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Guideline Summary
Guideline Title
Elbow (acute & chronic).
Bibliographic Source(s)
Work Loss Data Institute. Elbow (acute & chronic). Encinitas (CA): Work Loss Data Institute; 2011. Various p.
Guideline Status

Note: This guideline had been updated. The National Guideline Clearinghouse (NGC) is working to update this summary.

FDA Warning/Regulatory Alert

Note from the National Guideline Clearinghouse: This guideline references a drug(s) for which important revised regulatory and/or warning information has been released.

  • August 1, 2013 – Acetaminophen External Web Site Policy: The U.S. Food and Drug Administration (FDA) notified healthcare professionals and patients that acetaminophen has been associated with a risk of rare but serious skin reactions. Acetaminophen is a common active ingredient to treat pain and reduce fever; it is included in many prescription and over-the-counter (OTC) products. These skin reactions, known as Stevens-Johnson Syndrome (SJS), toxic epidermal necrolysis (TEN), and acute generalized exanthematous pustulosis (AGEP), can be fatal. These reactions can occur with first-time use of acetaminophen or at any time while it is being taken. Other drugs used to treat fever and pain/body aches (e.g., non-steroidal anti-inflammatory drugs, or NSAIDS, such as ibuprofen and naproxen) also carry the risk of causing serious skin reactions, which is already described in the warnings section of their drug labels.

Scope

Disease/Condition(s)

Work-related disorders of the elbow (acute and chronic)

Guideline Category
Diagnosis
Evaluation
Management
Treatment
Clinical Specialty
Emergency Medicine
Family Practice
Internal Medicine
Neurological Surgery
Orthopedic Surgery
Physical Medicine and Rehabilitation
Radiology
Intended Users
Advanced Practice Nurses
Health Care Providers
Health Plans
Nurses
Occupational Therapists
Physical Therapists
Physician Assistants
Physicians
Utilization Management
Guideline Objective(s)

To offer evidence-based step-by-step decision protocols for the assessment and treatment of workers' compensation conditions

Target Population

Workers with occupational disorders of the elbow

Interventions and Practices Considered

The following interventions/procedures were considered and recommended as indicated in the original guideline document:

  1. Acupuncture
  2. Bone-growth stimulators, electrical and ultrasound
  3. Causality (determination)
  4. Cold packs
  5. Elbow extension test
  6. Exercise
  7. Heat packs
  8. Hospital length of stay
  9. Injections (corticosteroid)
  10. Iontophoresis
  11. Laser treatment (LLLT)
  12. Magnetic resonance imaging (MRI)
  13. Manipulation/chiropractic
  14. Nonprescription medications, including acetaminophen, topical and oral nonsteroidal anti-inflammatory drugs (NSAIDs) (aspirin and ibuprofen)
  15. Office visits
  16. Open reduction internal fixation (ORIF)
  17. Patient education
  18. Physical therapy
  19. Radial head fracture surgery (level III and IV fractures)
  20. Radiography (x-rays)
  21. Return to work
  22. Splinting (padding)/dynamic extensor brace
  23. Static progressive stretch (SPS) therapy
  24. Stretching
  25. Surgery for cubital tunnel syndrome (ulnar nerve entrapment)
  26. Surgery for radial tunnel syndrome (lesion of radial nerve)
  27. Surgery for ruptured biceps tendon (at the elbow)
  28. Tennis elbow band for epicondylitis
  29. Total elbow replacement (TER)/arthroplasty (elbow)
  30. Ultrasound, diagnostic and therapeutic
  31. Work/activity restrictions
  32. Work conditioning, work hardening

The following interventions/procedures are under study and are not specifically recommended:

  1. Augmented soft tissue mobilization (ASTM)
  2. Autologous blood injection
  3. Botulinum toxin injection
  4. Massage
  5. Platelet-rich plasma
  6. Prolotherapy
  7. Radial shockwave therapy (RSWT)
  8. Soft tissue mobilization
  9. Splinting for epicondylitis
  10. Surgery for epicondylitis
  11. Surgery for pronator syndrome
  12. Surgery for level II radial head fractures
  13. Tests for cubital tunnel syndrome, epicondylitis, and pronator syndrome
  14. Ulnar motor nerve conduction velocity test

The following interventions were considered, but are not currently recommended:

  1. Biofeedback
  2. Deep transverse friction massage
  3. Diathermy
  4. Electrical stimulation (E-STIM)
  5. Extracorporeal shockwave therapy (ESWT)
  6. Fatty acid supplements
  7. Friction massage
  8. Immobilization as primary treatment
  9. Magnets
  10. Manipulation under anesthesia (MUA)
  11. Opioids
  12. Phonophoresis
  13. Pulsed electromagnetic field therapy
  14. Radiofrequency epicondylitis treatment (Topaz procedure)
  15. Surgery for olecranon bursitis
  16. Surgery for level I radial head fractures
  17. Transcutaneous electrical neurostimulation (TENS)
  18. Viscosupplementation/hyaluronic acid injections
Major Outcomes Considered
  • Sensitivity and specificity of diagnostic tests
  • Effectiveness of treatment for relief of pain and other symptoms, optimizing healing/function, increasing work, minimizing risk factors that contributed to the injury

Methodology

Methods Used to Collect/Select the Evidence
Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence

Work Loss Data Institute (WLDI) conducted a comprehensive medical literature review (now ongoing) with preference given to high quality systematic reviews, meta-analyses, and clinical trials published since 1993, plus existing nationally recognized treatment guidelines from the leading specialty societies. WLDI primarily searched MEDLINE and the Cochrane Library. In addition, WLDI also reviewed other relevant treatment guidelines, including those in the National Guideline Clearinghouse, as well as state guidelines and proprietary guidelines maintained in the WLDI guideline library. These guidelines were also used to suggest references or search terms that may otherwise have been missed. In addition, WLDI also searched other databases, including MD Consult, eMedicine, CINAHL, and conference proceedings in occupational health (i.e., American College of Occupational and Environmental Medicine [ACOEM]) and disability evaluation (i.e., American Academy of Disability Evaluating Physicians [AADEP], American Board of Independent Medical Examiners [ABIME]). Search terms and questions were diagnosis, treatment, symptom, sign, and/or body-part driven, generated based on new or previously indexed existing evidence, treatment parameters and experience.

In searching the medical literature, answers to the following questions were sought: (1) If the diagnostic criteria for a given condition have changed since 1993, what are the new diagnostic criteria? (2) What occupational exposures or activities are associated causally with the condition? (3) What are the most effective methods and approaches for the early identification and diagnosis of the condition? (4) What historical information, clinical examination findings or ancillary test results (such as laboratory or x-ray studies) are of value in determining whether a condition was caused by the patient's employment? (5) What are the most effective methods and approaches for treating the condition? (6) What are the specific indications, if any, for surgery as a means of treating the condition? (7) What are the relative benefits and harms of the various surgical and non-surgical interventions that may be used to treat the condition? (8) What is the relationship, if any, between a patient's age, gender, socioeconomic status and/or racial or ethnic grouping and specific treatment outcomes for the condition? (9) What instruments or techniques, if any, accurately assess functional limitations in an individual with the condition? (10) What is the natural history of the disorder? (11) Prior to treatment, what are the typical functional limitations for an individual with the condition? (12) Following treatment, what are the typical functional limitations for an individual with the condition? (13) Following treatment, what are the most cost-effective methods for preventing the recurrence of signs or symptoms of the condition, and how does this vary depending upon patient-specific matters such as underlying health problems?

Criteria for Selecting the Evidence

Preference was given to evidence that met the following criteria: (1) The article was written in the English language, and the article had any of the following attributes: (2) It was a systematic review of the relevant medical literature, or (3) The article reported a controlled trial – randomized or controlled, or (4) The article reports a cohort study, whether prospective or retrospective, or (5) The article reports a case control series involving at least 25 subjects, in which the assessment of outcome was determined by a person or entity independent from the persons or institution that performed the intervention the outcome of which is being assessed.

More information about the selection of evidence is available in the "Methodology Outline" and "Appendix A. ODG Treatment in Workers' Comp. Methodology description using the AGREE instrument" (see "Availability of Companion Documents" field).

Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence

Ranking by Type of Evidence

  1. Systematic Review/Meta-Analysis
  2. Controlled Trial - Randomized (RCT) or Controlled
  3. Cohort Study - Prospective or Retrospective
  4. Case Control Series
  5. Unstructured Review
  6. Nationally Recognized Treatment Guideline (from www.guideline.gov External Web Site Policy)
  7. State Treatment Guideline
  8. Other Treatment Guideline
  9. Textbook
  10. Conference Proceedings/Presentation Slides

Ranking by Quality within Type of Evidence

  1. High Quality
  2. Medium Quality
  3. Low Quality
Methods Used to Analyze the Evidence
Review of Published Meta-Analyses
Systematic Review
Description of the Methods Used to Analyze the Evidence

The Work Loss Data Institute (WLDI) reviewed each article that was relevant to answering the question at issue, with priority given to those that met the following criteria: (1) The article was written in the English language, and the article had any of the following attributes: (2) It was a systematic review of the relevant medical literature, or (3) The article reported a controlled trial – randomized or controlled, or (4) The article reported a cohort study, whether prospective or retrospective, or (5) The article reported a case control series involving at least 25 subjects, in which the assessment of outcome was determined by a person or entity independent from the persons or institution that performed the intervention the outcome of which is being assessed.

Especially when articles on a specific topic that met the above criteria were limited in number and quality, WLDI also reviewed other articles that did not meet the above criteria, but all evidence was ranked alphanumerically (see the "Rating Scheme for the Strength of the Evidence" field) so that the quality of evidence could be clearly determined when making decisions about what to recommend in the Guidelines. Articles with a Ranking by Type of Evidence of Case Reports and Case Series were not used in the evidence base for the Guidelines. These articles were not included because of their low quality (i.e., they tend to be anecdotal descriptions of what happened with no attempt to control for variables that might affect outcome). Not all the evidence provided by WLDI was eventually listed in the bibliography of the published Guidelines. Only the higher quality references were listed. The criteria for inclusion was a final ranking of 1a to 4b (the original inclusion criteria suggested the methodology subgroup), or if the Ranking by Type of Evidence was 5 to 10, the quality ranking should be an "a."

Methods Used to Formulate the Recommendations
Not stated
Rating Scheme for the Strength of the Recommendations

Not applicable

Cost Analysis

The guideline developers reviewed published cost analyses.

Method of Guideline Validation
External Peer Review
Description of Method of Guideline Validation

Prior to publication, select organizations and individuals making up a cross-section of medical specialties and typical end-users externally reviewed the guideline.

Recommendations

Major Recommendations

Note: This guideline had been updated. The National Guideline Clearinghouse (NGC) is working to update this summary. The recommendations that follow are based on the previous version of the guideline.

Note from the Work Loss Data Institute (WLDI) and the National Guideline Clearinghouse (NGC): The following recommendations were current as of April 28, 2011. However, because the Work Loss Data Institute updates their guidelines frequently, users may wish to consult the WLDI Web site External Web Site Policy for the most current version available.

Initial Diagnosis

  • First visit: with Primary Care Physician MD/DO (100%)
  • Determine cause: Initial Evaluation:
    • Determine the type of trauma (e.g., fall, repetitive motion, twisting, etc.)
    • Determine whether the problem is acute, subacute, chronic, or of insidious onset.
    • Determine the severity and specific anatomic location of the pain.
    • Assess the ability of the patient to use the elbow, from no to full ability.
    • Search for any evidence of an open or penetrating wound.
    • Test the range-of-motion of the joint (normal, mild restriction, severe restriction).
    • Search for any evidence of vascular or nerve injury distal to the injury.
    • Determine any present medication.
    • Determine any previous medical history, history of systemic disease, previous elbow injury or disability, job requirements, and hobbies.
  • Initial diagnosis (Refer to the original guideline document for International Classification of Diseases, Ninth Revision [ICD-9] codes):
    • Traumatic (Go to Fractures and Dislocations):
      • Fracture or dislocation
    • Other (Go to Initial Conservative Treatment):
      • Sprain or contusion
      • Laceration
      • Epicondylitis, medial
      • Epicondylitis, lateral
      • Olecranon bursitis
      • Pronator syndrome
      • Ulnar nerve entrapment (Cubital tunnel syndrome)
      • Radial nerve entrapment

Fracture or Dislocation of Elbow (35% of cases)

  • Definitive Evaluation:
    • Search for any evidence of an open wound in the vicinity of the fracture; if there is an open wound, treat for infection and examine for the presence of foreign bodies (visual, x-ray, etc.)
    • Perform a clinical examination for deformity, tenderness, or ecchymosis, or associated nerve, neurovascular, or tendon injury. Also look for the inability to perform spontaneous movement of the elbow.
    • Search for any evidence of dislocation and arterial vascular compromise (cold, dusky hand and forearm with loss of sensation). If found, an immediate reduction should take place (prior to x-rays if necessary).
    • X-ray the elbow. Special views should be obtained when necessary.
  • Initial Therapy
    • Simple, undisplaced, stable fractures of the elbow can be treated by the primary care physician.
    • Apply a sling and/or a posterior splint with medial and lateral gutter splints. A portion of patients should be converted to a long arm cast after 10 to 14 days.
    • Ice and elevation whenever lying down for the first 72 hours.
    • Analgesics and/or nonsteroidal anti-inflammatory drugs for up to two weeks.
    • Aspirating the radiohumeral joint and injection of local anesthetic to evacuate hematoma is appropriate to relieve pain in selected cases of radial head fractures.
    • Physical therapy (3 to 6 visits) to teach patient range-of-motion and muscle-strengthening exercises out of the splint should begin as soon as tolerated at two to four weeks.
    • Recheck at seven days, then at two-week intervals until healed. Repeat x-rays at seven days and at two weeks to assure that the fracture has not slipped. X-ray again at five weeks.
    • Complex, displaced, or unstable fractures should be immobilized and referred to an orthopedic surgeon. Compound fractures, when appropriate, should have a tetanus toxoid injection before being referred to a surgeon.
    • Dislocations of the elbow are accompanied by significant ligament injuries. Even if full reduction has been achieved, orthopedic referral is appropriate.
Official Disability Guidelines (ODG) Return-To-Work Pathways - Fracture

Stable, clerical/modified work: 2 days
Stable, manual work: 14 days
Reduction/manipulation, clerical/modified work: 14 days
Reduction/manipulation, manual work: 28 days
Reduction/manipulation, heavy manual work: 42 days

ODG Return-To-Work Pathways - Dislocation

Non-dominant arm, clerical/modified work: 0 days
Non-dominant arm, manual work: 10 days
Non-dominant arm, heavy manual work: 21 days
Dominant arm, clerical/modified work: 7 days
Dominant arm, manual work: 21 days
Dominant arm, heavy manual work: 42 days

(See ODG Capabilities & Activity Modifications for Restricted Work under "Work" in the Procedure Summary of the original guideline document)
  • Secondary evaluation for patients with persistent symptoms or minimal improvement after six weeks of therapy
    • Review for compliance of the employee and employer to therapy programs and job modifications and restrictions. Also review for insurance company cooperation.
    • Evaluate for delayed union, malalignment, or signs of associated tendon or nerve injury.
    • Promptly refer to an orthopedic surgeon if one of these conditions is found.

Initial Conservative Treatment of Disorders Other than Fractures (65% of cases)

  • Definitive Evaluation:
    • Typical symptoms of lateral epicondylitis ("tennis elbow") include pain in the lateral aspect of the elbow with pain or burning radiating to the forearm (and occasionally proximal radiation). With medial epicondylitis ("golfers elbow") the pain is on the inside of the elbow (versus outside of the elbow for tennis elbow). There may be loss of grip strength due to forearm pain with hand grip. Pain is usually insidious in onset but may be provoked by an acute trauma or strain. Initial complaints may be vague, such as a dull forearm ache.
    • Specific attention should be directed towards confirming occupational risk factors, such as repetitive, sustained, or forceful wrist dorsiflexion, power grip, exposure to vibration, repetitive extended elbow reach with forceful pulling, and repetitive pronation and supination of the forearm against resistance.
    • Rule out non-occupational activities that could be causing or aggravating the condition, such as activities that require gripping or hyperextending the wrist.
    • Olecranon bursitis may be secondary to systemic illness.
    • A physical examination should be performed with documentation of the following findings:
      • Inspection for deformity, swelling, or erythema.
      • Provocative maneuvers, such as the presence or absence of pain with resisted dorsiflexion of the wrist, passive wrist flexion with the elbow in full extension, resisted supination of the forearm, and Tinel's sign.
      • Range of motion: elbow flexion and extension, pronation and supination, wrist flexion and extension. Note any flexion contracture deformity of the elbow.
      • Palpation: Document the presence or absence of the following: elbow deformity, tenderness, heat, or crepitus (including olecranon process and medial epicondyle). Also check the forearm for deformity, heat, or tenderness.
      • Muscle strength testing of the entire upper extremity should be performed as relevant.
      • Appropriate distal extremity exam should include neurological testing. A routine examination of the shoulder, neck, wrist, and hand (palpation, range of motion, strength testing) should be performed.
      • A differential diagnosis should be considered at this point, such as radiculopathy or shoulder pathology with referred pain.
    • As a rule, the diagnosis of elbow problems does not require an imaging study.
    • Appropriate laboratory studies should be considered if there is evidence of an infectious or diffuse inflammatory process as a contributing or causative factor.
    • Nerve conduction studies may be indicated for elbow problems associated with neurological deficits.
    • Aspiration of the olecranon bursa is not routinely indicated unless there is suspicion of infection or metabolic disease.
  • Initial Treatment
    • The purpose of the initial treatment is to reduce symptoms, optimize healing/function, and increase work, with appropriate modifications to minimize the risk factors that contributed to the injury.
    • All injured workers should receive instruction concerning the nature of their condition, its risk factors, preventive measures, and goals of initial therapy. The injured worker should be instructed on how to eliminate or modify any aggravating non-occupational activities and sports during treatment.
    • Work restrictions or modifications that reduce the injured worker's exposure to the etiologic or aggravating activity are of central importance. Examples of such restrictions include preclusion from or reduction in time performing tasks requiring repetitive, sustained, or repetitive forceful wrist or hand activities, repetitive elbow motion, prolonged elbow positioning, or prolonged exposure to vibration.
    • Nonsteroidal anti-inflammatory agents (NSAIDs) can be used. Acetaminophen is an analgesic that may be used as an adjunct or alternative to NSAIDs.
    • Physical treatments and passive modalities: If there is no improvement after 2 weeks, the treatment should be modified. Use of thermal modalities in conjunction with physical treatment may be useful. Physical treatments for pain management, splinting, and/or functional retraining and instruction in a graded exercise program. Appropriate exercises may include, but are not limited to 1) gentle muscle stretching, 2) flexibility, and 3) graduated strengthening. Care should be taken while incrementing exercises so that the condition is not aggravated. Appropriate manual therapies may include manipulation, or joint or soft tissue mobilization, supplemented by physical modalities and exercise.
    • Acupuncture: Use of acupuncture in the first 4 weeks of treatment as a part of an overall treatment plan.
    • Protective devices: The use of an elbow and/or wrist support for immobilization may be indicated for a brief period. The use of a splint at work must be carefully considered, as it may put the injured worker at risk for further musculoskeletal injury by forcing the adoption of awkward compensatory postures. A forearm strap can be aggravating in the acute stage, so its use should be individualized. It is contraindicated in the presence of nerve compression symptoms. Night splinting may be indicated for nerve entrapment syndromes.
    • Local corticosteroid injection: Local corticosteroid injections of the myofascial areas or bursae may be appropriate, especially if the pain is moderate to severe. Before the injection, it is important to be aware that the olecranon bursa may be the site of infection. In such an instance, a steroid injection would be contraindicated. Refer to an orthopaedic surgeon if infection is present.
    • Surgery is rarely indicated.
  • Secondary Assessment
    • A reconsideration of the initial diagnosis is necessary at this stage, and a differential diagnosis should be reviewed: cervical radiculopathy, shoulder pathology with referred pain and nerve entrapment.
    • Diagnostic imaging: Radiographic studies of the elbow and forearm may be considered if, on re-evaluation, the physician suspects morphologic pathology. The use of magnetic resonance imaging (MRI) and arthrography is rarely indicated except for the evaluation of intraarticular pathology.
    • Laboratory studies: Laboratory studies may be performed if there is evidence of an infectious or diffuse inflammatory process as a contributing pathology.
    • Electromyography/nerve conduction studies (EMG/NCS) to rule out other conditions: Electrodiagnostic studies should be considered if there is clinical evidence of nerve entrapment or cervical radiculopathy as alternative diagnoses.
    • Surgical referral: Orthopaedic surgical consultation may be recommended after failure of conservative treatment and indication of a surgically correctable condition.
ODG Return-To-Work Pathways – Sprain

Moderate, clerical/modified work: 4 days
Moderate, manual work: 21 days
Severe, clerical/modified work: 7 days
Severe, manual work: 35 to 42 days

ODG Return-To-Work Pathways - Contusion

Superficial contusions: 0 days
Deep contusions, clerical/modified work: 5 days
Deep contusions, manual work: 21 days

ODG Return-To-Work Pathways - Laceration

Minor: 0 days
Major, clerical/modified work: 3 days
Major, manual work: 8 days

ODG Return-To-Work Pathways - Epicondylitis, Medial

Without surgery, modified work: 0 days
Without surgery, regular manual work: 7 days
Without surgery, heavy manual work: 42 days

ODG Return-To-Work Pathways - Epicondylitis, Lateral

Without surgery, modified work: 0 days
Without surgery, regular manual work: 7 days
Without surgery, heavy manual work: 42 days
Without surgery, heavy manual vibrating work, if cause of disability: indefinite
With surgery (rare), modified work, non-dominant arm: 6 days
With surgery (rare), modified work, dominant arm: 21 days
With surgery (rare), regular work, non-dominant arm: 28 days
With surgery (rare), regular work, dominant arm: 42 days
Acupuncture (3 to 6 treatments): 7 to 21 days

ODG Return-To-Work Pathways - Olecranon Bursitis

Without surgery, modified work: 0 days
Without surgery, regular manual work: 4 days
Without surgery, heavy manual work: 35 days

ODG Return-To-Work Pathways - Ulnar Nerve Entrapment

Without surgery, modified work: 0 days
Without surgery, regular work: 14 days
With surgery, modified work: 14 days
With surgery, regular work, non-dominant arm: 21 days
With surgery, regular work, dominant arm: 49 days

ODG Return-To-Work Pathways - Radial Nerve Entrapment

Diagnostic testing: 0 days
Treatment, clerical/modified work: 14 days
Treatment, manual work: 42 days

Clinical Algorithm(s)

None provided

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations

During the comprehensive medical literature review, preference was given to high quality systematic reviews, meta-analyses, and clinical trials over the past ten years, plus existing nationally recognized treatment guidelines from the leading specialty societies.

The heart of each Work Loss Data Institute guideline is the Procedure Summary (see the original guideline document), which provides a concise synopsis of effectiveness, if any, of each treatment method based on existing medical evidence. Each summary and subsequent recommendation is hyper-linked into the studies on which they are based, in abstract form, which have been ranked, highlighted and indexed.

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

These guidelines unite evidence-based protocols for medical treatment with normative expectations for disability duration. They also bridge the interests of the many professional groups involved in diagnosing and treating disorders of the elbow.

Potential Harms
  • The use of a splint at work must be carefully considered, as it may put the injured worker at risk for further musculoskeletal injury by forcing the adoption of awkward compensatory postures. A forearm strap can be aggravating in the acute stage so its use should be individualized.
  • Steroid injection has been associated with an increase in reported pain for the first 24 hours of treatment.
  • Topical nonsteroidal anti-inflammatory drugs (NSAIDs) have been reported to occasionally cause mild skin rashes.

Contraindications

Contraindications
  • A forearm strap can be aggravating in the acute stage, so its use should be individualized. It is contraindicated in the presence of nerve compression symptoms.
  • Before a steroid injection, it is important to be aware that the olecranon bursa may be the site of infection. In such an instance, a steroid injection would be contraindicated.
  • Contraindications for total elbow replacement include Type II or III Gustilo-Anderson open fractures (primary irrigation and debridement); preexisting infection, open wounds; younger, high-demand, or noncompliant patient; paralysis of the biceps muscle.
  • Extracorporeal shock wave therapy is contraindicated in pregnant women; patients younger than 18 years of age; patients with blood clotting diseases, infections, tumors, cervical compression, arthritis of the spine or arm, or nerve damage; patients with cardiac pacemakers; patients who had physical or occupational therapy within the past 4 weeks; patients who received a local steroid injection within the past 6 weeks; patients with bilateral pain; patients who had previous surgery for the condition.

Qualifying Statements

Qualifying Statements

The Treatment Planning section is not designed to be a rule, and therefore should not be used as a basis for Utilization Review. The Treatment Planning section outlines the most common pathways to recovery, but there is no single approach that is right for every patient and these protocols do not mention every treatment that may be recommended. See the Procedure Summaries (in the original guideline document) for complete lists of the various options that may be available, along with links to the medical evidence. The Procedure Summaries are the most important section of Official Disability Guidelines (ODG) Treatment, and that section, not the Treatment Planning section, should be used as a basis for Utilization Review.

Implementation of the Guideline

Description of Implementation Strategy

An implementation strategy was not provided.

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

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Getting Better
Living with Illness
IOM Domain
Effectiveness
Patient-centeredness

Identifying Information and Availability

Bibliographic Source(s)
Work Loss Data Institute. Elbow (acute & chronic). Encinitas (CA): Work Loss Data Institute; 2011. Various p.
Adaptation

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

Date Released
2003 (revised 2011 Apr 28)
Guideline Developer(s)
Work Loss Data Institute - For Profit Organization
Source(s) of Funding

Not stated

Guideline Committee

Not stated

Composition of Group That Authored the Guideline

Editor-in-Chief, Philip L. Denniston, Jr. and Senior Medical Editor, Charles W. Kennedy, Jr., MD, together pilot the group of approximately 80 members. See the ODG Treatment in Workers Comp Editorial Advisory Board External Web Site Policy.

Financial Disclosures/Conflicts of Interest

There are no conflicts of interest among the guideline development members.

Guideline Status

Note: This guideline had been updated. The National Guideline Clearinghouse (NGC) is working to update this summary.

Guideline Availability

Electronic copies of the updated guideline: Available to subscribers from the Work Loss Data Institute Web site External Web Site Policy.

Print copies: Available from the Work Loss Data Institute, 169 Saxony Road, Suite 210, Encinitas, CA 92024; Phone: 800-488-5548, 760-753-9992, Fax: 760-753-9995; www.worklossdata.com External Web Site Policy.

Availability of Companion Documents

The following are available:

  • Methodology outline is available from the Work Loss Data Institute (WLDI) Web site External Web Site Policy.
  • Appendix A. Official Disability Guidelines (ODG) Treatment in Workers' Comp. Methodology description using the AGREE instrument. Available from the WLDI Web site External Web Site Policy.
  • ODG for eReader. Treatment and disability duration guidelines are available for purchase from the WLDI Web site External Web Site Policy.
Patient Resources

The following is available:

  • Appendix C. Official Disability Guidelines (ODG) Treatment in Workers' Comp. Patient information resources. Electronic copies: Available to subscribers from the Work Loss Data Institute Web site External Web Site Policy.

Print copies: Available from the Work Loss Data Institute, 169 Saxony Road, Suite 210, Encinitas, CA 92024; Phone: 800-488-5548, 760-753-9992, Fax: 760-753-9995; www.worklossdata.com External Web Site Policy.

Please note: This patient information is intended to provide health professionals with information to share with their patients to help them better understand their health and their diagnosed disorders. By providing access to this patient information, it is not the intention of NGC to provide specific medical advice for particular patients. Rather we urge patients and their representatives to review this material and then to consult with a licensed health professional for evaluation of treatment options suitable for them as well as for diagnosis and answers to their personal medical questions. This patient information has been derived and prepared from a guideline for health care professionals included on NGC by the authors or publishers of that original guideline. The patient information is not reviewed by NGC to establish whether or not it accurately reflects the original guideline's content.

NGC Status

This summary was completed by ECRI on February 2, 2004. The information was verified by the guideline developer on February 13, 2004. This NGC summary was updated by ECRI Institute on March 28, 2005, January 3, 2006, November 9, 2006, March 29, 2007, August 16, 2007, December 18, 2008, and June 3, 2011. This summary was updated by ECRI Institute on October 28, 2013 following the U.S. Food and Drug Administration advisory on Acetaminophen.

Copyright Statement

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.

Disclaimer

NGC Disclaimer

The National Guideline Clearinghouseâ„¢ (NGC) does not develop, produce, approve, or endorse the guidelines represented on this site.

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