2000 Evaluation and Management of Chronic

AMERICAN JOURNAL OF INDUSTRIAL MEDICINE 37:7593 (2000)
Evaluation and Management of Chronic

Work-Related Musculoskeletal Disorders
of the Distal Upper Extremity
George Piligian, MD, MPH, 1 Robin Herbert, MD,1 Michael Hearns, MD,2
Jonathan Dropkin, MS, PT,1 Paul Landsbergis, EdD, MPH,1,3 and Martin Cherniack,
MD, MPH
This clinical review will describe the epidemiology, clinical presentation, and management of the following work-related musculoskeletal disorders (WMSDs) of the distal
upper extremity: deQuervain's disease, extensor and exor forearm tendinitis/tendinosis,
lateral and medial epicondylitis, cubital tunnel syndrome, and hand-arm vibration
syndrome (HAVS). These conditions were selected for review either because they were
among the most common WMSDs among patients attending the New York State
Occupational Health Clinics (NYSOHC) network, or because there is strong evidence for
work-relatedness in the clinical literature. Work-related carpal tunnel syndrome is
discussed in an accompanying paper. In an attempt to provide evidence-based treatment
recommendations, literature searches on the treatment of each condition were conducted
via Medline for the years 19851999. There was a dearth of studies evaluating the
efcacy of specic clinical treatments and ergonomic interventions for WMSDs.
Therefore, many of the treatment recommendations presented here are based on a
consensus of experienced public health-oriented occupational medicine physicians from
the NYSOHC network after review of the pertinent literature. A summary table of the
clinical features of the disorders is presented as a reference resource. Am. J. Ind. Med.
37:7593, 2000. 2000 Wiley-Liss, Inc.
KEY WORDS: work-related musculoskeletal disorder; nerve entrapment syndromes;
tendinitis; deQuervain's disease; epicondylitis; cubital tunnel syndrome; hand-arm
vibration syndrome
INTRODUCTION
Work-related musculoskeletal disorders (WMSDs) of
the upper extremities (UE) are common and potentially
Mount Sinai School of Medicine, The Mount Sinai Hospital, One Gustave L. Levy Place,
New York, NY
2
Hearns Professional Services, 3051 36th Street, Astoria, NY
3
Division of Hypertension,Weill Medical College of Cornell University, 525 East 68 St., New
York, NY
4
Ergonomics Technology Center, Division of Occupational and Environmental Medicine,
University of Connecticut Health Center, 263 Farmington Ave., Farmington, CT
*Correspondence to: Dr. George Piligian, Department of Community Medicine, Box 1057,
Mount Sinai School of Medicine, One Gustave L. Levy Place, New York, NY 10029-6574.
Accepted 30 July1999
2000 Wiley-Liss, Inc.
disabling, yet preventable. WMSDs comprise a heterogeneous group of diagnoses which include numerous specic
clinical entities, including disorders of the muscles, tendons
and tendon sheaths, nerve entrapment syndromes, joint
disorders, and neurovascular disorders. In 1994, 332,000
musculoskeletal disorders due to repeated trauma were
reported in United States workplaces, representing nearly
65% of the occupational disease cases reported to the
Bureau of Labor Statistics [BLS, 1997]. According to a
recent National Institute for Occupational Safety and Health
(NIOSH) report, the cost associated with these disorders is
high, with more than 2.1 billion dollars in workers'
compensation costs and 90 million dollars in indirect costs
incurred annually [U.S. Department of Health and Human
Services, 1996].
76
Piligian et al.
This review will describe the epidemiology, clinical

features, and management of several more common
musculoskeletal disorders of the distal upper extremity
(i.e., elbow, forearm, wrist, and hand) originating from and/
or aggravated by work activities. The following disorders
will be discussed: deQuervain's disease, tendinitis/tendinosis of the exor and extensor tendons of the forearm,
epicondylitis (lateral and medial), cubital tunnel syndrome,
and handarm vibration syndrome (HAVS). Approaches to
the diagnosis and management of work related carpal tunnel
syndrome are presented in Herbert et al. [1999; this issue].
We will focus on the management of chronic distal upper
extremity disorders arising from chronic exposures to workrelated risk factors. Evaluation of upper extremity pain of
short duration is described in the Occupational Medicine
Practice Guidelines developed by the American College
of Occupational and Environmental Medicine [Harris,
1997].
The conditions described here were selected because
they are frequently seen among patients with UE MSDs who
attend the New York State Occupational Health Clinics
Network, or because there is strong evidence for workrelatedness in the literature. For this document, diagnostic
criteria are based, when feasible, on consensus documents
published in peer-reviewed literature. For conditions lacking ``consensus'' clinical denitions, the clinical literature
was searched and the most commonly used diagnostic
criteria were selected. A similar approach was taken with
respect to treatment recommendations for each condition. A
literature search via Medline was conducted for each
condition to identify randomized clinical trials and
prospective outcome studies; when such studies were
identied, they were incorporated into the treatment
recommendations. However, there is a dearth of research
evaluating efcacy of treatment of WMSDs and, in
particular, few studies have evaluated the role of ergonomic modication in the secondary and tertiary prevention
of upper extremity WMSDs. Therefore, many of the
treatment recommendations are based on the consensus
of experienced public health-oriented occupational medicine physicians involved in the New York State Occupational Health Clinics Network after review of the pertinent
literature.
WORK-RELATED RISK FACTORS

Studies of the association between workplace factors
and upper extremity musculoskeletal disorders have been
constrained by a lack of standardized diagnostic criteria
and terminology, limited `òbjective'' diagnostic modalities,
and the multi-factorial nature of MSDs [Gerr et al., 1991;
Mackinnon and Novak, 1997]. Despite this, a substantial
body of credible epidemiological research exists which
provides evidence for an association between various
non-acute upper extremity musculoskeletal disorders

(MSDs) and certain work-related physical factors or
combinations of factors [NAS, 1998; Bernard, 1997].
Physical risk factors which have been associated with
at least some WMSDs include repetitive/prolonged activities, forceful exertion, awkward and/or static posture,
vibration, localized mechanical stress, and cold temperatures [Hagberg et al., 1995; Bernard, 1997]. Additionally,
work organization factors have been associated with
upper extremity symptomatology in a number of studies
[Bongers et al., 1993; Moon and Sauter, 1996]. The
clinician should be alert to the possibility of workrelatedness in any patient with an MSD whose job
exposes him/her to highly repetitive tasks, forceful exertions, sustained or awkward postures, or vibration. Ergonomic modications are designed to decrease upper limb
exposures to tasks and jobs involving these known risk
factors.
BACKGROUND TO CLINICAL EVALUATION

In the clinical setting, it is generally possible to render a
specic diagnosis for a patient presenting with upper
extremity symptoms and, based on exposure history, to
ascertain work-relatedness. This requires a systematic
approach to diagnosis and the recognition that, frequently,
workers present with multiple WMSDs simultaneously.
Therefore, to avoid omission, the evaluation of any upper
extremity complaint should begin at the neck and upper
back and then proceed down to the ngers and include the
ipsilateral and contralateral regions. It should include evaluation of soft tissue (e.g., muscle, tendon, nerve) and joints,
and should include a description of the patient's body
habitus (e.g., neck rotation, shoulder depression, spine
kyphosis).
Once a precise diagnosis or diagnoses have been
made, work-relatedness is ascertained relying on general
principles of occupational medicine: relation of symptoms
to work, any change of symptoms away from work, history
of workplace exposures to ergonomic factors likely to
contribute to the condition, presence of similar conditions
among coworkers, presence of prior trauma to the affected
body parts, and avocational activities that may cause or
contribute to injury. Those systemic illnesses that may be
associated with the specic disorder(s) should be considered
by the clinician. Table I summarizes the characteristic
symptoms, physical ndings, and treatment approaches
for the non-acute disorders described in this paper. Suggested diagnostic criteria are included to aid the practitioner
[Andersen and Gaardboe, 1993; Harrington et al., 1998;
Kurppa et al., 1991]; however, the reader is cautioned
that, for many of the conditions discussed in this review,
there is limited consensus on appropriate diagnostic
criteria.
Evaluation and Management of WMSDs
77
TABLE I. Summary of Symptoms, Signs, Suggested Diagnostic Criteria, and Management Options for Selected WRMSDs of the Distal Upper Extremity
Disorder
Physical
examination findings
Symptoms
Suggested
diagnostic criteria
Management options
Wrist/Hand/Forearm
DeQuervain's disease
Pain and swelling in the

`ànatomical''snuffbox
Pain radiating into the
hand and forearm
Pain worsened by
abduction and/or extension
of the thumb
Tenderness at the `ànatomical''

snuffbox on palpation
Pain worsened by active
abduction and/or extension
of the thumb
Crepitus may be palpated
along the radial forearm
Positive Finkelstein's test
* Pain at radial wrist

and
* Tenderness to palpation at radial
wrist
and
* Positive Finkelstein's test
*
*
ExtensorTendinous
Disorders
(tendinosis,
tenosynovitis,
tendinitis)
FlexorTendinous
Disorders
(tendinosis,
tenosynovitis, or
tendinitis)
Lateral Epicondylitis
(``tennis elbow'')
Pain in the affected

tendon(s)
Pain worsened by wrist
or finger extension
especially against
resistance
Pain localized to the
affected tendon(s)
Pain localized to the

affected tendon(s)
Pain in the affected

tendon(s) associated with
wrist flexion and ulnar
deviation, especially
against resistance
Lateral elbow pain

exacerbated by repetitive
wrist movements
Pain emanating from the
lateral aspect of the elbow
or
*
Pain,tenderness, or swelling
along the dorsal aspects
of the hand,wrist, or forearm
Pain with active and/or resisted
wrist or digit extension
Audible creaking (crepitus)
may be present upon with
wrist extension along
extensor tendons
Pain localized to extensor tendons

in distal forearm or wrist
and
* Pain to palpation of extensor
aspect of forearm or wrist
and
* Pain localized to the affected
tendon(s) upon resisted wrist or
digit extension
Pain in the flexor tendon(s)

in wrist or distal forearm
upon palpation
Pain associated with wrist or
digit flexion and ulnar deviation
Crepitus may be present with
active movement of the
flexor tendons
Pain localized to flexor tendons in

distal forearm or wrist
and
* Pain to palpation of flexor tendons
in forearm or wrist
and
* Pain localized to the affected
tendon(s) with resisted wrist or
digit flexion
Tenderness to palpation over

the lateral epicondyle
Pain localized to lateral
epicondyle with resisted
wrist extension
Lateral elbow pain exacerbated
by repetitive wrist movements
Pain or burning in elbow

and
* Tenderness to palpation of lateral
epicondylar region
and
* Pain localized to lateral
epicondyle with resisted wrist
extension
*
*
*
*
*
*
*
*
*
Medial Epicondylitis
(``golfer's elbow'')
Pain emanating from the

medial aspect of the elbow
Grip weakness, but less
than with lateral
epicondylitis
Medial elbow pain
exacerbated by repetitive
wrist movements
Tenderness to palpation of the

medial epicondyle
Pain localized to the medial
flexion
Pain or burning in elbow

and
* Tenderness to palpation of medial
epicondyle
and
* Pain localized to the medial
flexion
*
*
*
*
*
Worksite modification
Rest from inciting/aggravating
movements
Anti-inflammatory and/or pain
medication
Neutral wrist splinting with thumb
spica
Physical or hand therapy with
iontophoresis
Cortisone injection
maneuvers
Anti-inflammatory or pain
medication
Physical or hand therapy
Monitor for coexisting radial
nerve or posterior interosseous
nerve injury in forearm
maneuvers
Anti-inflammatory or pain
medication
Physical or hand therapy
Monitor for co-existing median
or ulnar neuropathy at wrist
or forearm
Compression tennis elbow straps
NSAIDS
Physical therapy modalities
(manual modalities,
iontophoresis)
Acupuncture [NIH,1998]
Monitor for coexisting nerve
injury in forearm to radial or
posterior interosseous nerves
Steroid injections if above fails
Avoid leaning on elbows
NSAIDS
Physical therapy (manual
modalities, iontophoresis)
Monitor for coexisting injury to
median or ulnar nerves in forearm
Steroid injections if above fails
78
Piligian et al.
Disorder
Physical
Symptoms
Suggested
diagnostic criteria
Management options
Elbow
Ulnar Nerve Injury in
the Elbow/``Cubital
Tunnel Syndrome''
Activity-related pain or
paresthesias (e.g.,
numbness, cold sensation,
stiffness) involving the 4th
and 5th fingers coupled
with pain in the medial
aspect of the elbow which
may extend proximally
or distally
Pain or paresthesias
worse at night
Decreased sensation of
little finger and ulnar (outer)
half of ring finger (including
dorsum of little finger)
Progressive inability to
separate fingers
Loss of power grip and
dexterity
Atrophy or weakness of
the ulnar intrinsic muscles
of the hand (late sign); this
symptom alone may
indicate cervical nerve
roots C8 and T1dysfunction;
this symptom may also be
absent in often-occuring
anomalies involving crossinnervation of these
muscles by both median
and ulnar nerve fibers (e.g.,
Martin^Gruber
anastomosis)
Clawing contracture of
the ring and little fingers
``Benediction posture''
(late sign)
*
*
Pain or paresthesias involving

*
the 4th and 5th fingers coupled
with pain in the medial aspect
of the elbow and proximal
forearm upon palpation in medial
aspect of the elbow including
slightly proximal and distal to
this region
Diminished sensation of little
finger and ulnar (outer) half
of ring finger (excluding dorsum
of little finger) [AAEM,1999]
upon sensory testing (pin
*
prick or soft touch Semmes^
Weinstein monofilament testing)
Elbow flexion/ulnar compression
test [Novak et al.,1994]
Tinel's sign (electric shock
sensation radiating into the ring
and little fingers) is often
described
Weakness in abduction of fingers
with IP joints in extension (weak
intrinsic hand muscles)
Progressive inability to separate
fingers
Wartenberg's sign is described
wherein the patient is asked
to extend the fingers and
abduction or clawing of the little
finger occurs [Preston and
Shapiro,1998]
Loss of power grip and dexterity
Atrophy of the ulnar intrinsic
muscles (see notes under
``symptoms''section in adjoining
column)
Froment's sign is described in
which the patient cannot pinch
between the index finger and
thumb without flexion at the PIP
joint [Preston and Shapiro,1998]
Clawing contracture of the ring and
little fingers``Benediction posture''
[Preston and Shapiro,1998]
(late sign)
Paresthesias or numbness
involving the 4th and 5th digits
coupled with pain in the medial
aspect of the elbow which may
extend proximally or distally; or
Pain or paresthesias involving the
4th and 5th digits coupled with
pain in the medial aspect of the
elbow and proximal forearm upon
palpation in medial aspect of the
elbow including slightly proximal
and distal to this region;
Positive electrodiagnostic test
consistent with ulnar neuropathy
at the elbow
*
*
Non-surgical (conservative)
management:
Ergonomic modifications in work
or non-work environments
Avoid leaning on elbows
Minimize or avoid aggravating
movements or upper limb
postures (especially elbow
flexion)
Splint elbow in slightly flexed
position (40) at night (daytime
splinting for limited periods if
condition severe)
Physical and/or occupational
therapies with appropriate
modalities
Surgical management if patient
initially presents with significant
motor or sensory ulnar nerve
impairment, or if conservative
treatment fails after at least
3^6 months [Idler,1996]
Disorder
Hand-ArmVibration
Syndrome (HAVS)
Physical
Symptoms
*
*
*
*
Pain or paresthesias in
the digits (e.g., tingling,
numbness, cold sensation)
Blanching in the digits
Cold intolerance
Tenderness or swelling of
the digits, hand or forearm
Muscle weakness of the

hand
Joint pains in hand,wrist,
elbow, neck, shoulders
Trophic skin changes and
cyanotic color in hand or
digits
*
*
*
*
Suggested
diagnostic criteria
Sensory deficits in the digits and * Use of vibrating tools currently or

hand
in past (latency period varies;
Blanching of digits
refer to text)
Tenderness or swelling of the
and
digits, hand and forearm
* Digital pain and paresthesias
Muscle weakness of the hand
or
Joint arthroses in hand,wrist,
* Blanching in at least one of the
elbow, neck or shoulders
digits
Trophic skin changes and
cyanotic color in hand or digits
79
Management options
*
*
*
Avoid exposure to vibrating tools

or cold
Maintain central body
temperature
Splinting at night to treat
associated neuropathies
Discontinue smoking
Consider use of medications to
improve peripheral blood flow or
reduce platelet deposition
(limited effectiveness)
Monitor for response to
treatments using any of the
clinical laboratory tests for
vasospasm in the hands or digits
(e.g., plethysmography pre- and
post-cold provocation) and for
peripheral neuropathies (e.g.,
NCV testing, quantitiative
vibrometry).
TABLE II. Recommendations for Movement in RepetitiveWork
Body area
Shoulder
Upper arm, elbow
Forearm,wrist
Finger
Frequency
repetition per minite
Level of risk
Very high risk if modified by either:
More than 2.5

More than10
More than10
More than 200?
High
High
High
High
High external force, speed, high static load, extreme posture

Lack of training, high output demands, lack of control
Long duration of repetitive work
Modified version printed with permission of B.Bernard (personal communication,1999).
DISORDERS OF THE TENDON UNITS

Most of the muscle-tendon units of the distal upper
extremity originate in the elbow region from the distal
aspects of the humerus and insert into the phalanges, thus
spanning several different joints (inter-phalangeal, metacarpophalangeal, wrist joints and elbow joint). The precise
pathology of work-related tendinous disorders has not been
fully characterized, leading some authors to use the term
tendinopathy [Almekinders and Temple, 1998]. Most
studies of pathologic changes in chronic tendon injuries
demonstrate degenerative changes with some brovascular
hyperplasia (e.g., in epicondylitis) and no acute inammatory changes [Almekinders and Temple, 1998]. For this
reason, tendinosis, referring to a degenerative process, may
be a more accurate descriptor of chronic work-related
tendinous disorders. However, work-related tendon disorders are commonly reffered to in the literature as tendinitis, implying that inammation is the primary pathologic process. For example, a recent paper by Tittiranonda
et al., states ``Work-related tendinitis refers to a disorder of
the tendons or tendon sheaths that results from cumulative
loading during highly repetitive tasks or forceful tasks
involving awkward postures over a prolonged period.''
[Tittiranonda et al., 1999]. Recognizing that this nosologic
challenge has yet to be fully resolved, the term tendinitis/
tendinosis will be used in this paper, except when refering to
prior studies, underscoring the more accurate pathologic
descriptor tendinosis, but also acknowledging the widespread use of the term tendinitis in the scientic literature.
Regardless of the underlying pathologic process, while
tendinous disorders are classied segmentally, the muscle
80
Piligian et al.
tendon units function over several different anatomic regions.

Hence, evaluation and management of the muscle tendon
disorders warrants consideration of all structures comprising
the distal upper extremity, their functional anatomy, and
interrelationships. Thorough knowledge of the gross and
functional anatomy is indispensable to the effective clinical
management of the disorders under consideration.
Hand/Wrist Tendinitis
Epidemiology
NIOSH's review of studies of musculoskeletal disorders and workplace factors [Bernard, 1997] found (1)
evidence of associations between individual risk factors
(repetition, force, and extreme or static posture) and hand/
wrist tendinitis, and (2) strong evidence that job exposure to
a combination of risk factors (e.g., repetition and force)
increased the risk for hand/wrist tendinitis. Epidemiologic
studies of this group of disorders typically have combined a
variety of diagnoses such as tenosynovitis, tendinitis,
peritendinitis, and deQuervain's tendinitis into the general
category of ``hand/wrist tendinitis''.
Two of the eight studies reviewed by Bernard [1997]
met all four of NIOSH's study acceptability criteria, and
these demonstrated a substantial magnitude of association.
For example, female assembly line workers in a food
production factory had a prevalence of hand/wrist tendinitis
four times greater than female department store assistants,
excluding cashiers [Luopajarvi et al., 1979]. Among
industrial workers at seven U.S. manufacturing plants, the
prevalence of hand/wrist tendinitis was 5.5 times higher for
the high repetition/low force group compared to the low
repetition/low force (non-exposed) group, and 4.8 times
higher for the high force/low repetition group compared to
the non-exposed group. Workers facing both exposures, i.e.,
the high force/high repetition group, had an odds ratio (OR)
of 17.0 compared to the non-exposed group, suggesting a
synergistic effect when both risk factors are present
[Armstrong et al., 1987].
Functional anatomy
The functionally important movements of the distal
upper extremity at the wrist include exion, extension,
pronation, supination, and radial and ulnar deviations. The
functionally important movements of the digits are exion,
extension, abduction, adduction, and circumduction and at
the elbow, exion and extension. Some muscle tendon units
are supercial and can be readily delineated by examination,
such as the tendons involved in deQuervain's disease.
The main muscles that can pronate the forearm are the
pronator teres and pronator quadratus (three other exor
muscles contribute to a small extent). The pronator teres
muscle is supercial, with the bulk of the muscle located just

distal to the antecubital crease of the elbow. The pronator
quadratus crosses transversely over the ulna and the radius in
the distal forearm near the wrist. It is deeply situated on the
palmar side, lying directly over the bones and the interosseous membrane, and is covered by the long exors of the
wrist [Smith et al., 1996]. The main muscles that supinate the
forearm are the biceps brachii, and supinator (three lesser
muscles of supination also exist). The muscular portion of
the biceps is located above the elbow and its distal
attachment on the proximal radius. The supinator is a deep
muscle, with a triangular, at shape, on the dorsal side of the
interosseous membrane between the two bones of the
forearm [Smith et al., 1996].
There are six muscles that have tendons crossing the
volar aspect of the wrist capable of creating wrist exion.
These are: palmaris longus (PL), exor carpi radialis, exor
carpi ulnaris, exor digitorum supercialis, exor digitorum
profundus, and exor pollicis longus. The rst three of these
muscles are primarily wrist exors. The last three are exors
of the digits with secondary actions at the wrist. All pass
under the exor retinaculum of the wrist surrounded by the
lubricating synovial sheaths, except the PL [Norkin and
Levangie, 1992].
The dorsum of the wrist is crossed by the tendons of
nine muscles, all of which pass under the extensor retinaculum. Three are primary wrist extensors: the extensor carpi
radialis longus and brevis (ECRL, ECRB), and the extensor
carpi ulnaris (ECU). The other six muscles are nger and
thumb muscles that may act secondarily on the wrist: the
extensor digitorum (ED), the extensor indicis (EI), the
extensor digiti minimi (EDM), the extensor pollicis longus
(EPL), the extensor pollicis brevis (EPB), and the abductor
pollicis longus (APL) [Norkin and Levangie, 1992]. The
rst dorsal compartment contains the APL and EPB tendons
commonly affected in deQuervain's disease. The second
dorsal compartment contains the ECRL and ECRB, while
the third compartment contains the EPL. The fourth compartment contains the ED and EI tendons with EDM
occupying the fth, while ECU lls the sixth compartment.
[Gordon, 1995].
Pathology
Tendons transmit mechanical tension (tensile loads)
that occurs during muscular effort. However, forces that
exceed the ability of tendinous tissue to adapt, e.g., high
force, repetition, or awkward posture can result in inammation, tissue repair, and brotic changes [MacKinnon and
Novak, 1997]. As noted previously, although the term
``tendinitis'' is used commonly in the medical literature,
implying that inammation is the pathology underlying
chronic tendinous disorders, another hypothesis states that
relatively low level chronic insult to tendons may involve
chronic degeneration and/or proliferation of associated

synovial tissue as the predominant pathologic processes
[Hart et al., 1995]. Recently, diagnostic criteria for disorders
of the distal upper extremity have been developed and published [Harrington et al., 1998]. Classication is generally
based upon 1) location of pain (i.e., elbow, forearm, wrist,
digits), 2) the presence of pain during movement of the
affected tissue, 3) presence of pain during palpation of the
affected tissue, and 4) response to specic provocative tests.
Clinical presentation
The cardinal complaint of the patient with a chronic
tendinous disorder is pain, which is typically located near
the region of the muscle origin or tendon insertion. The
clinical signs of tendinous disorders are primarily based
on eliciting pain upon palpation of the involved tendon, or
with resisted movement of the affected tendon; additional
ndings may include the sensation of crepitation on palpation and the presence of warmth, swelling, or tenderness
overlying the tendon [Harrington et al., 1998]. Evaluation of
contiguous or underlying structures is important since these
may be injured concurrently. For example, injury to a wrist
ligament may complicate the presentation of a wrist exor
or extensor tendinous injury. Likewise, ulnar nerve injury at
the Guyon's canal may coexist with tendinitis/tendenosis of
the distal insertion of the exor tendon (exor carpi ulnaris)
along the volar and medial aspect of the wrist.
Treatment
In general, treatment of chronic tendinous disorders is
``conservative'' (i.e., non-surgical). The aims of treatment
are reduction of pain and prevention of disability by
restoration of function. Workplace interventions for occupationally induced chronic tendinous disorders are essential
to promote effective treatment and prevent recurrence or
chronicity of the condition. In mild cases of tendonitides,
the initial treatment approach should include worksite
exposure assessment and modication to provide rest from
inciting and/or aggravating movements, and anti-inammatory medication. There is evidence of symptomatic pain
relief of chronic tendinous disorders using NSAIDs in some
clinical studies with limited follow-up periods of at most 7
to 28 days [Almekinders and Temple, 1998]. For more
severe cases, or when symptoms have persisted despite
modication of worksite exposures and use of non-steroidal
anti-inammatory medication, physical or occupational
therapy may be added to the treatment regime. The therapeutic modalities widely used in the U.S. at present include
regional applications of ice or heat, manual modalities such
as myofascial release and deep friction massage, transcutaneous electrical nerve stimulation, ultrasound, iontophoresis, stretching, and strengthening exercises. Many of these
81
modalities have yet to undergo evaluation for efcacy for

the treatment of work-related tendonitides in well-designed
experimental studies, although their widespread use has led
to a practice-derived body of knowledge. For treatment of
chronic pain or sleep disturbance associated with more
severe, chronic tendinous disorders, low dose antidepressant
medications may be useful [Herrington and Morse, 1995].
Again however, given the paucity of clinical trials in this
area, such treatment needs considered to be pragmatic rather
than evidence-based.
Conditions unresponsive to conservative measures may
require steroid injections or surgical intervention. Most
tendon muscle units are accessible to injections; however,
caution should be used with tendons prone to rupture, such
as the extensor pollicis longus [Gordon, 1995]. Conditions
that are usually reported to be responsive to injections are
deQuervain's disease, intersection syndrome and trigger
nger; for these conditions surgery should be reserved for
cases in which severe debilitating symptoms have been
present for over a year despite adequate conservative
measures [Herrington and Morse, 1995].
Disorders of the Extensor Tendons of

the Forearm
Among the forearm extensors, six separate compartments of the extensor muscles are described within the
forearm and wrist (see Functional Anatomy). Although any
muscle tendon unit of the upper extremity can be subject to
chronic injury, the most commonly affected extensor
tendons are in the rst dorsal compartment (deQuervain's
disease) [Turek et al., 1994].
First Dorsal Compartment Syndrome

(deQuervain's Disease)
Epidemiology
Although the incidence and prevalence are not well
established for deQuervain's disease, reports from limited
studies indicate that women are affected more frequently
than men and the age of onset is between 30 and 60 years
[Kelsey, 1982; Amadio, 1995]. High risk occupations and
activities associated with deQuervain's disease include
knitting, switchboard operation, typing, piano playing,
golng, ycasting and attempting new kinds of repetitive
work or resuming repetitive work after a vacation [Kelsey,
1982]. In a study of 146 female workers in highly repetitive
jobs, 8% were found to have deQuervain's tenosynovitis.
Among the 63 sewers, the prevalence was 6% [Ranney et al.,
1995], identical to the prevalence of this condition among
sewers found by Punnett et al. [1985]. The prevalence ratio
for deQuervain's disease among 199 automobile assembly
line workers was 2.49 (95% CI 1.006.23) compared to 186
82
Piligian et al.
randomly selected subjects from the general Swedish population [Bystrom et al., 1995].
Anatomy and pathology
DeQuervain's disease is a painful condition involving
the abductor pollicis longus and extensor pollicis brevis
tendons (rst compartment tendons) as they traverse the rst
dorsal compartment of the extensor retinaculum at the wrist.
Tenosynovitis, which implies an inammatory process, was
used in early literature to describe deQuervain's disease.
However, one study of the histopathology of this condition
revealed peritendinous brosis without inammation and
brocartilaginous metaplasia of the tendon sheath tissue
[Amadio, 1995]. It is now generally accepted that there is no
evidence of an inammatory process occurring in deQuervain's disease and the term tenosynovitis should not be used
to describe this condition.
The primary clinical symptoms of deQuervain's disease
of the wrist include: (1) pain, tenderness, and/or swelling
over the radial styloid in the area of the anatomic snuffbox
and (2) pain worsened by abduction and extension of the
thumb. The physical ndings include: (1) tenderness to
palpation over the radial styloid and (2) a positive
Finkelstein's maneuver (which involves the patient holding
the thumb in the palm, closing the ngers over it, while the
examiner ulnar deviates the wrist). Additional physical
examination ndings which may be present include swelling
or thickening of the rst extensor compartment of the wrist
[Harrington et al., 1998] or swelling, erythema, and crepitus
which can be palpated along the radial forearm if signicant
uid is present in the tendon sheath.
The diagnosis of deQuervain's disease is mainly
clinical; however, specic diagnostic tests are indicated to
differentiate among other pathologies that can mimic
deQuervain's disease. Recent studies have suggested that
high-resolution ultrasound [Giovagnorio et al., 1997] or
MRI [Glajchen and Schweitzer, 1996] may be useful
imaging studies for the diagnosis of deQuervain's disease;
however, further studies are needed to validate these
techniques.
Treatment
The initial treatment of deQuervain's disease should
consist of conservative medical management which includes
workplace modication, rest to the hand, anti-inammatory
medication, and neutral splinting of the wrist using a splint
with a thumb spica [Winzeler and Rosenstein, 1996].
Iontophoresis may be added to the treatment regime for
short-term pain relief, based on anecdotal reports by
physicians and therapists, and on clinical studies suggesting its usefulness in other upper limb soft tissue disorders
[Banta, 1994; Demirtas and Oner, 1998]. If conservative
management fails or in severe cases, injection of cortisone
should be performed in addition to splinting and antiinammatory medication. If these fail, surgical debridement of the peritendinous scarring should be considered
[Amadio, 1995; Gordon, 1995; Winzeler and Rosenstein,
1996].
Repetitive, forceful radial deviation of the wrist with
abduction and extension of the thumb are common motions
that cause deQuervain's disease [Turek et al., 1994], as are
rapid rotational movements of the forearm and repetitive
movements and forceful ulnar deviation of the wrist [PutzAnderson, 1988]. Abatement of these movements should be
the focus of workplace modications.
Other Disorders of the Extensor

Tendons of the Forearm and Wrist
Because the tendinous disorders of the 2nd6th
compartments are similar with respect to their diagnosis
and treatment, they will be considered as a group; however,
the practitioner should determine which compartments
are affected based on the location of pain and physical
ndings.
Extensor tendinous disorders are diagnosed by compartment based on the presence of reported pain in the
region of the tendon, or localized pain in the affected tendon
with passive, active and/or resisted movement, and pain
upon palpation of the affected tendon. The common clinical
presentation includes pain or tenderness, with or without
swelling, along the affected extensor tendon or tendons.
Pain in the tendon elicited upon performing movements
requiring wrist extension against resistance is a frequently
reported physical sign. Typically, the pain is temporally
related to work, increasing as the workday and workload
progresses and remitting with cessation of inciting exposures.
Treatment
The treatment of the extensor forearm tendinous
disorders and workplace interventions are similar to other
tendonous disorders. Conservative treatment used in the
NYSOHC includes (a) avoidance or reduction of inciting
workplace and avocational exposures, and NSAIDs for very
mild cases and (b) avoidance or reduction of inciting
workplace and avocational exposures, NSAIDs, and hand
therapy for moderate to severe cases with or without
adjuvant pain medication.
Disorders of the Flexor Tendons of the

Forearm and Wrist
As with extensor tendinous disorders, chronic workrelated forearm exor tendon disorders are characterized by
the presence of pain in the affected tendon or tendons that is
reproduced with active, passive or resisted movements and/
or palpation of the affected area, and which is temporally
associated with work.
The clinical presentation of exor tendinous disorders
at the wrist is characterized by the presence of pain in the
region of the tendon, which increases with repetitive wrist
exion and ulnar deviation, especially against resistance.
Specic physical ndings on examination include: (1)
tenderness to palpation over the affected tendon, which
may be associated with swelling and erythema, and (2) pain
with resisted exion [Harrington et al., 1998]. Additionally,
crepitation may be felt in the tendon with passive exion of
the digits or wrist. Forearm exor tendinitis/tendinosis is a
clinical diagnosis; to date, there are no ``gold standard''
diagnostic tests.
Treatment
Treatment of exor forearm tendon disorders is of a
conservative nature and rarely requires surgical intervention. Again, initial treatment should include avoidance of
inciting exposures, workplace modication, NSAIDs, and,
for cases with symptom duration longer than four weeks
[Herrington and Morse, 1995], or for cases associated with
severe pain, physical or occupational therapy.
EPICONDYLITIS
The term epicondylitis is used to describe conditions
characterized by pain in the region of the epicondyle, which
is exacerbated by resisted use of either the extensor or exor
muscles of the forearm.
Epidemiology
Hagberg et al. [1995], who reviewed six studies of
epicondylitis, concluded that there was not a convincing
case for the work-relatedness of this disorder. However, in
the more recent NIOSH review [Bernard, 1997] which was
based on 19 epidemiologic studies, occupational risk factors
were assessed individually, and some re-analyses of the
original data were conducted. NIOSH concluded that there
is evidence for an association between forceful work and
epicondylitis, and strong evidence for a relationship
between exposure to a combination of risk factors (e.g.,
83
force and repetition, force and posture) and epicondylitis.

However, there was insufcient evidence to support
associations between this disorder and repetitive work alone
or extreme posture alone [Bernard, 1997].
Three studies assessing the association between force
and epicondylitis met all of NIOSH's study evaluation
criteria, and the strength of association in some of the
comparisons in these studies was substantial: an OR of 6.8
among male sh processing workers, although a nonsignicant OR of 1.4 among women [Chiang et al., 1993];
an OR of 2.7 (95% CI 0.6615.94) for lateral epicondylitis
among female assembly line workers [Luopajajarvi et al.,
1979]; and an OR of 5.5 among ``hazardous jobs'' in a pork
processing plant [Moore and Garg, 1994]. The one
prospective study of this association, which met three of
four evaluation criteria, also found a strong association
(OR 5.56.7) between strenuous meat processing jobs
and epicondylitis, among both men and women [Kurppa
et al., 1991]. The highest incidence of this disorder appears
to occur in `òccupations and job tasks which are manually
intensive and require high work demands in dynamic
environmentsfor example, in mechanics, butchers, construction workers, and boilermakers'' [Bernard, 1997].
Other examples of industries associated with epicondylitis
are wallboard installation, roong, masonry, foundries,
building construction, furniture/casket manufacturing,
wood frame building construction, paper products manufacturing, meat dealers (wholesale), and concrete construction [Silverstein et al, 1998].
Lateral Epicondylitis (Tennis Elbow)

The elbow is a hinge and pivot joint that allows the joint
to ex, extend, and rotate. Lateral epicondylitis, or tennis
elbow, is a term used to describe a condition characterized
by pain in the region of the lateral epicondyle exacerbated
by active and resisted movements of the extensor muscles of
the forearm [Harrington et al., 1998]. The pathology is
generally believed to be a chronic tear at the origin of
extensor carpi radialis brevis with resultant development of
chronic granulation tissue [Nirschl, 1992; Bennett, 1994].
Inciting motions include grip intensive activities involving
repetitive forceful elbow movements.
The classic symptom of lateral epicondylitis is pain in
the region of the lateral epicondyle with radiation down the
arm [Harrington et al., 1998]. Common physical examination ndings include: (1) tenderness with palpation over and
distal to the lateral epicondyle, and (2) elbow pain with
resisted wrist extension while the elbow is extended.
84
Piligian et al.
Treatment
For early symptoms, abatement of inciting exposures at

the workplace and home, coupled with NSAIDS and
compression tennis elbow straps (to minimize repetitive
trauma to the tendon insertion) are generally adequate
treatment. The tennis elbow strap has been advised for use
during performance of work activities involving the hand
and wrist, and should be otherwise removed to avoid
venous congestion. It is applied just below the elbow with
the forearm muscles relaxed using Velcro fasteners
[Froimson, 1971]. However, its use has been associated
with supercial radial nerve entrapment in the forearm
[Enzenauer, 1991], posterior interosseous or ulnar nerve
entrapment [Bennett, 1994], and referral to an experienced
specialist (e.g., physical or occupational therapist or a
physiatrist) may help ensure the proper tting of the strap
and provision of instructions for its use.
For more chronic or severe symptomatology, treatment
should include NSAIDs, modication of activities to avoid
lifting, gripping, and pronation or supination of the affected
extremity, and, optionally, physical or hand therapy with
iontophoresis, ultrasound and/or manual modalities or local
steroid injection. The literature on efcacy of physical
therapy in the treatment of epicondylitis is sparse. However,
there is considerable experience among the New York State
Occupational Clinics in the use of physical therapy in the
treatment of patients with epicondylitis, with resulting
short-term symptomatic relief among patients. Additionally,
a recent consensus document from NIH suggests that
acupuncture may be used in the treatment of lateral
epicondylitis [NIH, 1998]. Some authors advocate that
surgery be considered when conservative treatment and
workplace interventions have failed. However, this is a
controversial recommendation. Bennett [1994] recommends
surgery after one year of persisting symptoms with
treatment, claims surgery (e.g., resection of the affected
tendon) is `èffective in selected series'' of patients when
appropriate post-surgery care is also provided, such as
splinting or bracing and with appropriate job modication
and retraining. Herrington and Morse [1997] suggest it is a
very poor treatment option and rarely successful.
Medial epicondylitis is characterized by tenderness and

pain emanating from the medial aspect of the elbow. The
salient ndings on physical exam include: (1) tenderness to
palpation over the medial epicondyle and (2) pain in the
elbow with restricted wrist exion. Palpation over the
medial epicondyle should reproduce the patient's symptoms. A provocative test to aid in the diagnosis is
exacerbation of pain with resisted pronation of the forearm
with wrist exion.
Medial Epicondylitis (Golfer's elbow)

The origin of the supercial forearm exor muscles is at
a common tendon at the medial epicondyle of the humerus.
The exor muscles insert onto the middle phalanges (FDS),
the bases of the metacarpal bones (FCR), the pisiform,
hamate and metacarpal bone (FCU) and into the palmar
aponeurosis (PL). The pathology affecting the common
exor tendon is described under `Èpicondylitis''.
Treatment
Medical management of medial epicondylitis is similar
to that of lateral epicondylitis with some exceptions. The
shape of the compression or ``counterforce'' straps may
differ [Nirschl, 1992] and are less commonly advised in
practice. Furthermore, some practitioners advise soft elbow
pads wrapped around the elbow to protect the medial
epicondylar region from further trauma when leaning the
elbow on various surfaces (e.g., armrests of chairs, table
surfaces). In addition, surgery is less frequently advised
[Bennett, 1994] and steroid injection is not recommended
[Herrington and Morse, 1995].
CUBITAL TUNNEL SYNDROME (ULNAR

NERVE AT ELBOW: A SENSORY AND
MOTOR SYNDROME)
While focal entrapment of the ulnar nerve is an
increasingly recognized cause of work-associated morbidity, the literature on these disorders in the occupational
setting is sparse. Cubital tunnel syndrome is ulnar nerve
entrapment at the medial aspect of the elbow. It is the second
most common entrapment neuropathy of the upper extremity after carpal tunnel syndrome [AAEM, 1999; Idler,
1996].
Epidemiology
Two recent comprehensive reviews of the epidemiology
of WMSDs [Hagberg et al., 1995; Bernard, 1997] did not
assess studies of nerve entrapments in the upper extremity
aside from carpal tunnel syndrome. While Hagberg and
Silverstein [1995] stated that ulnar nerve entrapment in the
elbow region (cubital tunnel syndrome) was the second most
frequent upper extremity entrapment neuropathy, they did
not review this disorder, stating that studies providing
evidence of its work-relatedness are currently lacking.
However, earlier and subsequent articles and texts
provide some evidence of the work-relatedness. Specic
work related risk factors common to the cubital tunnel
syndrome appear to be aggravating motions consisting of
repetitive and sudden elbow exion, and repeated trauma or

pressure to the elbow at the ulnar groove [Feldman et al.,
1983; Herrington and Morse, 1995; Gordon, 1995]. Job
tasks associated with cubital tunnel syndrome include
shoveling, hammering, lifting, manipulating handles of
boring and punching machines, leaning on the elbow at a
desk or work bench, working in tight places, digging, and
use of hand saws or large power machinery [Feldman et al.,
1983; Gordon, 1995; Blair, 1995].
Anatomy and Pathology

The ulnar nerve originates from the inferior roots of the
brachial plexus (C8-T1). Compressions of the nerve at given
points along its course through the upper extremity give rise
to the various nerve entrapment syndromes. While cubital
tunnel is a general term used to describe localized
entrapment of the ulnar nerve at the elbow, the site of
entrapment of the ulnar nerve in the region of the elbow can
occur in several locations including proximal to the elbow
by the medial head of the triceps' `àrcade of Struther's,'' at
the elbow by the arcuate ligament, or in the mid-forearm by
the exor carpi ulnaris muscle. Precise localization of
entrapment is important if surgery is being contemplated
[Hilburn, 1996].
Clinical Presentation
Depending upon the severity of the entrapment, typical
symptoms of cubital tunnel syndrome include: (1) activityrelated numbness or paresthesias involving the 4th and 5th
ngers; (2) pain in the medial aspect of the elbow and
proximal forearm; (3) progressive inability to separate
ngers, pick up small objects between the thumb and index
nger; (4) loss of power grip and dexterity and, in severe
cases, claw position of the ring and little ngers, hand
fatigue and atrophy of the hypothenar and interosseous
muscles [Idler, 1996; Feldman et al., 1983; Herrington and
Morse, 1995; Blair, 1995]. As with carpal tunnel syndrome,
symptoms of cubital tunnel syndrome are often associated
with nocturnal awakening.
A variety of provocative tests have been suggested for
use in diagnosing cubital tunnel syndrome. These include
Tinel's sign (paresthesias in the fth digit and medial half of
the fourth digit when tapping over the ulnar nerve at the
elbow), the elbow exion test in which symptoms in digits 4
and/or 5 (paresthesias and/or numbness) develop following
maximum exion of the elbow with the forearm in
supination and the wrist in neutral, and the pressure
provocative test, in which pressure is applied proximal to
the cubital tunnel with the elbow in 20 exion and the
forearm in supination [Novak et al., 1994].
Novak and colleagues [1994] evaluated the sensitivity
and specicity of Tinel's sign over the cubital tunnel, the
85
``pressure provocative test,'' and the elbow exion test. The

sensitivity and specicity of the Tinel's sign were 0.70 and
0.98, respectively. The sensitivity of the exion test at 60
seconds was 0.75 and the specicity 0.99. The 60 second
pressure test's sensitivity was 0.89, with a specicity of
0.98. A maneuver combining the elbow exion test with
maintaining local pressure over the cubital canal for 30
seconds, resulted in sensitivity 0.91, specicity 0.97,
and ppv 0.93.
Tests of function in muscles innervated by the ulnar
nerve may not always be impaired because of cross supply
to these muscles by the median nerve. Clinical methods
described to test the ulnar innervated intrinsic muscles of the
hand include: abduction of the digits (with the IP joints in
extension) against resistance; exion of the fth digit DIP
joint against resistance; difculty in adducting the fth digit
while it is in extension (Wartenberg's sign); inability to
properly cross the index and middle ngers (Scott Earle
test); and inability to pinch index and thumb tips together
rmly without sharp exion of the DIP joint (positive
Froment's sign) [Idler, 1996]. The ``late'' signs include
wasting of the intrinsic muscle mass of the rst dorsal
interosseous (FDI) muscle, one of the intrinsic muscles best
viewed in the space between the thumb and the second
metacarpal bone.
Sensory testing over the ulnar nerve distribution should
include the palmar and dorsal aspects of the fourth and fth
digit, comparing the affected and non-affected sides. Such
testing can be accomplished using standardized (Semmes
Weinstein) monolaments or vibratory testing, since light
touch and vibration sense are the rst affected in early stages
of nerve entrapment [Idler, 1996].
A classication of causes of cubital tunnel syndrome
is described by Tetro and Pichora [1996]. Of the classication systems devised for describing the severity of
cubital tunnel syndrome, that of Dellon [1989] is the
most comprehensive, incorporating progression of symptoms and clinical tests of motor and sensory ulnar nerve
function.
Electrodiagnostic Testing
Electrodiagnostic testing including nerve conduction
velocity and electromyography should be performed whenever an entrapment neuropathy is suspected, but the severity
of the clinical ndings may not always correlate with the
results of such testing. In addition, the proper technique and
interpretation by the specialists performing these tests is of
paramount importance for the evaluating physician who
must decide when to refer a patient for surgery. Blair [1995]
writes ``the denition of cubital syndrome on the basis of
absolute electrophysiologic values is of limited merit, as
normal and abnormal values are technique and laboratory
dependent''.
86
Piligian et al.
The reader is referred to a recent comprehensive review,

the American Association of Electrodiagnostic Medicine's
``Practice Parameter for Electrodiagnostic Studies in Ulnar
Neuropathy at the Elbow'' [AAEM, 1999]. This document
attempts to standardize the methodology and technique for
performing electrodiagnostic testing of the ulnar nerve at the
elbow. Its four-page summary is a useful guide in assessing
the quality of electrodiagnostic testing for the clinician who
refers a patient. Two of the three AAEM practice standards
listed are: limb temperatures should be maintained and
noted within a reference range (34 C is most commonly
used), and, elbow position should be the same during
electrodiagnostic stimulation and measurement of the nerve
and also when comparing the patient's results with the
normal values adopted by the testing laboratory. The AAEM
suggests moderate elbow exion of 7090 from horizontal
but recognizes that studies have used different elbow
exion/extension angles [AAEM, 1999].
The information provided by electrodiagnostic testing
of the ulnar nerve can help:
1.
2.
3.
conrm injury to the nerve;

gauge the severity of nerve injury;
locate the site(s) of injury along the course of the
nerve.
Electrodiagnostic studies are useful in documenting

mild to marked entrapment of the ulnar nerve in the cubital
tunnel. However, the values of electrodiagnostic tests must
be interpreted in the clinical context, for 65% of the
population may have 1020 m/second slowing across the
elbow [Blair, 1995]. Very mild cubital tunnel syndrome is a
clinical diagnosis based on practitioner experience [Blair,
1995]. Comparison of the affected and unaffected limbs (if
the condition is not bilateral) could also prove useful for
reaching an accurate diagnosis. A review paper by Hilburn
[1996] provides an excellent overview of the use of
electrodiagnostic studies in the diagnosis of cubital tunnel
syndrome as does a textbook by Preston and Shapiro [1998].
Once it is clear that the ulnar nerve is probably involved in
the injury process, referral to an experienced specialist in
electrophysiologic testing is warranted for the reasons listed
above. In addition, the specialist can select, from among the
various nerve conduction testing parameters available, those
appropriate for the patient.
Treatment
The treatment of cubital tunnel syndrome is generally
based on assessment of (1) the severity of symptoms and
sensory or motor impairment upon presentation of the
patient and (2) the duration of symptoms and nerve function
impairment. In mild or moderate cubital tunnel syndrome a
minimum of six months of non-surgical, conservative
(medical) management is suggested before considering

surgery [Idler, 1996]. Surgical intervention is generally
recommended for severe sensory or motor impairment
[Idler, 1996; Tetro and Pichora, 1996]. However, there is
less agreement in the literature on the best method of initial
treatment for moderate cubital tunnel syndrome, based on
less successful outcomes compared to mild neuropathy.
Medical monitoring of patients at 13 month intervals is
warranted, which should include assessment of symptoms,
signs of nerve impairment and compliance with treatment
recommendations. If no improvement is seen or the clinical
condition deteriorates, electrodiagnostic retesting is recommended by most authors and operative intervention should
be considered [Tetro and Pichora, 1996].
Non-surgical management of the cubital tunnel syndrome should include modication of inciting exposures
and activities at work and at home. Extreme elbow exion
should be avoided at home and at work. Patients frequently
benet from use of an elbow splint. The elbow should be
splinted in elbow extension which limits exion to no
greater than 45 but does not apply direct pressure to the
nerve [Sailer, 1996]. Splints should be used at night even in
the absence of nighttime paresthesias noted upon awakening. During the day, elbow pads may be used to protect the
ulnar nerve within the ulnar groove from direct pressure or
trauma. Use of elbow padding and night splinting is
suggested for a trial of at least three months. In severe
cases, daytime splinting may be tried [Idler, 1996].
Additionally, for more chronic and severe cases of cubital
tunnel syndrome, physical or occupational hand therapy
should be performed.
Authors differ over the time from the onset of
symptoms for which adequate conservative measures are
to be tried before surgery should be considered in patients
who present with mild or moderate cubital tunnel syndrome,
but it ranges from six months [Idler, 1996] to one year [Tetro
and Pichora, 1996]. Dellon et al. [1993] have found that a
high percentage (89%) of patients with ``mild, intermittent
disease were successfully treated nonoperatively, whereas
only 38% of those with moderate disease(persistent
paresthesias, muscle weakness, abnormal two-point discrimination [less than 10 mm] were successfully managed
conservatively.'' Urbaniak [1991] recommends a trial of
conservative measures in patients with the following
ndings: ``(1) early symptoms, intermittent episodes; (2)
mild paresthesias without signicant pain; (3) minimal
physical ndings (slight numbness), with normal motor
examination.'' He suggests operative exploration without a
trial of conservative treatment in those with ``severe ndings
of weakness, decreased two-point discrimination, and
electromyographic evidence of denervation potentials...''
[Tetro and Pichora, 1996].
The medical literature varies on the most appropriate
operative procedure for the different subtypes of cubital
tunnel syndrome. Basically, releasing constrictions at all

affected sites along the nerve in the elbow region is one
surgical option (simple decompression), and changing the
position of the nerve to the front of the elbow (anterior
transposition) is the second major category of operation,
with variations used within each category. Needless to say,
there is debate over the best operative procedure to be used,
and the reader can refer to the reference article by Tetro
and Pichora for a discussion of the different operative
procedures.
It is important to modify ergonomic risk factors
associated with ulnar nerve entrapment syndromes to reduce
recurrence of these disorders. Such risk factors include
sustained elbow exion (greater than 45 ), repetitive elbow
exion, and forceful exertions of the wrist, forearm or
elbow.
VASCULAR DISORDERS OF THE HAND

AND ARM
There are currently four recognized disorders of the
hand and arm reported among working populations which
include signicant vascular components, namely handarm
vibration syndrome (HAVS), hypothenar hammer syndrome, Raynaud's phenomenon, and reex sympathetic
dysfunction (RSD, also termed complex regional pain
syndrome, type I). Of these, HAVS has been best dened
and established in the literature on epidemiology and workrelatedness [Bernard, 1997] and was, therefore, chosen for
discussion.
HandArm Vibration Syndrome

HAVS is frequently under-diagnosed and misdiagnosed
as carpal tunnel syndrome since the two entities can coexist
[Miller et al., 1994; Szabo and Madison, 1995]. Hence, for
patients having worked with or currently working with
vibrating tools, the possibility of HAVS should be
considered.
Epidemiology
The twenty studies reviewed by NIOSH [Bernard,
1997] provide strong evidence of a positive association
between high-level exposure to hard-arm vibration and the
vascular symptoms of Hand-Arm Vibration Syndrome
(HAVS), also known as Vibration White Finger (VWF).
These studies provide evidence that the intensity and
duration of exposure are associated with risk of developing
HAVS, with HAVS symptom severity, and with reduced
time to onset of HAVS symptoms [Bernard, 1997]. High risk
sources of vibration include air-compressed drills, grinders,
electrical drills and saws, and combustion engines [Pelmear,
1995].
87
Six studies met at least three of the four NIOSH study

evaluation criteria, and these show substantial magnitudes
of association. Vibration-exposed stone drillers, carvers and
cutters/chippers had a six-fold increase in the risk of
vibration white nger (VWF) in one study [Bovenzi et al.,
1988] and an OR of 9.3 in another [Bovenzi, 1994] when
compared to unexposed quarry and mill workers or machine
operators. A doseresponse relationship was seen for VWF
and lifetime vibration dose, with an OR of 10.2 for the
highest exposure category [Bovenzi et al., 1994]. Forestry
workers exposed to chain saw vibration and compared to
non-exposed controls demonstrated an OR of 11.8 for VWF
in one study [Bovenzi et al., 1995] and an OR of 6.5 in
another [Kivekas et al., 1994]. A cohort of forestry workers
studied during a period when chain saws were being
modied in weight, vibration frequency, and acceleration,
showed an eight-fold reduction in prevalence between
19721990 [Koskimies et al., 1992]. Machine manufacturing platers also demonstrated a substantially increased risk
of HAVS in one studyan 85-fold increased risk compared
to ofce workers [Nilsson et al., 1989]. Other examples of
workers in industries exposed to handarm vibration
syndrome include stone drillers, stone cutter/chippers,
quarry drillers, forestry workers, tree fellers, aircraft engine
workers, sheet metal workers, polishers/grinders, molders,
cleaners, forklift-truck drivers, engine testers, tters,
electric welders, lumberjacks, shipyard workers, riveters,
dental technicians, orthopedists, laborers, sewing machine
operators, tea harvesting machine operators, chain-saw
operators, construction workers (power shovel operators,
bulldozer operators), impact power tool users, pedestal
grinders, and railway workers [Bernard, 1997].
The pathophysiology of HAVS is not well understood.
However, anatomic vascular changes occur with hypertrophy of the vessel wall and endothelial cell damage. The
cold-induced vascular spasm is thought to be mediated by
alpha-2 adrenoceptors in the wall of the vessels. Pathologic
changes have been described in the digital tuft mechanoreceptors (Pacinian corpuscles) and among myelinated
digital nerve bers; however, it is still not clear whether
vibratory forces alone are the cause of more proximal
myelinated nerve pathology e.g., carpal tunnel syndrome.
The diagnosis of HAVS is based on a history of HAV
exposure and sensorineural or vascular symptoms. The role
of several diagnostic tests available help to assess the results
of medical treatment (baseline and follow-up testing);
however, exposure history and thorough physical examination is the basis for establishing the diagnosis of HAVS
88
Piligian et al.
currently [Lawson and Nevell, 1997; Gemne, 1997].

Exposure to handarm vibration varies according to (1)
the character of the vibration (which includes intensity and
other characteristics), (2) the effective duration of vibration
exposures, (3) the intermittent nature of vibration exposure,
and (4) cumulative hours of vibration exposure [Gemne,
1997; Bernard, 1977]. The vibration intensity is measured as
acceleration (meters per seconds squared) transferred to the
worker's hands. However, vibration intensity is just one of
the factors that affect the latency period for HAVS (time
from onset of vibration exposure to development of
symptoms). Among the types of vibratory forces which
characterize different tools, oscillatory and continuous
vibration predominate in electric drills while impulse type
(sudden peak) forces predominate in rivet guns. Without
entering into detail, these differing forces may produce
predominantly different effects on clinical manifestations as
well.
Studies by Gemne et al., cited in Bernard [1977]
showed that exposure to various vibration intensities was
correlated with the mean latencies of symptoms ranging
from 6 weeks to 14 years. Sensorineural manifestations
typically have shorter latencies than vascular effects; among
foundry workers Behrens et al. [1982] found a median
latency period of 7 months for development of tingling in
the ngers, 9 months for numbness, and 17 months for onset
of reported blanching [Berger and Kleinert, 1991]. However, the shorter latencies mentioned are controversial and
raise the possibility of coexisting systemic disease or other
causes capable of producing vascular or sensorineural
compromise in the distal extremities.
The clinical presentation of HAVS includes vascular,
sensorineural, and musculoskeletal disturbances. The clinical ndings vary depending on the severity of the condition
upon initial presentation. Symptoms include episodic
tingling, numbness, blanching white ngers, pain and
paresthesias, burning sensation, clumsiness, poor coordination, sleep disturbance, hand weakness and diffuse muscle,
bone and joint pain from the ngers and hand to the elbow.
Furthermore, more proximal effects in the body, especially
in the neck, and also the shoulders, have been reported
among workers using high impulse tools. But it is still
unclear to what extent biomechanical forces, physiological
adaptation, or vibration forces alone are involved in these
more proximal effects. It is important to ask the patient
about cold intolerance, a noteworthy early symptom
[Stromberg et al., 1998; Matoba et al., 1995; Cederlund
et al., 1999]. Initially these symptoms may be episodic,
especially with cold exposure, and affect only a few digits.
With progression, symptoms persist without cold exposure
and the paresthesias and blanching affect more digits. The
thumb is rarely affected [Berger and Kleinert, 1991]. The
sensorineural and vascular manifestations of HAVS can
occur independent of each other, with sensorineural effects
occurring earlier [Berger and Kleinert, 1991]. Other

reported manifestations, including ``headache, insomnia,
tinnitus, palmar hyperhidrosis, bradycardia, cardiac hypertrophy, deafness, and impotence'' have been attributed by
some authors to the combined effects of vibration, cold, and
noise exposure, but these have not been demonstrated to
arise from vibration exposure in the clinical literature
[Berger and Kleinert, 1991].
The clinical signs include mild to severe sensory
decits on sensory testing, mild to severe muscular
weakness, blanching, tenderness and swelling of the digits
and forearm tissue, trophic skin changes (e.g., ulceration,
sclerodactyly) and cyanotic tinge to the skin. Arthrosis of
the wrist and elbow is also reported [Gemne, 1997] but the
epidemiologic data is still to be developed [Bovenzi, 1998].
Sensorineural tests in the clinic setting include use of
SemmesWeinstein monolaments, vibration perception
threshold (tuning fork at 125 Hz), two-point discrimination
and digital perception of small objects. Laboratory testing
includes nerve conduction velocity (NCV). Median nerve
(carpal tunnel syndrome) or ulnar neuropathy can accompany HAVS, therefore NCV testing of ulnar and median
innervated digits should be performed [Stromberg et al.,
1998]. NCV testing should include sensory nerve conduction velocity (SCV) of the median nerve across the wrist, the
digital nerves and the nger-to-palm and wrist-to-elbow
segments for comparison. One study showed slowed SCV in
the digital nerves in 36% of patients with vibration exposure
compared with SCV slowing across the carpal tunnel (wrist)
in 20% [Sakakibara et al., 1998]. Vibrometry testing is the
standardized test approved by the Stockholm Handarm
Committee [Olsen, 1994]. Additionally, the current perception threshold test (CPT) has been described. It is essential
to perform quantitative vibrotactile (e.g., vibrometry) testing of the digits to differentiate vibration-induced injury to
the vibration and touch receptorsnot measureable by
NCV or EMG testingfrom injury to larger myelinated
nerves, e.g., CTS, which can indeed be measured by NCV
and EMG testing. Unnecessary CTS surgery should be
avoided by applying the specic tests for each of these
separate neurologic injuries and diagnosing what is
warranted.
Testing for vascular signs pertinent to HAVS (primarily
vasospam) in the clinic setting is limited. Nailbed compression testing can assess for impaired digital circulation and
sclerodactyly by looking for the pattern of blanching and
reddening. The Allen test (to assess for patency of the
supercial and deep palmar arches) [Hoppenfeld, 1976] is
only useful to rule out vaso-occlusion in a segment of a
larger vessel, e.g., the larger ulnar artery if considering
hypothenar hammer syndrome in the differential diagnosis.
Plethysmography before and after cold provocation is the
laboratory test accepted by the Stockholm Handarm
Committee for evaluating vascular manifestations of HAVS
[Olsen, 1994; Sumner, 1998]. Another laboratory test

commonly cited is systolic blood pressure ratios of the
capillary and deep nger vessels before and after cold
provocation [Gemne, 1997; Mirbod et al., 1998]. Doppler
and duplex studies are also used to assess the patency and
blood pressure ratios of digital vessels [Pelmear, 1995;
Mirbod et al., 1998]. The classication system of coldinduced Raynaud's phenomenon in HAVS is based on the
Stockholm Scale [Pelmear, 1995]. The stages range from
04, with stage zero indicating no attacks and stage four
representing frequent attacks with trophic changes in the
nger tips. The sensorineural and vascular manifestations are
characterized separately.
Treatment
The treatment of HAVS includes maintaining central
body temperature, avoiding exposure to cold and vibrating
tools, job modication or change of job, and splinting at
night to treat the associated neuropathies. Medications,
including calcium channel blockers, pentoxiphylline to
improve exibility of red blood cells, and drugs to reduce
platelet deposition are used for symptomatic treatment
[Berger and Kleinert, 1991; Pelmear, 1995]. Surgical
intervention e.g., cervical sympathectomy is unsuccessful
and not warranted for treating HAVS. [Pelmear, 1995].
The prognosis in one study of medical treatment showed
that over six years, only 31% of all the HAVS patients
had complete resolution of symptoms, with improvement less likely in severe cases and in those with
continued use of vibratory tools [Ogasawara et al.,
1997]. Surgical release of the exor retinaculum may
provide relief of symptoms from median nerve entrapment at the wrist (carpal tunnel syndrome) if the two
conditions coexist; however, it does not affect the vascular
symptoms (e.g., cold intolerance, blanching) [Szabo and
Madison, 1995].
It has not been shown conclusively in clinical studies
that smoking accelerates the development of HAVS
[Pelmear, 1995]. However, smoking cessation is highly
recommended in the treatment of HAVS, given the known
peripheral arterial vasoconstrictive effects of cigarette
smoking [Pelmear, 1995]. The use of physical therapy
modalities is considered palliative in the absence of clinical
studies on their efcacy for this condition [Pelmear, 1995].
Biofeedback therapy is reported to be useful with long-term
results in some reports [Pelmear, 1995].
The prevention of HAVS is at least as important as the
medical management because HAVS is dose-related. The
preventive measures to reduce the intensity of vibration
include use of isolation and damping equipment, and use of
anti-vibration tools. Job modication and avoidance of cold
and vibration exposure is also warranted when tingling,
numbness or cold intolerance occur in the distal extremities
89
of a worker exposed to vibration, so as to minimize chances

of progression to full blown HAVS.
WORKSITE INTERVENTION
Workplace ergonomic interventions (i.e., modications) has been shown to diminish musculoskeletal symptoms in workers [Aaras et al., 1998; Nelson and Silverstein,
1998]. It is often a critical adjunct to medical management
of work-related musculoskeletal disorders, and may prevent
disease in similarly exposed workers. Such modications
should include identication and remediation of risk factors
for MSDs. Table II provides recommendations for risk
assessment in repetitive work adapted from Kilbom [1994]
by Bernard (personal communication, 1999). Workplace
ergonomics programs should also include worker education
and training on proper body mechanics and use of new
equipment and tools.
The eld of ergonomics involves the design of work
tasks and equipment to better t the working individual.
Ergonomists often suggest modications to work equipment
and work practice design, and offer guidance in scheduling
adequate rest periods (recovery pauses). Redesigning of
work practice or equipment has the following goals: (1)
reducing awkward postures (i.e., anatomic positions deviating from the physiological ``neutral posture''), (2) minimizing the need to use excess force, (3) reducing highly
repetitive movement, (4) reducing prolonged periods
spent in one position (e.g., static posture) and (5) assuring
sufcient rest/recovery periods [Erdil and Dickerson,
1997].
While ergonomists are ideally suited to evaluate the
workplace and make recommendations regarding proper
ergonomic design, many health care providers do not have
access to them. In the absence of an ergonomist, it is
important for the health care provider to evaluate the
patient's workplace exposures to risk factors for WMSDs.
Much of the information about the patient's job, including
general and specic occupational tasks, can be gathered
through the use of questionnaires administered in the ofce
rather than at the worksite. Questions focusing on exposure
to WMSD risk factors, including repetitive movements,
awkward and/or static postures, forceful exertions, extremes
in temperature, segmental vibration and work organization
issues can supply much of the qualitative information that
may be required for job analysis. Having the patient bring in
tools or equipment, and using mock-ups, and job simulation
can assist those physicians in identication and remediation
of risk factors for WMSDs. Pictures and videotapes can aid
in the evaluation of the job tasks.
Since the use of computers is widespread and has been
associated with a number of upper extremity WMSDs
[Tittiranonda et al., 1999; Bernard et al., 1994; Hales et al.,
1994], approaches that should be employed in primary and
90
Piligian et al.
secondary disease prevention of upper extremity WMSDs

among computer users follow.
Risk factors that may be associated with computer use
include rapid, repetitive movement (as high as 20,000
200,000 keystrokes per day), static neck, shoulder and distal
upper extremity postures, insufcient rest and recovery
periods, and work organization factors (e.g., deadline
pressures) [Tittiranonda, 1999; Pascarelli and Kella, 1993].
Adding or interchanging ofce tasks (i.e., task variability),
such as talking on the phone or using the copying machine,
is one method of providing recovery periods from exposure
to repetition and static posture. Standing up and taking
short, frequent, mini-breaks is another way of decreasing
repetition and static posture. Static posture can also be
decreased by resting the upper limbs on the lap when not
keying or mousing. In addition, this risk factor can be
present if the keyboard and mouse are not frequently
repositioned. Using a keyboard and mouse tray whose
height and angle can be frequently adjusted may help
change the positioning of the upper limbs. Split and/or tilted
keyboards may also help to position the upper limbs in more
neutral postures [Brophy and Grant, 1996; Sanders and
McCormick, 1993; Kroemer et al., 1994]. Additional mouse
input devices are available (e.g., touch pad, tablet and stylus,
and foot pedals) to offer alternative upper limb postures to
the computer user. Currently, however, there is a lack of the
clinical studies needed to determine the efcacy of
alternative mouse input devices for decreasing known
ergonomic risk factors.
CONCLUSION
Physical risk factors that have been associated with at
least some WMSDs include repetitive/prolonged activities,
forceful exertion, awkward and/or static posture, vibration,
localized mechanical stress, and cold temperatures. Frequently, workers present with multiple WMSDs simultaneously. Therefore, the evaluation of any upper extremity
complaint should begin at the neck and upper back and then
proceed down to the ngers and include the ipsilateral and
contralateral regions. Recently, various groups have published diagnostic criteria for WMSDs of the distal upper
extremity, based upon (1) symptom location (i.e. elbow,
forearm, wrist, digits), (2) the presence of reported pain, (3)
presence of pain during palpation of the affected tissue, and
(4) response to specic provocative tests. Evaluation of
contiguous or underlying structures (e.g., the ulnar nerve
when evaluating medial epicondylitis) is important since
these may be injured concurrently. In general, treatment of
chronic work-related tendinous disorders is ``conservative''
(i.e., non-surgical). The aims of treatment are reduction of
pain and prevention of disability by restoration of function.
Many treatment modalities for work-related tendon disorders have yet to undergo evaluation for efcacy in well-
designed experimental studies, although their widespread

use has led to a practice-derived body of knowledge.
Cubital tunnel syndrome is entrapment of the ulnar
nerve at the medial aspect of the elbow. It is the second most
common entrapment neuropathy of the upper extremity
after carpal tunnel syndrome. Electrodiagnostic testing
should be performed whenever an entrapment neuropathy
is suspected, but the severity of the clinical ndings may not
always correlate with the results of such testing. The
information provided by electrodiagnostic testing of the
ulnar nerve can help conrm injury to the nerve, gauge the
severity of nerve injury, and locate the site(s) of injury along
the course of the nerve. Very mild cubital tunnel syndrome
is a clinical diagnosis based on practitioner experience. The
treatment of cubital tunnel syndrome is generally nonsurgical for mild symptoms, sensory or motor impairment,
with surgery recommended for prolonged symptoms or
severe sensory or motor impairment. There is less
consensus on treatment recommendations for moderate
disease but patients should be monitored at 13 month
intervals for progression of the condition.
HAVS is frequently under-diagnosed and misdiagnosed
as carpal tunnel syndrome since the two entities can coexist.
For workers currently using or having worked with vibrating
tools, the possibility of HAVS should be considered.
Appropriate early intervention can prevent the onset or
progression to full-blown HAVS. Exposure history and
thorough physical examination is the basis for establishing
the diagnosis of HAVS currently.
Workplace ergonomic modication is often a critical
adjunct to medical management of work-related musculoskeletal disorders. Ergonomists often suggest modications
to work equipment and work practice design with the
following goals: (1) reducing awkward postures (i.e.,
anatomical positions deviating from the physiological
``neutral posture''); (2) minimizing the need to use excess
force, (3) reducing highly repetitive movement, (4) reduce
prolonged periods spent in one position (e.g., static posture),
and (5) ensuring sufcient rest/recovery periods.
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2000 Evaluation and Management of Chronic

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AMERICAN JOURNAL OF INDUSTRIAL MEDICINE 37:7593 (2000)

Evaluation and Management of Chronic

2000 Wiley-Liss, Inc.

This review will describe the epidemiology, clinical

WORK-RELATED RISK FACTORS

non-acute upper extremity musculoskeletal disorders

BACKGROUND TO CLINICAL EVALUATION

Evaluation and Management of WMSDs

Pain and swelling in the

Tenderness at the ``anatomical''

* Pain at radial wrist

Pain in the affected

Pain localized to the

Pain in the affected

Lateral elbow pain

Pain localized to extensor tendons

Pain in the flexor tendon(s)

Pain localized to flexor tendons in

Tenderness to palpation over

Pain or burning in elbow

Pain emanating from the

Tenderness to palpation of the

Pain or burning in elbow

Pain or paresthesias involving

Evaluation and Management of WMSDs

Muscle weakness of the

Sensory deficits in the digits and * Use of vibrating tools currently or

Avoid exposure to vibrating tools

TABLE II. Recommendations for Movement in RepetitiveWork

Very high risk if modified by either:

More than 2.5

High external force, speed, high static load, extreme posture

Modified version printed with permission of B.Bernard (personal communication,1999).

DISORDERS OF THE TENDON UNITS

tendon units function over several different anatomic regions.

muscle is supercial, with the bulk of the muscle located just

Evaluation and Management of WMSDs

chronic degeneration and/or proliferation of associated

modalities have yet to undergo evaluation for efcacy for

Disorders of the Extensor Tendons of

First Dorsal Compartment Syndrome

Other Disorders of the Extensor

Evaluation and Management of WMSDs

Disorders of the Flexor Tendons of the

force and repetition, force and posture) and epicondylitis.

Lateral Epicondylitis (Tennis Elbow)

For early symptoms, abatement of inciting exposures at

Medial epicondylitis is characterized by tenderness and

Medial Epicondylitis (Golfer's elbow)

CUBITAL TUNNEL SYNDROME (ULNAR

Evaluation and Management of WMSDs

repetitive and sudden elbow exion, and repeated trauma or

Anatomy and Pathology

``pressure provocative test,'' and the elbow exion test. The

The reader is referred to a recent comprehensive review,

conrm injury to the nerve;

Electrodiagnostic studies are useful in documenting

(medical) management is suggested before considering

Evaluation and Management of WMSDs

tunnel syndrome. Basically, releasing constrictions at all

VASCULAR DISORDERS OF THE HAND

HandArm Vibration Syndrome

Six studies met at least three of the four NIOSH study

currently [Lawson and Nevell, 1997; Gemne, 1997].