J. Mark Melhorn MD (Panel Member)

Orthopaedic Practice The Hand Center PA; and Clinical Assistant Professor Section of Orthopaedics Department of Surgery University of Kansas School of Medicine at Wichita

National Regional Local Committee Affiliations—Board of Directors American Academy of Disability Evaluating Physicians (AADEP); CME Course Co-chair Annual Meeting AADEP; CME Advance Skills Course Co-chair AADEP; Ethics and Discipline Committee AADEP; Return to Work/Stay at Work Process Improvement Committee ACOEM; Program Director Occupational Orthopaedics and Workers' Compensation: A Multidisciplinary Perspective American Academy of Orthopaedic Surgeons (AAOS); Occupational Health Committee AAOS

Guidelines Related Professional Activities—Member Guidelines Committee ACOEM (2nd Edition); Associate Editor APG Insights ACOEM; Lead Author Section on Musculoskeletal Upper Extremity AMA Guides 6th Ed.; Medical Advisory Board Medical Disability Advisor; and Medical Advisory Board Official Disabilities Guidelines Work Loss Data Institute

Research Grants/Other Support—None

Financial/Non-Financial Conflict of Interest—None

Jack Richman MD (Panel Member)

Executive Vice President and Medical Director AssessMed Inc.; and President AssessMed Quality Review

National Regional Local Committee Affiliations—Chair Research Committee of the Canadian Institute for the Relief of Pain and Disability (CIRPD)

Guidelines Related Professional Activities—Member Guidelines Committee ACOEM (2nd Edition); Ontario Government Occupational Disease Panel for the Workplace Safety and Insurance Board; and Chair Standards Committee Canadian Society of Medical Evaluators

Research Grants/Other Support—None

Financial/Non-Financial Conflict of Interest—None

Bruce Sherman MD (Managing Editor-Technical)

Medical Director Global Services The Goodyear Tire & Rubber Co.; Director Health and Productivity Initiatives Employers Health Coalition of Ohio; Consultant Comprehensive Health Services; and Assistant Clinical Professor Division of Pulmonary and Critical Care Medicine Case Western Reserve University School of Medicine

National Regional Local Committee Affiliations—Examiner Corporate Health Achievement Award ACOEM; Member Health and Productivity Section ACOEM; and Faculty "Health and Productivity Course" ACOEM

Guidelines Related Professional Activities—Assistant Section Chair Medical Disability Advisor 5th Ed.; and Editor Utilization Management Knowledgebase ACOEM

Research Grants/Other Support—None

Financial/Non-Financial Conflict of Interest—None

Phillip Zinni DO (Panel Member)

Regional Medical Director Whole Health Management Medical and Wellness Clinic Harrah's Entertainment

National Regional Local Committee Affiliations—Secretary/Treasurer American Osteopathic Academy of Sports Medicine; and Member Health and Productivity Section ACOEM

Guidelines Related Professional Activities—Medical Director The Industrial Athlete Institute for Research and Education Inc.

Research Grants/Other Support—None

Financial/Non-Financial Conflict of Interest—None

Guideline Status

This is the current release of the guideline.

This guideline updates a previous version: Elbow complaints. Elk Grove Village (IL): American College of Occupational and Environmental Medicine (ACOEM); 2004. 25 p.

The Guidelines are currently being updated on a 3-year rolling process.

Guideline Availability

Print copies are available from ACOEM 25 Northwest Point Boulevard Suite 700 Elk Grove Village IL 60007; Phone: 847-818-1800 x399. To order a subscription to the online version call 800-441-9674 or visithttp://www.acoempracguides.org/.

Availability of Companion Documents

None available

Patient Resources

None available

NGC STATUS

This NGC summary was completed by ECRI on May 31 2006. The information was verified by the guideline developer on November 3 2006. This NGC summary was updated by ECRI Institute on July 23 2007. The updated information was verified by the guideline developer on August 15 2007.

COPYRIGHT STATEMENT

The American College of Occupational and Environmental Medicine the signator of this license represent and warrant that they are the publisher of the guidelines and/or possess all rights necessary to grant the license rights to AHRQ and its agents.

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The National Guideline Clearinghouse™ (NGC) does not develop produce approve or endorse the guidelines represented on this site.

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NGC AHRQ and its contractor ECRI Institute make no warranties concerning the content or clinical efficacy or effectiveness of the clinical practice guidelines and related materials represented on this site. Moreover the views and opinions of developers or authors of guidelines represented on this site do not necessarily state or reflect those of NGC AHRQ or its contractor ECRI Institute and inclusion or hosting of guidelines in NGC may not be used for advertising or commercial endorsement purposes.

Readers with questions regarding guideline content are directed to contact the guideline developer.

Details

0

FDA Warning

Category:
Family Practice, Internal Medicine, Orthopedic Surgery, Physical Medicine and Rehabilitation, Preventive Medicine, Sports Medicine, Surgery
Conditions:
Elbow disorders
Published:
1997 (revised 2007)
Endorsed by:
American College of Occupational and Environmental Medicine