saltsa.pdf

Sluiter et al

Scand J Work Environ Health 2001, vol 27, suppl 1 3

Upper-extremity musculoskeletal disorders (UEMSD)have been recognized to occur in relation to work forhundreds of years. They were described by BernardiniRamazzini, an Italian physician and father of occupa-tional medicine, in the 18th century, when he said thediseases: “… arise from three causes; first constant sit-ting, the perpetual motion of the hand in the same man-ner, and thirdly the attention and the application of themind ...” (as quoted in Euro Review, Issue on Repeti-tive Strain Injuries, European Foundation for the Im-provement of Living and Working Conditions, 1994).

Today, there is growing concern in Europe andelsewhere both about the effects of work-related upper-extremity musculoskeletal disorders(WRUEMSD) on the health and well-being of work-ers and about the economic and social impact ofthese conditions (1—4). Musculoskeletal disorders,in general, are considered a major cause of sicknessabsence, disability, and health care (5—7), and manystudies have found high prevalences of musculoskel-etal symptoms and disorders in a wide range of oc-cupational groups. These studies have been describedor systematically reviewed or both in many publica-tions. [See, for example, the reports of Hagberg &Wegman (8), Armstrong (9), Hagberg et al (10),Gorden et al (11), Bernard (12), National ResearchCouncil (13), Punnett & Bergqvist (14).]

A variety of umbrella terms has been used in differ-ent countries to describe UEMSD thought to be relatedto repeated trauma. These include repetitive strain inju-ry (RSI), occupational overuse syndrome (OOS), occu-pational cervicobrachial disorder (OCD), and cumula-tive trauma disorder (CTD). These terms assume a linkbetween the clinical disorder(s) and the suspected caus-al factor or mechanism of injury. Like many research-ers (1, 9, 12, 15), we use the term work-related to re-flect the multifactorial nature of most UEMSD. Accord-ing to the World Health Organization (WHO), work-re-lated diseases are defined as multifactorial when thework environment and the performance of work contrib-ute significantly, but as one of a number of factors, tothe causation of disease (16). Although different abbre-viations and acronyms are used to identify work-relat-ed upper-extremity musculoskeletal disorders (eg,WMSD, WRUED, WMD), we use WRUEMSD in thisdocument in order to be as precise and descriptive aspossible.

Despite the impressive number of studies onWRUEMSD, considerable uncertainty and even contro-versy still exist about the extent and etiology of these

problems, the contribution of work and nonwork riskfactors to their development and resolution, the criteriaused to diagnose them, the outcomes of various treat-ment methods, and the appropriate strategies for inter-vention and prevention. Progress in advancing our un-derstanding of these problems has been hampered by anumber of things. These include (i) the acknowledgedmultifactorial nature of WRUEMSD, (ii) the uncertain-ty of pathophysiological mechanisms, and (iii) the meth-odological and practical challenges associated with ep-idemiologic research on WRUEMSD, the last on this listincluding the following:

• choice and use of different case definitions and diag-nostic criteria for assessing health effects

• lack of “gold standards” for the clinical diagnosis ofmost UEMSD

• problems associated with the meaningful measure-ment of exposure

• inherent biases associated with different study designsand study populations

• inability or failure to control for known or suspectedconfounders

• unfortunate adversarial and acrimonious climate insome countries due, in large part, to issues surround-ing compensation.

Although many hypotheses have been suggested inthe last few decades about possible underlying mecha-nisms for the development of nonspecific musculoskel-etal symptoms in particular and (chronic) pain in gen-eral, definitive knowledge is still lacking. One well-known potential mechanism at the muscular level is theCinderella hypothesis, namely, that the lack of recov-ery from repeated recruitment of the same motor unitsis responsible for fatigue and complaints when the samemovements and forces are asked for in a repetitive man-ner. Interested readers are referred to, for example, thereports of Hagberg & Wegman (8), Johansson & Sojka(17), Armstrong et al (9), Wright (18), Main & Watson(19), and Bushnell & Cobo-Castro (20).

Taken together, the aforementioned problems makeit difficult to compare the results of different epidemio-logic studies, surveillance systems, and registrationdatabases. This difficulty hampers efforts to assess andcompare the magnitude and nature of WRUEMSD with-in and across different countries, geographic areas, in-dustries, workplaces, and occupational groups overtime. Similarly, it impedes the ability to assess theeffectiveness of different types of medical and work-place intervention.

Introduction

Criteria for WRUEMSD

4 Scand J Work Environ Health 2001, vol 27, suppl 1

sician with this process of recognizing and diagnosingWRUEMSD. It includes clinical diagnostic criteriabased on symptoms commonly associated with differ-ent UEMSD, signs that may be elicited during the phys-ical examination and information about the diagnosticvalue of these signs and other diagnostic tests, if avail-able, and criteria for assessing the work-relatedness ofthese clinical disorders. The focus of this document islimited to the recognition and diagnosis of WRUEMSD;it does not contain information on treatment, prevention,or reintegration strategies.

Physicians can review the information in this docu-ment at any time. It may be especially helpful when theyare required to register or report work-related disorders.Although the criteria proposed in this document do notdiminish the importance of physicians’ clinical judg-ment, adherence to these criteria when WRUEMSD arereported will enhance the usefulness of their reportingactivities.

Meso level: in the workplace with groups of workers

Sometimes, information about WRUEMSD is solicitedin a more active way to help identify existing or poten-tial problems and risks in certain occupational groupsor in particular workplaces. This activity can be initiat-ed by occupational health professionals who provideprevention-oriented services to companies and groupsof workers — perhaps at the request of employers orworkers. Health or labor authorities may engage in orrequire occupational health surveillance for high-riskgroups or when alerted to possible problems throughother means. According to the International Labour Or-ganization (21), occupational health surveillance in-cludes both workers’ health surveillance and the surveil-lance of the work environment. The primary purpose ofoccupational health surveillance is prevention. If sur-veillance activities suggest or identify a problem, actionmust follow. Workers’ health surveillance forWRUEMSD or symptoms is especially important be-cause these problems may not come to the attention ofphysicians or be captured by existing administrative da-tabases for a variety of reasons (10). Thus relying onthese sources of information may not provide the fullpicture of WRUEMSD in any workplace, occupation,industrial sector, geographic area, or time period.

Most workplace health surveillance activities forWRUEMSD are based on symptoms only, because theprovision of medical examinations is neither realistic noraffordable. Thus this document provides surveillancecase definitions and criteria based on symptoms alone.The criteria can serve as the basis for conducting inter-views or using questionnaires to collect a common setof data elements on symptoms and work factors.Of course, if resources permit, medical examinations

Purpose and target users of this document

The underlying purpose of this document is the preven-tion of WRUEMSD. Such prevention can take differ-ent forms (primary, secondary, and tertiary), occur atdifferent levels [in the clinical setting (the micro level),in the workplace (the meso level), at the national level(the macro level)], and involve many types of activi-ties. Information is the foundation upon which these pre-vention activities rely. This document seeks to facili-tate a more uniform collection, recording, and report-ing of information about WRUEMSD in the EuropeanUnion (EU) by providing evidence- or consensus-basedcase definitions and criteria for identifying and classi-fying them. Because prevention is the main goal, thecriteria provided by this document are not intended tobe used for compensation purposes. The document isdesigned primarily for occupational health physicianswho provide care for individual workers with healthproblems and who provide occupational health servic-es to workers and employers in different companies.However, it may also be useful to other providers, in-cluding occupational health nurses, general practice andprimary care physicians, physiotherapists, and ergono-mists.

This document can be used at the aforementionedlevels of prevention. A description of them follows.

Micro level: in the clinical setting with individualpatientsThe recognition of work-related disease and injury of-ten begins in the physician’s office, once patients de-cide to seek help for their symptoms, complaints, orfunctional limitations. Physicians rely on the anamne-sis and the findings of the physical examination to be-gin to develop a differential or working diagnosis byintegrating information about symptoms, signs, and riskfactors (work and nonwork). Sometimes, additional con-sultation or specialized medical testing is needed to con-firm or rule out specific diagnoses. Clearly, the clinicalprocess is dynamic, and physicians use their best medi-cal judgment in making a diagnosis. The informationprovided in this document is designed to help the phy-

Current problems

••••• Too many definitions and concepts for WRUEMSD••••• Lack of unequivocal criteria with which to establish

UEMSD and decide on work-relatedness••••• Uncertainty about pathophysiological mechanisms for

UEMSD

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might also be done, and this would provide additionalinformation on diagnostic signs. Indeed, physical exam-inations may be particularly important for high-riskgroups, as WRUEMSD may be more likely to occur inthese workers.

It is important that the criteria be applied consist-ently and without deviation. This attention will enhancethe validity of comparisons over time and across differ-ent workplaces, industrial sectors, occupations, andgeographic areas. Once collected, the data can be usedto help identify potential problem areas in the workplaceand signal the need for more intense investigation orintervention. This document provides criteria that helpassess the work-relatedness of UEMSD, but it is beyondits scope to provide detailed risk assessment methodsor instruments for use in the active surveillance of thework environment.

Macro level: in the community, region or country

Health and labor authorities, researchers, and, perhaps,occupational health services may use existing recordsand data to help identify WRUEMSD patterns and po-tential problem jobs (10). These records and data includeinjury and illness reports, company dispensary logs, in-surance records, absentee records, and other data oftencollected for administrative purposes. The collection andrecording of a uniform set of data elements by physi-cians as the basis for reporting cases of WRUEMSDshould facilitate these more passive surveillance activi-ties and also provide more reliable data for epidemio-logic research. If reporting physicians use the criteriaconsistently, users can have more confidence that thecases have been diagnosed and reported similarly. This

consistency and confidence will help agencies more val-idly target workplaces and jobs most in need of assist-ance, which might include the initiation of more activesurveillance activities. Moreover, it will enhance thevalidity of comparisons made over time and across jobs,workplaces, industries, and geographic areas.

Criteria for different levels

As depicted in table 1, the criteria used for the diagno-sis of individual patients in the office setting includesboth symptoms (ie, the nature of a patient’s present com-plaints) and clinical signs (ie, positive findings, accord-ing to some definition, in a physical examination). Thusthey are more extensive than the criteria used for work-ers’ health surveillance workplace activities, which gen-erally are based on symptoms only. Accurate diagnosishelps determine the most appropriate treatment and pro-tects the patient from treatments that are ineffective,unwarranted, or unnecessarily invasive. In other words,specificity is more important than sensitivity at the mi-cro level. Criteria based on symptoms alone will gener-ally not provide the accuracy needed in this setting. Thecriteria are based on what the occupational or primaryphysicians can do in their own offices. In some cases,additional diagnostic testing or specialty consultationwill be helpful. However, many UEMSD lack a “goldstandard” for making or confirming a diagnosis; there-fore, signs and symptoms are often the only tools avail-able to physicians.

Because workers’ health surveillance in the work-place does not focus on the diagnosis and treatment of

Table 1. Information ideally needed or available and the methods used in different settings for diagnosing work-related upper-extremitymusculoskeletal disorders (WRUEMSD) (�= criteria provided in this document)

Purpose Information needed Methods

Micro Level For diagnosing and managing WRUEMSD � Symptoms • Anamnesiswith individual persons in the clinical setting � Signs • Physical examination

� Work Factors • Specialized testing, as necessary• Other anamnestic data• Specialized testing or consultation, as necessary

Meso Level For active occupational health surveillance � Symptoms • Questionnairesin the workplace � Work factors • Worker interviews

� Signs, if possible and desirable • Checklists• Observation• Physical examinations• Specialized testing, as necessary

Macro Level For passive occupational health surveillance Diagnoses or diagnostic codes, • Review and analysis of (existing)using existing records ideally based on: records, databases, questionnaires

� Symptoms� Signs

· • Other anamnestic data· • Specialized testing or consultation,

as necessary� Work factors



individual patients, case definitions and criteria are gen-erally designed to capture most, if not all, persons withwork-related musculoskeletal complaints. In this con-text, sensitivity becomes more important than specifici-ty. Moreover, tools used to collect data for surveillancepurposes must be practical, rapid, uniform, and easy touse (22). Thus the surveillance case definitions includ-ed in this report for use at the meso level are based onsymptoms only. If physical examinations are offered,then the criteria on diagnostic signs can also be used.Surveillance data can suggest the need for further ac-tivity, including referring workers to physicians for clin-ical assessment.

At the macro level, occupational health surveillanceactivities are more passive in nature. They entail the useof existing records to identify or monitor worker healthproblems. Existing records, such as insurance records,physician reports, and company records, may providesome information about health outcomes. Informationon work factors is generally not available in existingrecords. The information provided in this document mayhelp classify data found in existing records in the short-term. A long-term goal is to facilitate more uniform re-porting, collection, and recording of information in ex-isting databases.

The document addresses 11 specific UEMSD andnonspecific UEMSD, referred to in this document asnonspecific UEMSD. The methods used to develop thisdocument are detailed later in this section.

Specific Disorders

The following 11 more or less specific disorders andcomplaints are included in this document:

1. Radiating neck complaints 2. Rotator cuff syndrome 3. Epicondylitis - lateral and medial 4. Ulnar nerve compression at the elbow: cubital tun-

nel syndrome 5. Radial nerve compression: radial tunnel syndrome 6. Flexor-extensor peritendinitis or tenosynovitis of the

forearm-wrist region 7. De Quervain’s disease 8. Carpal tunnel syndrome 9. Ulnar nerve compression at the wrist: Guyon canal

syndrome10.Raynaud’s phenomenon (vibration white finger) and

peripheral neuropathy associated with hand-armvibration

11.Osteoarthrosis of the distal upper-extremity joints.

Clearly, this is not a list of every specific UEMSD.For example, the document does not include sections onosteoarthrosis of the cervical spine, cervical radiculo-pathy, osteoarthrosis of the glenohumeral joint, frozenshoulder, thoracic outlet syndrome, pronator teres syn-drome, or trigger finger. These disorders are not includ-ed because of very low prevalences (eg, pronator teressyndrome), the relationship to work is not yet clear (eg,osteoarthrosis of the cervical spine and glenohumeraljoint, cervical radiculopathy), or because the diagnosisis difficult or controversial (thoracic outlet syndrome).However, these and other UEMSD could be addressedin future studies of this kind.

For each of these specific disorders, the documenthas the following sections:

• description and clinical features of the disorder• information on the differential diagnosis specific to other UEMSD• information on test properties• examples of case definitions and criteria proposed or used in different epidemiologic and clinical studies — based on symptoms only and on symptoms plus signs (The examples were chosen to reflect case definitions and criteria used by researchers in different countries or were included because of their frequent citation in the literature.)• proposed case definitions based on symptoms only and on symptoms and signs

Contents and use of this document

The document is based on the following 2-step proce-dure for diagnosing and conducting surveillance forWRUEMSD: (i) establishing the clinical diagnosis and(ii) assessing the work-relatedness of the diagnosis. Tohelp users with the 1st step, the document provides casedefinitions and diagnostic criteria. Once the diagnosisis made, the user can consult the criteria on region-spe-cific work factors for help in making a determinationof work-relatedness. Like the Swedish National Boardof Occupational Safety and Health (23) and the pro-posed 3-zone model for action of Buckle & Devereux(24), this report uses a “traffic light model” to help theuser determine whether the disorder is work-related (redlight), possibly work-related (yellow light), or most like-ly not work-related (green light).

Purpose and use of the document

••••• Prevention: by facilitating more uniform collection,recording, and reporting of information aboutWRUEMSD in the European Union

••••• For both active and passive surveillance activities••••• Targeted for use by (occupational health) physicians

and other health care providers••••• Not designed for use in determining compensation

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• proposed criteria based on symptoms only and on symptoms and signs• references.

Temporal criteria are included in each proposed casedefinition and its accompanying diagnostic criteria. Therationale for these temporal characteristics is describedlater in this document.

The strength of the evidence used to develop the casedefinitions and criteria for these disorders varies. Forsome disorders, such as carpal tunnel syndrome, thesymptoms and signs included as criteria in this docu-ment have been well characterized, and their diagnosticvalue has been studied. For other disorders, such as os-teoarthrosis and forearm tendinitis, the diagnostic val-ue of symptoms and signs has not been subject to rigor-ous evaluation. Criteria are included because of theirgeneral acceptance and wide use in clinical practice andtheir common inclusion in medical textbooks. Some cri-teria, such as those for radial nerve compression at theelbow and ulnar nerve compression at the wrist (Guy-on’s canal), have been derived primarily from clinicalstudies and case series. Their value for the health sur-veillance of active workers in occupational settings isless certain. For the 11 listed disorders, the criteria thathave been evaluated clinically to some extent or arewell-accepted by the medical community include thosefor rotator cuff syndrome, epicondylitis, cubital tunnelsyndrome, de Quervain’s disease, carpal tunnel syn-drome, and hand-arm vibration syndrome. The criteriafound for the remaining disorders (ie, radiating neckcomplaints, radial tunnel syndrome, flexor-extensor per-itendinitis-tenosynovitis, Guyon canal syndrome, andosteoarthrosis) can be considered scientifically weaker.Moreover, the case definitions and criteria proposed foractive surveillance — that is, criteria based solely onsymptoms — are, by definition, considerably weakerthan the criteria that can be applied when physical ex-aminations are possible. The existence of clinical signsincreases diagnostic certainty.

Nonspecific upper-extremity musculoskeletal disorders

For most cases, upper-extremity musculoskeletal com-plaints cannot be classified into specific diagnostic cat-egories. The complaints may reflect mild early cases ofspecific disease, symptoms compatible with multiplediagnoses, or chronic pain processes that do not fit nice-ly into any accepted diagnostic category. A variety ofterms has been applied to these nonspecific UEMSD,including repetitive strain injuries, cumulative traumadisorders, occupational overuse syndrome, and others.

Although there is growing concern about the preva-lence of these disorders, little is known about their epi-demiology, etiology, pathomechanisms, symptomatolo-

gy, diagnosis, clinical course, prognostic factors, andtreatment or intervention outcomes. Some studies havefocused on nonspecific complaints (25—28), but mostclinical studies have focused on specific disorders. Mostoccupational studies of upper-extremity pain or symp-toms have been cross-sectional in nature, and they havenot included a follow-up. Thus the evidence for devel-oping valid and reliable case definitions and diagnosticcriteria for nonspecific UEMSD is lacking.

However, this document provides guidance to phy-sicians and others who frequently encounter these non-specific disorders in their clinical practice or in theworkplace. It suggests the structured collection of acommon set of data elements. Information about thenature, location, and onset of symptoms will help ad-vance the clinical understanding of nonspecific UEMSDand facilitate research into this important occupationalhealth problem.

Criteria for work-relatedness by body region

After the 12 UEMSD sections, the document describesa 4-step process for determining the level of work-re-latedness of the UEMSD (eg, probable, possible, mostlikely not). The first step concerns the important ques-tion of the temporal relationship between the exposureand the development of the UEMSD.

The 2nd step of this process is described in the sec-tion on criteria for determining work-relatedness. Thissection addresses risk factors according to the region ofthe upper extremity affected. To clarify and help stand-ardize what the different regions mean, the documentincludes definitions of the upper-extremity body regionsusing precise anatomic landmarks and a graphic bodychart. The work factors commonly associated withUEMSD are categorized into the following 4 main re-gions of the upper body: neck, shoulder-upper arm, el-bow-forearm, and wrist-hand. The work risk factors in-clude physical factors such as posture, force, movement,and vibration and nonphysical factors that may increaserisk, such as work organizational factors, includingwork:rest ratios, and other work environment character-istics, such as psychological demands and social sup-port.

Knowledge of the relationship between these workfactors and UEMSD comes primarily from epidemiolog-ic studies on groups of workers and laboratory studieson humans and animals in experimental conditions. Thecriteria for work-relatedness in this document are basedon the best available evidence from the literature or onthe consensus of expert groups. Because they have gen-erally been derived from studies on groups of workers,the criteria are, perhaps, the most valid when used forworkers’ health surveillance activities at the meso andmacro levels. However, they are also informative and



helpful when determining work-relatedness at themicro level with individual patients.

Clearly, a variety of confounding and mediating fac-tors may affect the development of UEMSD in individ-ual persons. These include personal characteristics, suchas age, gender, life-style and familial risk factors, med-ical anamnesis, and nonoccupational exposures (whichare addressed in step 3). For example, osteoarthrosis in-creases with age, smoking may increase the risk of Ray-naud’s disease in workers exposed to hand-arm vibra-tion, carpal tunnel syndrome is more common in wom-en and in persons with diabetes mellitus, and certainHLA (human leucocytlocus A) antigens may predisposepersons to repeating tenosynovitis. These “red flags”must be always considered when WRUEMSD is diag-nosed in the clinical setting. Similarly, workplace con-ditions, exposures, practices, and techniques are impor-tant and may vary among individual persons — eventhose from the same workplace. However, the generalcriteria included in this section will help the physicianassess work-relatedness with individual patients, and theregion-specific work risk factors will guide inquiry withboth individual workers and groups of workers. Final-ly, in step 4, rules for making decisions are provided toestablish the probability of work-relatedness.

Appendices

The appendices include descriptions and photographs ofthe provocative tests included in the criteria (appendixA), a glossary of anatomic terms and acronyms usedthroughout the document (appendix B), a tabular sum-mary of the evidence on work factors per region (ap-pendix C), a list of codes of the International Classifi-cation of Diseases (ICD) for the disorders (appendix D),and a quick-scan to decide what case definitions haveto be checked (appendix E).

page.) The group included experts in WRUEMSD, withspecific expertise in:

• occupational medicine• ergonomics• exposure assessment• epidemiology.

This supervising group met 3 times during the courseof the project. The group (i) provided advice on whichdisorders to include in the document and the type of in-formation about each disorder, (ii) assisted in the searchfor relevant grey literature by identifying individuals andorganizations doing work in this area, and (iii) critiquedthe first drafts of this report and participated in the finalconsensus workshop.

Literature study

Scientific and grey literature was sampled to gather asmuch literature as possible on the existing case defini-tions, criteria, and guidelines used in Europe, as well ason the most current information on occupational riskfactors.

In order to make the guidelines as evidence-basedas possible, literature searches were conductedusing the Medline, EMBASE, NIOSHTIC, PsychINFO,SPORTSDiscus, and Ergonomic Abstracts databases.The initial search was limited to articles published dur-ing 1995—1998, because the National Institute for Oc-cupational and Safety (NIOSH) in the United States hadrecently published a comprehensive review of prior lit-erature (12) and a report prepared for the Dutch Minis-try of Social Affairs and Employment on guidelines fordiagnosing WRUEMSD was also based on a systematicreview of the literature (29). Key words (singly or incombination) included upper limb, upper extremity, arm,elbow, wrist, finger, neck, shoulder, musculoskeletal,repetitive strain injury, cervicobrachial, cervicothorac-ic, glenohumeral, thoracic outlet syndrome, rotator cuff,periarthritis, humeroscapularis, referred, symptoms. Theyield was over 9500 references. The search was nar-rowed to approximately 1500 references with the fol-lowing key words (singly or in combination): occupa-tional, disorder, work-related, diagnosis, and syndrome.Further narrowing to 165 references was accomplishedwith the following key words: criteria, guideline, casedefinition, surveillance, consensus, evidence-based, ep-idemiology, exposure, work factors, and dose-response.A second search was done using the key words muscu-loskeletal disorders and psychosocial. Additional search-es were done on specific clinical diagnoses, includingepicondylitis, elbow, ulnar nerve compression, radialnerve compression, Raynaud’s phenomenon, hand-armvibration syndrome, and stenosing tenosynovitis. Thetitles and abstracts resulting from these searches were

Project methods

Supervising group

An international group of experts was assembled to pro-vide advice and guidance on the project. (See the cover

Contents of the document

Case definitions and criteria for:••••• Eleven specific UEMSD••••• Nonspecific UEMSD••••• Temporal criteria••••• Definitions of upper-extremity body regions••••• Four-step process to establish the work-relatedness

of UEMSD

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reviewed, and relevant references were retrieved. Ad-ditional references from earlier periods were also col-lected via the snowball method and reviewed.

The project team systematically abstracted informa-tion on prevalence, risk ratios, case definitions, diagnos-tic criteria, diagnostic testing, work factors, psychoso-cial factors, and nonwork factors from these articles. Toensure that the 2 researchers (JS, KR) responsible forreviewing the literature were abstracting similar infor-mation, 5 articles on nonspecific disorders were random-ly selected and abstracted by both. The results werecompared, and minor differences in abstracting tech-nique were corrected.

Grey literature was collected by contacting approx-imately 75 persons active in fields concerning muscu-loskeletal disorders and by contacting national institutesfor occupational health throughout the European Union.Approximately 22 persons responded to this inquiry andprovided approximately 43 pieces of grey literature, in-cluding reports, conference papers and abstracts, doc-toral theses, and guidelines.

Because of the paucity of data in the literature aboutthe clinical diagnosis of nonspecific WRUEMSD andtheir associated work factors, the authors of this reportconducted a questionnaire survey of all members of anorganization for repetitive strain injury in The Nether-lands. As described later in this document, these data,along with available literature, were used to develop

both the guidelines for the nonspecific UEMSD cate-gory included in this report and the associated work-factor criteria.

WorkshopFinally, a workshop was held to develop a consensuson the document. In addition to the project staff, 29 per-sons from 14 European countries (Austria, Belgium,Denmark, Finland, France, Germany, Greece, Ireland,Italy, The Netherlands, Norway, Portugal, Sweden, andthe United Kingdom) participated in the 2-day work-shop. These persons were invited for one of the follow-ing reasons: (i) they were expert members from the su-pervising group, (ii) they had expertise or experiencewith WRUEMSD, or (iii) they had the potential to in-fluence the practice of occupational health physiciansin their countries. These persons represented govern-ment, academia, health services, industry, and trade un-ions.

Project methods

••••• Supervising group of European experts••••• Literature search (scientific and grey)••••• Survey of members of an organization for repetitive strain injury••••• Workshop



Case definitions used in epidemiologic studies of work-related upper-extremity musculoskeletal disorder(s)(WRUEMSD) often include elements of time frame (eg,symptoms ever, within the last 12 months, within thelast 7 days), frequency (eg, symptoms at least once amonth or >3 times within the past year), duration (symp-toms lasting >7 days), severity (symptoms of moderateintensity, symptoms that interfere with work, home orsocial activities), or a combination of these. Clearly, thedefinition used will affect the prevalence ofWRUEMSD found in any study or investigation (30).

Clinical studies sometimes report how long patientsexperience symptoms before consulting a physician.Sports medicine literature often refers to the phasing oftendinitis. The phases reflect symptom severity and thetemporal occurrence in relation to certain activities (eg,training). However, very few clinical studies report thefrequency or duration of symptoms as part of their casedefinitions. This practice has implications for diagnoses.A physician’s diagnosis may be different for the patientwho comes to the office with mild symptoms shortlyafter the symptoms begin than for the patient who waitsmany months and seeks help when the symptoms be-come severe.

We have developed temporal criteria for theWRUEMSD addressed in this document. The follow-ing basic assumptions underlie these criteria:

• The criteria should be useful at different levels — inthe clinical setting with individual patients (currentcases) and in the workplace for screening and sur-veillance activities (current and past or recoveredcases).

• For workplace-based prevention, the criteria shouldfacilitate the capture of possible cases and cases withmild symptoms so that intervention strategies can beimplemented in a timely manner. They should not re-strict cases only to those with the most severe symp-toms, longest duration, or highest frequency.

• At the same time, the criteria should be strict enoughto differentiate normal and transient aches and painsfrom symptoms suggestive of specific (and non-specific) disorders of the upper extremities. This stip-ulation is especially important for muscle and tendonsymptoms, which are common.

• Unless symptoms are present at the time of the exam-ination or have been present regularly in the imme-diate past, people are unlikely to exhibit clinical signsin a physical examination.

• Entrapment neuropathies often have cyclical symp-toms (31). Therefore, the duration criteria shouldallow enough time to recognize the intermittent oc-currence of neurological symptoms.

Using these basic assumptions and in an attempt tobe as consistent as possible with the widely used ques-tionnaires used to study work-related musculoskeletaldisorders [eg, the Nordic questionnaire (32)], we haveused several temporal elements for the symptom-relat-ed time rule presented in this document. They includea timeframe (symptoms now, within the past week, orwithin the last 12 months), an element of frequency (onat least 4 days during the last 7 days), and an elementof duration (during at least 1 week). We believe thiscombination of elements is strict enough to differenti-ate common aches and pain from true UEMSD, but in-clusive enough to identify persons in the early phase ofthe disorder.

We have used the same temporal criteria for all thedisorders included in this document. Because the evi-dence for these temporal criteria is sparse, it was notpossible to develop different criteria for the differentcategories (tendon-muscle versus entrapment neuropa-thies) or types of disorders addressed in this document.As more evidence becomes available on the temporalnature of symptoms, the criteria in this document mayrequire future revision.

The following criteria can be used to identify bothcurrent and past cases. The 1st is the most useful in theclinical setting, where physicians encounter symptoma-tic patients and have the opportunity to do a physicalexamination. The 2nd is more useful in the context ofsurveillance for WRUEMSD in the workplace. Becauseintervention and prevention are the primary reasons formonitoring workers’ health, the use of both criteria to-gether facilitates the identification of current cases andcases that have occurred in the past year — thus pro-viding a more complete picture of potential problemsin the workplace.

Description and rationale of the temporal criteria used in thisdocument

Temporal criteria••••• Symptoms present now or on at least 4 days during

the last 7 daysOR

••••• Symptoms present on at least 4 days during at least1 week in the last 12 months

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Definitions of the upper-extremity body regions

4 Elbow: The elbow region is defined from the line runningbetween the lateral and medial epicondyles and transversally ap-proximately 5 cm distal and proximally to the middle of the hu-meral bone.

5 Forearm: The forearm region is defined proximally as a trans-versal plane at 5 cm below the olecranon and distally as a trans-versal plane off just proximally from the processus styloideusulnae.

The Nordic questionnaire (32) defined 5 upper-body re-gions (ie, neck, upper back, shoulders, elbows, andwrists-hands) without covering the whole upper extrem-ity.

The goal for the present criteria document on upper-extremity disorders differs from the goal of the devel-opers of the Nordic questionnaire because their goal wasto develop and test standardized questionnaires on gen-eral, low-back and neck-shoulder complaints. In addi-tion, the Nordic questionnaire intentionally defined onlyregions from the back aspect of the body, and the au-thors acknowledged the gap for disorders located in thefrontal part of the shoulder or on the flexor side of theupper limbs (32).

The Medical Research Council (MRC) in the Unit-ed Kingdom is preparing 7 definitions of upper-limbareas and will differentiate between the neck, shoulder,

elbow, forearm, wrist, and 2 parts of the hands (MRC,personal communication, 1999).

The present criteria document presents a categori-zation of the upper-extremity body regions that mightbe used to cluster upper-extremity complaints and reg-ister them in a common way across studies and examin-ers. As defined, the regions have logical or functionalboundaries and are practical in terms of symptoms aris-ing in some specific disorders. To be as complete aspossible, and to acknowledge the anatomic landmarksand joints in the upper extremity, 7 regions have beendefined for this criteria document. These regions are theneck, the upper back, the shoulder, the elbow, the fore-arm, the wrist, and the hand.

Definitions of the 7 upper-extremity regions are giv-en hereafter. The body chart in which the regions aremarked is also shown.

1 Neck: The neck region is defined caudally bythe line that crosses the Th4 junction in the mid-dle and laterally at the acromioclavicular joints.The cranial border is the skin at the top of thehead.

2 Upper back: The upper-back region is definedcranially by the line that crosses the Th4 junc-tion in the middle and laterally by the medialborders of the scapula bones. The caudal borderis the line that crosses at about Th10.

3 Shoulder: The shoulder region is defined dis-tally as the transversal plane off the middle ofthe humeral bone. The dorsal borders are fromthe line between the acromioclavicular joint tothe medial border of the scapula and the line thatcrosses the inferior angle of the scapula. Ventral-ly, the line between the sternal end of the cla-vicula to about 5 cm below the axilla on the chestwall is the border. The scapula is included total-ly in this region.

6 Wrist: The wrist region is proximally defined as a transversalplane off just proximally from the processus styloideus ulnae,and the distal boundary as a transversal plane from the base ofthe fifth metacarpal bone.

7 Hand: The hand region is proximally defined as a transversalplane from the base of the fifth metacarpal bone, and distally bythe fingertips of all digits.

1

23

35

4

7

61

4

5

6

7

Back (dorsal side)

Front (ventral side)

Definitions for the following upper-extremity body regions

••••• Neck • • • • • Upper back ••••• Shoulder ••••• Elbow • • • • • Forearm ••••• Wrist ••••• Hand



Case definitions and criteria for upper-extremitymusculoskeletal disorders

How to use criteria for specific upper-extremitymusculoskeletal disorders

Symptom case definition in the diagrams

Complaints in a certain body region form the entrypoint of each diagram for the symptom case definition,which is the first indicator that could lead to a diagno-sis. The symptom criteria should be checked one byone. Failure to meet any part of the criteria will lead toa rejection of the specific disorder in question. Afterrejection, the other possible disorders listed in the dia-grams (by number) should be checked. For some disor-ders, the symptoms may be present, but the temporalcriteria may not be met. In such cases, the symptomsstill suggest the disorder, and the disorder can be con-sidered a �latent case�. If some of the criteria are met,the complaints may be nonspecific and therefore con-sidered a �deviant case�.

A summary of the decision process for case defini-tions based on symptoms only follows:

1. Diagrams are examined for symptoms in a certainbody region.

2. Criteria are checked.3. Other listed possibilities are checked if the disorder

is rejected.or

4. Symptom case is considered present and is registeredor a physical examination may follow (dependent onthe goal of the examination (micro, meso, or macrolevel) when the criteria are met.

Sign case definition in the diagrams

When the criteria for the symptom case definition aremet, a physical examination may reveal positive signsthat fulfill the sign case definition for that disorder. A�symptom case� is the entry marker to the flow diagramfor this 2nd case definition. However, positive tests aregenerally found for patients whose symptoms arepresent at the time of examination or in the immediatepast. These patients can be considered �current cases�.Signs will not generally be present in �past cases�. Thus

In daily clinical practice, musculoskeletal disorders arediagnosed after the anamnesis reveals characteristicsymptoms reported by the patient, and the physical ex-amination elicits positive findings upon inspection, pal-pation, and provocative testing. Sometimes, consulta-tion with a specialist and further diagnostic testing areneeded to confirm the working diagnosis.

In order to facilitate more uniform collection, re-cording, and reporting of information aboutWRUEMSD in the upper extremities, physicians areencouraged to practice their normal clinical routines butto check the criteria presented in this document to seeif the requirements for the case definitions are met.

Case definitions

Two case definitions are prepared for each specificUEMSD, one with symptoms only and the other withboth symptoms and signs. The 1st (on symptoms only)is probably most useful in worker health surveillanceactivities, while the 2nd (on symptoms and signs) isprobably best applied in a clinical context when a phys-ical examination is possible. Both case definitions in-clude temporal criteria. The codes of the 10th revisionof the International Classification of Diseases (ICD-10)for each specific UEMSD are presented in appendix D.The diagrams provide a visual aid to the decision proc-ess that occurs when the criteria are applied to the casedefinitions.

Criteria in diagrams

The criteria presented in the diagrams provide a struc-ture to the diagnostic process as it takes place in theclinical situation. Heuristics give direction in the dif-ferential diagnosis process and are unconsciouslypresent in patient contact and therapy sessions. Duringand after the anamnesis, many disorders are excludedimmediately. The few disorders that remain possibleshould be checked.


Sluiter et al

the 1st part of the time rule must be obeyed if a patientis to be considered a �current case�. When a patient is a�past case�, the label �symptom case� remains.

A summary of the decision process for case defini-tions based on symptoms and signs follows:

1. Diagrams are examined for the symptom case of thedisorder in question.

2. Adherence to time rule is checked for the patient.3. Criteria for physical examination tests are checked.

4. Decision is kept as �symptom case� and is regis-tered as such when the sign criteria are not met.or

5. Sign case is considered present and is registeredwhen the sign criteria are met.Appendix E has been constructed so that the user can

do a quick scan to decide which case definitions to con-sult when a patient complains of a specific upper bodyregion.



1. Radiating neck complaints

Differential diagnosis of radiating neck complaintsand other upper-extremity musculoskeletaldisorders

The disorder must be distinguished from osteoarthrosisof the cervical spine, cervical syndrome (ie, nerve rootcompression by herniated vertebral disc), thoracic out-let syndrome, and shoulder tendinitis (29 pp 61—67,37].

Information on test properties

Although not in an original study on test properties, butinformative in this context, Toomingas (38) assessed therelation between subjective cervical complaints and ob-jective findings. He calculated test properties (sensitiv-ity, specificity, positive predictive value, and negativepredictive value) of self-administered examinations of18 signs in the upper extremity with the medical exam-ination as criterion. Over 500 examinations were com-pared. The subjects came from the Stockholm MUSICI study population. The tests compared were the neckrotation range, the neck flexion-extension range, andpalpation of neck tenderness and trapezius tenderness(table 2).

Also relevant in this context is the study on interex-aminer reliability that was done in an evaluation of theprotocol used by the British Medical Research Council(MRC) (39). Of 56 hospital outpatients with rheumaticand orthopedic complaints, 31 pairs (62 limbs) of be-tween-observer data and 12 pairs (24 limbs) of within-observer data were formed. Physical examinations wereperformed by trained research nurses or rheumatolo-gists. The mean differences for measurements of neckmovements was small within-observers (between0.4—3.3 degrees) and between observers (differences0—5.3 degrees). The diagnostic conclusions wereperfect (100%) for the within and between-observer rat-ings for the only neck diagnosis made (cervical syn-drome). The sensitivity and specificity of this examina-tion schedule (gold standard in rheumatologists’ opin-ions) for the two observers were 60% and 73% and 60%and 69%, respectively.

Westaway et al (40) evaluated the test-retest relia-bility of self-reported neck complaints for 31 consecu-tive physician-referred patients with neck pain. The 72-hour intraclass correlation was 0.81 for the severity ofpain.

Table 2. Test properties [sensitivity, specificity, positive predic-tive value (PPV), and negative predictive value (NPV)] of self-ad-ministered examinations of 18 signs in the upper extremity withthe medical examination as the criterion for radiating neck com-plaints, according to Toomingas (38).

Test properties

Test Sensitivity Specificity PPV NPV

Neck rotation range 0.20 0.98 0.14 0.99Neck flexion-extension range 0.44 0.95 0.13 0.99Neck tenderness 0.55 0.86 0.39 0.92Trapezius tenderness 0.83 0.65 0.29 0.96

Description of disorder and clinical features

Textbooks [eg, that of Kelly et al (33)] and the litera-ture describe radiating neck complaints as mostly non-radicular complaints originating from structures in oraround the cervical spine. Symptoms are found not onlyin the neck region, but also in one or more regions ofthe upper extremity as well. Because the cervical nerveroots are bound above and below by the 2 vertebra pedi-cles of the uncovertebral and zygapophyseal joints, in-volvement of these joints is considered the most com-mon cause of nerve root irritation that leads to cervico-brachial neuralgia and, thus, to cervicobrachial pain.Whereas cervical nerve-root irritation causes well-lo-calized areas of pain, more poorly defined areas of re-ferred pain arise from irritation of deep connective tis-sue, structures, muscle, joint, bone, or disc.

With age, the intervertebral discs lose height. Theresult is increased pressure on the uncovertebral andzygapophyseal joints, which then are converted to jointsthat are load bearing, a function for which they are notdesigned (33).

Nonradiating neck pain is often called tension necksyndrome (TNS). TNS is not a specific disorder. Itmight be “defined”, however, as a complex of nonspe-cific symptoms in which myofascial and tendinomyo-gen complaints dominate and which is centered aroundthe neck-shoulder line (8, 9, 34). In this document,symptoms and signs that might be categorized as TNSwill be dealt with in the section of nonspecific UEMSD.

Radiating neck pain of nonradicular origin has beenfound in over 25% of 440 patients with neck-shouldercomplaints by Rekola et al (35) and in 86% of 517 pa-tients by Borghouts et al (36).


Sluiter et al

Viikari-Juntura et al (41) evaluated the predictive va-lidity of symptoms and signs in the neck and shoulderwith regard to sick leaves in a prospective study of 474patients seeking medical advice from occupationalhealth professionals. More than half of the subjects(64%) reported pain in the neck or shoulder upon rota-tion of the head, and 13% of the subjects reported painin the upper limb upon rotation of the head. Cervicalrotation leading to pain in the upper limb was the testthat remained a significant predictive value in the mul-tivariate analyses.

Examples of the case definitions and criteriaproposed or used in different studies

Definitions based on symptoms

Although not for �radiating neck pain�, the practiceguidelines for occupational medicine by Harris et al(42) provided the following diagnostic criterion for re-gional neck pain (ICD-9 723.1,3,5,7,8,9): diffuse pain.

Definitions based on symptoms and signs

Veierstedt & Westgaard (43) used the following �diag-nostic� criteria for trapezius myalgia: neck and shoul-der pain that lasts >2 weeks and is of a degree making itdifficult to continue work, plus at least 1 tender or trig-ger point present on palpation.

In a case-rerferent study of 142 male electricians and139 female laundry workers, Norlander et al (44) eval-uated whether mobility in the cervicothoracic motionsegment could be seen as an indicative factor of mus-culoskeletal neck-shoulder pain. Cases were defined as>7 days of complaints in the neck or shoulder region orboth according to the Nordic questionnaire. Positivesigns were based on cervical flexion, and the relativeflexion mobility was used as a sign according to the cer-vicothoracic ratio (a calculated ratio based on absolutevalues of skin distraction between C7 and T5). The re-sults showed that an invariable inverse C7-T1 functionhad an increased relative risk of developing >7 days ofneck-shoulder pain.

In the protocol used by the British MRC (39), de-veloped through a Delphi process, the following diag-nostic criteria are used for cervical syndrome: neck painand one of the following neck movements (cut-points)restricted: right or left rotation (<80 degrees), flexion(<60 degrees), extension (<75 degrees), or lateral flex-ion (<45 degrees).

Proposed case definitions

Because not many studies have described the symptomsbelonging to radiating neck complaints, the symptomsfor this criteria document are based on textbooks andcommon clinical practice. A positive test during the ex-amination of the cervical spine is included. The studyof Viikari-Juntura (41) could be used to add the appro-priate sign to the symptoms. A time criterion is also in-cluded on the basis of the time rule described earlier inthis document.

! Note ! : Descriptions and photographs of the tests involved can be found in appendix A Photos 1 and 2

Case definition 2: radiating neck complaints, based on symptomsand physical examination signs

Time rule: • Symptoms present now or on at least 4 days during thelast 7 daysAND

Symptoms: • At least intermittent pain or stiffness in the neck andpain or paresthesias in ≥1 upper-extremity regions inassociation with head movementsAND

Signs: • Pain in upper extremity on active or passivecervical rotation

Case definition 1: radiating neck complaints, based on symptoms only

Symptoms: • At least intermittent pain or stiffness in the neck andpain or paresthesias in ≥1 upper-extremity regionsin association with head movementsAND

Time rule: • Symptoms present now or present on at least 4 daysduring the last 7 daysor

• Symptoms present on at least 4 days during at least 1week in the last 12 months



SYMPTOM CRITERIA FOR RADIATING NECK COMPLAINTS

SIGN CRITERIA FOR RADIATING NECK COMPLAINTS

Symptom case radiatingneck complaints• no

yes

yes

no

Symptoms present now or on atleast 4 days during the last 7 days

= Symptom case radiating neck complaints

Pain in upper extremityupon active or passivecervical rotation

= Case radiating neck complaints (ICD code M53.1)

Symptoms present now oron at least 4 days duringthe last 7 days

Symptoms present on at least 4days during at least 1 week inthe last 12 months

OR

no

yes

yes yesno

At least intermittent pain orstiffness in the neck andpain or paresthesias in ≥1 upper-extremity regions in associationwith head movements

= Deviant case,check disorder 12

Symptoms in the neckregion

= Latent symptom case



•


Sluiter et al

lar nerve injury, acromioclavicular joint pathology, cal-cified tendinitis, and frozen shoulder as differential di-agnoses that should be excluded.


Pellechia et al (47) studied the intertester reliability ofmanual orthopedic physical examination of the shoul-der (active, passive, and resistance tests) following theCyriax approach. Certain combinations of positive testswere used to differentiate between diagnostic categoriesin the shoulder region (ie, all rotator cuff tendinitis, ar-thritis, and suprascapular neuritis). Agreement wasfound in the classification of 19 of 21 patients (kappa =0.88), 9 of which had rotator cuff tendinitis.

Although not in an original study on test properties,but informative in this context, Toomingas (38) calcu-lated the test properties [sensitivity, specificity, positivepredictive value (PPV), and negative predictive value(NPV)] of the self-administered examinations of 18signs in the upper extremities using the results of a med-ical examination as the criterion. He used this procedurefor a population for which over 500 examinations werecompared. The subjects were a part of the StockholmMUSIC I study (table 3).

The interexaminer reliability of physical tests and thevalidity of the diagnosis were examined in an evalua-tion of the Southampton examination schedule for thediagnosis of musculoskeletal disorders of the upper limb(48). In 88 hospital outpatients with rheumatic and or-thopedic complaints, 43 pairs (86 limbs) of between-ob-server data were formed. Physical examinations wereperformed by trained research nurses or rheumatologists.

m levator scapulae

m infraspinatus

m teres minor

m teres major

m triceps brachii

m deltoideus

m trapezius

m supraspinatus

2. Rotator cuff syndrome


Textbooks and the literature describe the rotator cuffsyndrome as an irritation of structures in the subacro-mial space due to a decrease in vascularization and de-generative change caused by repeated impingement ofthe various types of tissues under the shoulder tectum.The structures responsible for the accompanying symp-toms include the supraspinate muscle, the infraspinatemuscle, the tendon of the caput longum of the bicepsbrachii muscle, the subacromial bursa, the subscapularmuscle, and the tendons of the teres major and minormuscles.

The main symptom is intermittent, activity-depend-ent pain in the shoulder region. Symptoms are provokedwhen elevation movements of the upper arm, in com-parison with those of the trunk, occur. Examples ofthese kinds of movements are pulling of a sweater,scratching the other shoulder or upper back, or closinga bra backwards. Possible limitations of shoulder move-ments are caused by pain or stiffness and do not followthe capsular pattern of the glenohumeral joint.

Differential diagnosis of rotator cuff syndromeand other upper-extremity musculoskeletaldisorders

Most textbooks suggest distinguishing this disorderfrom osteoarthrosis of the glenohumeral joint. Ranneyet al (45) excluded frozen shoulder in diagnosing rota-tor cuff tendinitis. Lyons & Orwin (46) mention cervi-cal radiculopathy, glenohumeral instability, suprascapu-



At the test level, excellent interobserver agreement wasobtained for the presence of shoulder tenderness (kap-pa = 0.80), the presence of a painful arc (kappa = 0.93),pain on resisted shoulder abduction (kappa = 0.81), painon resisted elbow flexion (kappa = 0.83), and pain onresisted shoulder external rotation (kappa = 0.90). Thesensitivity and specificity of the examination schedulefor bicipital tendinitis and rotator cuff tendinitis (goldstandard in rheumatologists’ opinions) for the 2 observ-ers were 100% and 58% and 98 and 84%, respectively.

Marx et al (49) performed a formal literature searchfor a period of over 30 years (Medline 1966 to 1996,snowball method, expert references) to evaluate the re-liability and validity of using a physical examination forthe upper extremities. For rotator cuff, only 1 study wasfound (50); it concerned 45 patients with expected rota-tor cuff tears. With surgery as the gold standard, the sen-sitivity and specificity of the clinical diagnosis of rota-tor cuff tear by means of palpation and strength testingof shoulder abduction and external rotation was foundto be 91% (95% confidence interval 76—98) and 75%,respectively. The predictive value of a positive test was94%, and the predictive value of a negative test was66%.

Examples of case definitions and criteria proposedor used in different studies


No studies were found which used only symptoms todiagnose the rotator cuff syndrome.


For the development of epidemiologic criteria, Waris etal (51) reviewed the literature (6 studies which used casedefinitions) and sampled expert knowledge. For humeraltendinitis (supraspinous and biceps), the following di-agnostic criteria were developed: symptoms: pain in theshoulder joint region and limited active movement be-cause of pain; signs: the presence of a painful arc dur-ing arm abduction, pain on resisted shoulder abduction,

and tenderness during palpation of the bicipital or su-praspinous tendon.

Hagberg & Wegman (8) described 4 criteria used informer occupational studies of rotator cuff tendinitis(which they actually restricted to supraspinous tendini-tis). The criteria were (i) localized shoulder pain andtenderness on palpation of the humeral head, pain withisometric contractions, limitations of the active rangeof movement, and a reduction of gross power, (ii) painin the shoulder region and local tenderness on palpa-tion, (iii) local pain, local tenderness on palpation, painduring abduction, and limited active abduction, and (iv)local pain and tenderness on palpation, in addition topain at isometric abduction. Based on their review, theydefined rotator cuff tendinitis as follows: symptom: lo-calized shoulder pain; sign: tenderness on palpationover the humeral head.

In their cross-sectional study of 146 female indus-trial workers, Ranney et al (45) used the following min-imal clinical criteria for establishing worksite rotatorcuff tendinitis: symptom: pain in the deltoid area or inthe front of the shoulder increased by glenohumeralmovement; sign: rotator cuff tenderness on palpation.Frozen shoulder should be excluded. In addition, theyclassified the severity of the disorder as “mild” whenthese criteria were met, as “moderate” when pain per-sisted >2 hours after the cessation of work but was goneafter a night’s sleep or when the patient had tendernessplus pain on resisted activity if localized in an anatom-ically correct manner or a positive impingement test,and as “severe” when the pain was not completely re-lieved by a night’s sleep.

In their evaluation of the intertester reliability of theCyriax evaluation of shoulder patients, Pellechia et al(47) used the following criteria for rotator cuff tendini-tis: symptom: shoulder pain; signs: either painful resist-ed shoulder abduction, internal, external rotation or el-bow flexion and a painful arc during active abduction-elevation of the shoulder girdle, and pain on full pas-sive elevation.

In their cross-sectional study of cumulative traumadisorders (CTD) among 145 medical device assemblers,Meservy et al (52) used the following criteria for rota-tor cuff tendinitis: symptoms: cumulative trauma disor-ders in the upper extremities (ie, pain, aching, stiffness,burning, numbness or tingling in the shoulder and self-reported work as cause of the problem and exclusion ofnonwork accident or injury); signs: pain or tenderness(≥3 on a scale of 1—10) on active and resisted shoul-der abduction.

In his thesis based on 6 articles, Toomingas (53) usedthe following minimal diagnostic criteria for rotator cufftendinitis in his study, which was part of the MUSIC Istudy: present symptom location (ache, pain, or discom-fort) at the shoulder and rotator cuff tenderness (on pal-

Table 3. Test properties [sensitivity, specificity, positive predic-tive value (PPV), and negative predictive value (NPV)] of self-ad-ministered examinations of 18 signs in the upper extremities withthe medical examination as criterion for rotator cuff syndrome,according to Toomingas (53).

Test properties


Shoulder abduction range 0.29 0.93 0.05 0.99Shoulder external rotation range 0.59 0.81 0.12 0.98


Sluiter et al

pation) and pain on abduction of either shoulder, internalrotation or external rotation (on resisted active contrac-tion).

In their practice guidelines for occupational medi-cine, Harris et al (42 pp 11-17) provide the followingdiagnostic criteria for chronic rotator cuff tears (ICD-9727.61): symptoms: pain over the deltoid area with over-head work and weakness on elevation and external ro-tation of the shoulder; signs: weakness in shoulder“thumbs down” abduction and weak external rotation.

For the development of clinical diagnostic criteria,Menoni et al (54) and De Marco et al (31) chose clini-cal maneuvers and instrumental tests on the basis of asensitivity and specificity assessment and positive andnegative predictive values whenever such data wereavailable in the literature. For shoulder tendinitis, thefollowing criteria were set: exceeding the anamnesticthreshold (ie, pain, paresthesias, weakness or neuroveg-etative symptoms lasting for at least 1 week or occur-ring at least once a month without being preceded byacute trauma during the last 12 months), and activeshoulder movements trying to evoke pain during flex-ion or abduction (painful arc between 70 and 120 de-grees) or external rotation plus abduction, or internal ro-tation plus abduction.

In the Southampton examination schedule (48), thefollowing diagnostic criteria are used for rotator cufftendinitis: symptom as history of pain in the deltoid re-gion and one of the following positive signs: resistedshoulder abduction, external or internal rotation. For bi-cipital tendinitis, the criteria were history of anteriorshoulder pain as the symptom and pain on resisted ac-tive flexion or supination of the forearm as a positivesign. The physical examination protocol was startedwhen pain was present for ≥1 days during the previous7 days.

Lyons & Orwin (46) proposed diagnostic criteria forrotator cuff tendinopathy and the subacromial impinge-ment syndrome. They suggested the following symp-toms and signs in making the diagnosis for rotator cuffdisorders: pain, commonly at the anterior or lateral sideof the shoulder, aggravated by overhead work or throw-ing, decrease in internal rotation, tenderness on palpa-tion, and a positive resistance test against abduction orinternal rotation or external rotation. In addition, 10more specialized tests were mentioned by the authors.

Harrington et al (55) reached a multidisicplinary con-sensus on the following minimum surveillance criteria forshoulder tendinitis: history of pain in the deltoid regionand pain on ≥1 resisted shoulder movement (abduction,external rotation, or internal rotation). These criteria weretaken over by Davis (56) as well.

In the development of a diagnostic instrument for therotator cuff syndrome, the most weighted symptoms andsigns of Sluiter et al (29 pp 35—40) that minimally led

Case definition 1: rotator cuff syndrome, based on symptoms only

Symptoms: • At least intermittent pain in the shoulder region withoutparesthesias worsened by active elevation movement ofthe upper arm as in scratching the upper backAND

Time rule: • Symptoms present now or on at least 4 days during thelast 7 daysor


! Note !: Descriptions and photographs of the tests involved can be found in appendix A Photos 3—10

Case definition 2: rotator cuff syndrome, based on symptomsand physical examination signs


Symptoms: • At least intermittent pain in the shoulder region withoutparesthesias; pain worsened by active elevationmovement of the upper arm as in scratching of theupper backAND

Signs: • At least one of the following tests positive:� resisted shoulder abduction, external rotation, or

internal rotation� resisted elbow flexion� painful arc on active upper arm elevation

to a “probable” diagnosis were intermittent pain in theshoulder or deltoid region of the upper arm and a mini-mum of 2 of the following: painful arc during active el-evation of the shoulder girdle, passive, end-ranging painor restriction of 1 shoulder movement, a positive resist-ance test against 1 of the shoulder movements or elbowflexion.


Although no studies were found that based a diagnosisof rotator cuff syndrome on symptoms alone, most stud-ies were more or less consistent on the symptoms in-cluded in their criteria, and they contained both symp-toms and signs. Therefore, a case definition based onsymptoms only is constructed below, which includes 1general tendinitis characteristic regarding the contrac-tile feature of muscle-tendon tissue.

Because the subacromial bursa and the biceps ten-don are included in the definition of rotator cuff syn-drome, the signs included in the case definition for thisdocument is based on the latest consensus establishedin the United Kingdom and the validation of the South-ampton protocol. A time criterion is also included thatis based on the time rule described earlier in this docu-ment.



SIGN CRITERIA FOR ROTATOR CUFF SYNDROME

SYMPTOM CRITERIA FOR ROTATOR CUFF SYNDROME

OR

yes

yesyes


At least one of the followingtests positive

no

yes

OR

yes

no

Symptom case rotatorcuff syndrome•

Symptom caserotator cuff syndrome

One or more of the followingresisted shoulder movementspositive: • abduction • external rotation • internal rotation

Painful arc test on activeupper arm elevationResisted elbow flexion

= Case rotator cuff syndrome( ICD code M75.1, 75.2)


Symptoms present on at least4 days during at least 1 weekin the last 12 months

OR

yes

yes yesno


noAt least intermittent painin the shoulder regionwithout paresthesias

Deviant case: checkcriteria for disorders1 & 12

Worsened by active elevationmovement of the upper arm, as in scratching the upper back

= Symptom case rotatorcuff syndrome

= Symptom caserotator cuff syndrome

Symptoms in theshoulder region•

yes


Sluiter et al

3. Epicondylitis – lateral and medial

m abductor pollicis longus

lateral epicondyle

m supinator

m extensor pollicis brevis

olecranon

medial epicondyle

ulnar nerve

wrist/finger extensors

retinaculum

ulnar nervem biceps brachii

medial epicondyle

median nerve

carpal tunnel

Guyons� canal

wrist/finger flexors

median nerve

ulnar nerve

m pronator teres

Description of disorder and clinical feature

Epicondylitis is a condition characterized by intermittentpain at the muscle-tendon junction or at insertion pointsof the wrist extensors (lateral epicondylitis) or wrist flex-ors (medial epicondylitis) in the elbow region. In textbooksand the literature, the clinical features of epicondylitis aredescribed as patients' complaints of pain as the primarysymptom, generally localized around the lateral or medialepicondyles but sometimes radiating distally to the fore-arm. Weakness of grip can also be present. Symptoms areoften provoked by the grasping or lifting of objects (ie, bysupination and pronation movements of the forearm orupon elbow extension). In the acute phase, symptoms canalso occur during rest.

Differential diagnosis of epicondylitis and otherupper-extremity musculoskeletal disorders

Radial tunnel syndrome is another possible cause ofchronic elbow pain. Other possible causes include cer-vical syndrome and osteoarthrosis (eg, synovial irrita-tion and chronic irritation of the ulnar-humeral or radio-humeral joint capsule) (57, 58).


Sölveborn & Olerud (59) studied 123 patients with uni-lateral signs and symptoms of epicondylitis in a consec-utive prospective series from their university hospital inSweden in order to evaluate the range of motion (ROM)

characteristics of the elbow and wrist joints in patientswith radial epicondylalgia (tennis elbow). A related re-liability study involved 16 healthy persons without ahistory of elbow or wrist disorder. Active and passivejoint motion measurements were made with a simpleplastic goniometer for wrist flexion, wrist extension,supination, and pronation. Also measured were radialand ulnar deviation, elbow flexion, and elbow exten-sion. For the 92 patients with right-arm symptoms, thestudy found a significantly restricted ROM in the in-volved limb for every ROM measurement except pas-sive supination. The greatest mean differences werefound for wrist extension (11 degrees active, 8 degreespassive), wrist flexion (7 degrees active, 8 degrees pas-sive), and pronation (7 degrees active, 12 degrees pas-sive). For the 31 patients with left-arm symptoms, theROM was significantly restricted for wrist flexion (5degrees active, 4 degrees passive), supination (9 degreesactive, 8 degrees passive), and elbow extension (4 de-grees). The ROM of the healthy subjects used in the re-liability study were consistent with those of the symp-tom-free side of the patients in the clinical series.

Pienimaki et al (60) evaluated the motor performance(reaction time, speed of movement, accuracy, coordina-tion, and tapping speed) of 32 consecutive chronic tenniselbow patients referred to a university hospital and 32 ref-erents from a random age- and gender-matched sampleof healthy people in the local community. They found sig-nificantly slower reaction times for the involved arms ofthe patients than those of the corresponding arms of thereferents (19—35% slower); there was also a significant-ly slower speed of movement (31—32%). In addition the



patients’ healthy arms showed significantly slower re-action times (11—29% slower) and speed of movement(25—30% slower) than the corresponding arms of thereferents. The authors considered these findings prelim-inary but suggested that the measurement of motor armfunction may provide complementary data for diagno-sis, treatment, and rehabilitation.

In a prospective randomized trial comparing the out-comes of 2 treatment methods (Cyriax physiotherapyand corticosteroid injections) for 106 patients with lat-eral epicondylitis, Verhaar (58) studied all patients withthe disorder referred to an orthopedic elbow clinic ofan academic hospital in Maastricht over a 1-year peri-od. The physical examination of these patients includedthe measurement of ROM, pain provoked by resistedmotion, palpation, and grip strength. The ROM was lim-ited for only 7 of 107 patients, all induced by pain atpassive or active extension. All the patients had painupon resisted extension of the wrist (90 with severe painand 16 with slight pain). Fifty of 106 patients had at leastslight pain upon resisted supination of the forearm, but56 of the106 did not experience pain with this maneu-ver. Eighty-eight of the106 patients had at least slightpain upon resisted extension of the middle finger, and18 reported no pain with this maneuver. All of the 106patients reported tenderness on palpation of the lateralepicondyle, the tenderness being slight in 24, moderatein 52, and severe in 30. Absolute grip strength beforetreatment was not reported; increased or decreased gripstrength was reported only as an outcome parameter.

The interexaminer reliability of physical tests and thevalidity of diagnosis were examined in an evaluation ofthe Southampton examination schedule for the diagno-sis of musculoskeletal disorders of the upper limbs (48).For 88 hospital outpatients with rheumatic and ortho-pedic complaints, 43 pairs (86 limbs) of interobserverdata were formed. Physical examinations were per-formed by trained research nurses or rheumatologists.On the test level, excellent between-observer agreementwas obtained for the presence of elbow tenderness lat-erally (kappa = 0.75), pain in the lateral elbow on re-sisted wrist extension (kappa = 0.75), and pain medialelbow on resisted wrist flexion (kappa = 0.75). The sen-sitivity and specificity of the examination schedule oflateral epicondylitis (gold standard in rheumatologists’opinions) for the 2 observers were 73% and 97%, re-spectively.


Depending on their purpose, studies have used a varie-ty of case definitions and criteria for identifying and

describing elbow-related musculoskeletal disorders ingeneral and epicondylitis in particular. Some generalstudies of elbow-related musculoskeletal disorders havebeen based on self-reported symptoms. Most studies ofepicondylitis have included physical examinations andhave been based on both symptoms and signs.


Studies based on symptoms have generally examinedelbow disorders based on the frequency and duration ofsymptoms or on symptom interference with work activ-ities (12).

Punnett et al (61) defined cases of elbow disordersamong female garment workers as the presence of per-sistent elbow pain, numbness, or tingling lasting formost days for ≥1 month within the past year, not asso-ciated with previous injury, and beginning after first em-ployment in garment manufacturing.

In their study of neck and upper-extremity disordersin electrical equipment and automobile assemblers,Ohlsson et al (62) defined a case as any elbow pain, el-bow pain affecting work ability, and elbow pain in thelast 7 days and the last 12 months.

In studies of newspaper employees (63) and govern-ment-employed teleservice representatives (64), NIOSHinvestigators defined elbow-related musculoskeletal dis-orders as self-reported pain with numbness, tingling,aching, stiffness, or burning in the elbow region andsymptoms beginning after the start of the job, the symp-toms lasting at least 1 week or occurring once a monthwithin the past year and given a rating of 3 (“moder-ate”) or greater on a 5-point scale.


In an early study of occupational neck and upper-limbdisorders in a working population, Waris et al (51) useddiagnostic criteria developed by a multidisciplinarygroup of specialists using a their literature review andtheir own clinical experience. Diagnostic criteria forepicondylitis included pain during rest or active move-ments of the wrist and fingers plus tenderness on palpa-tion at the lateral or medial epicondyle plus pain on re-sisted extension (lateral) or resisted flexion (medial) ofthe wrist and fingers.

In a study of the prevalence of lateral epicondylitisin the general population of the Maastricht area in TheNetherlands, Verhaar (58) used the following criteria:(i) complaints of pain at the lateral side of the elbowand (ii) provokable pain at the lateral epicondyle uponresisted extension of the wrist.

Byström et al (65) studied automobile assembly-lineworkers and compared them with a randomly selected


Sluiter et al

group from the general population. Epicondylitis wasdefined by symptoms (pain, ache, or discomfort duringthe last 7 days) plus tenderness to palpation of thelateral or medial epicondyle plus pain at the same epi-condyle or in the forearm extensors or flexors on resist-ed wrist extension or flexion.

In their study of female workers with highly repeti-tive jobs, Ranney et al (45) used the following as “min-imal clinical criteria” for diagnosing epicondylitis ortendinitis: pain localized to the lateral or medial aspectof the elbow plus tenderness to palpation of the lateralor medial epicondyle localized to this area or to soft tis-sues attached for a distance of 1.5 cm plus a positivemodified Mill’s test or reverse Mill’s test (ie, extendingthe elbow, pronating the forearm, and then flexing thewrist; reversed for problems originating in the flexors).Of note is the authors’ inclusion of pain distal to theepicondyle, but in the proximal half of the forearm. Thisinclusion reflects the view that epicondylar tendernessmay be a proximal extension of a primary problem inthe forearm muscles.

In their case-referent study to assess the motor per-formance of the arm in 32 consecutive patients withchronic unilateral tennis elbow referred to a universityhospital, Pienimäki et al (60) used the following crite-ria to confirm the diagnosis of lateral epicondylitis: re-sisted wrist extension test plus Mill’s test producing typ-ical pain in the insertion area of the lateral epicondyleplus local tenderness on the lateral epicondyle upon pal-pation.

In their cross-sectional study of epicondylitis among209 nursery school cooks and 366 referents, Ono et al(66) used the following criteria: tenderness on palpationof the lateral-medial epicondyles plus epicondylar painon resisted extension (lateral) and flexion (medial) ofthe wrist with the elbow extended. Although “arm pain”was included as an item on a self-administered question-naire, the item was not specific to the elbow region andwas not analyzed in the study.

In a recent effort to establish consensus case defini-tions for the surveillance of common work-related up-per-limb pain syndromes, Harrington et al (55) definedlateral epicondylitis as a lesion at the common extensororigin of the lateral epicondyle of the humerus causingthe effects noted in the criteria. Their surveillance cri-teria included lateral epicondylar pain plus epicondylartenderness plus pain on resisted extension of the wrist.For medial epicondylitis, the criteria were similar, butwith pain on resisted flexion of the wrist.

In the Southampton examination schedule (48), theDelphi technique of Harrington et al (55) was used todevelop the following criteria for diagnosing lateral andmedial epicondylitis in large community surveys: painover the lateral-medial elbow plus tenderness over thelateral-medial elbow plus induced pain over the lateral

elbow upon wrist extension or over the medial elbowupon wrist flexion.

In the development of a diagnostic instrument for lat-eral-medial epicondylitis by Sluiter et al (29), the mostweighted symptoms and signs that minimally led to a“probable” diagnosis were intermittent pain in the re-gion of the lateral-medial epicondyle radiating into theforearm plus provocation of symptoms by exerting forcewith the hand plus a minimum of two of the followingsigns: positive resisted wrist extension or flexion, posi-tive resisted wrist pronation or supination, painfulstretching of collective wrist extensors or flexors, orpositive palpation of muscle insertions at the elbow.

Extending the work of Menoni et al (54), which pro-posed a protocol for the anamnestic examination of pa-tients with upper-limb complaints, De Marco et al (31)provided a guide to the clinical examination of patientswho exceed the anamnestic threshold. For epicondyli-tis, this examination would be done when patients havepain on grasping or lifting or upon movement or from atriggering cause (anamnestic threshold: over the past 12months, with a duration of at least 1 week or with a min-imum of a monthly frequency of occurrence plus notcaused by acute trauma). The examination for epi-condylitis must evoke pain on palpation of the epi-condyle plus pain on palpation of the tendons of the ep-icondyloid muscles, about 2 cm downstream from theepicondyle, plus pain upon passive wrist flexion withthe elbow extended.


The case definitions and diagnostic criteria proposed inthis document are drawn from and consistent with mostof those of the studies described in this section. All men-tion epicondylar pain as a common symptom, and mostmention tenderness to palpation and pain upon resisted ex-tension-flexion as commonly accepted signs. Most text-books and clinical and epidemiologic studies includedthese symptoms and signs in their case definitions and di-agnostic criteria. Although a right-left difference in ten-derness with located epicondylar palpation in one patientmight add valuable information for the individual clini-cian, in this document palpation is not included as a signfor this disorder because of the low reliability and com-parability of the site and pressure of palpation betweenexaminers that was found by Viikari-Juntura et al (67).

Some information was available about range of mo-tion and motor performance, but these tests did not ap-pear to be commonly used surveillance or diagnostic cri-teria for epicondylitis. The temporal dimension of thesymptoms included in this document follows the time ruledescribed earlier.



! Note ! : Descriptions and photographs of the tests involved can be found in appendix A Photos 11 and 12

Case definition 1: epicondylitis, based on symptoms only

Symptoms: • At least intermittent, activity-dependent paindirectly located around the lateral or medial epicondyleAND


• Symptoms present on at least 4 days duringat least 1 week in the last 12 months

Case definition 2: epicondylitis, based on symptoms andphysical examination signs


Symptoms: • At least intermittent, activity-dependent paindirectly located around the lateral or medial epicondyleAND

Signs: • Local pain on resisted wrist extension (lateral) oron resisted wrist flexion (medial)


Sluiter et al

SYMPTOM CRITERIA FOR LATERAL AND MEDIAL EPICONDYLITIS

SIGN CRITERIA FOR LATERAL AND MEDIAL EPICONDYLITIS

OR

no

yes

yes yes

no


•At least intermittent, activity-dependent pain directly locatedaround the lateral or medialepicondyle

Symptoms present now oron at least 4 days during thelast 7 days

Symptoms present on atleast 4 days during at least1 week in the last 12 months

= Symptom caselateral and medialepicondylitis

Deviant case: check criteriafor disorders 4, 5, 11, 12

= Symptom caselateral and medialepicondylitis

Symptoms inthe elbow region

Symptom case lateraland medial epicondylitis• no

yes

yes

no

Symptoms present or on at least 4days during the last 7 days

Symptom caselateral and medialepicondylitis

Local pain on resistedwrist extension (lateral) orwrist flexion (medial)

= Case lateral andmedial epicondylitis(ICD codeM 77.0 / M 77.1)



4. Ulnar nerve compression at the elbow: cubital tunnel syndrome


The ulnar nerve is a motor and sensory nerve for the hand(68). At the elbow, the ulnar nerve passes posterior to themedial epicondyle and enters the cubital tunnel. The cu-bital tunnel consists of osseous walls formed by the me-dial epicondyle and olecranon. The floor of the tunnel isthe medial collateral ligament of the elbow; the roof is afibrous band (retinaculum) extending from the medial ep-icondyle to the olecranon (69, 70).

The cubital tunnel is the most common site of ulnarnerve compression, and the cubital tunnel syndrome is the2nd most common peripheral compression neuropathy ofthe upper extremity (71—74). In textbooks and the litera-ture, the clinical features of ulnar neuropathy at the el-bow are described as follows: patient's common complaintof tingling or numbness in the 4th and 5th digits and theulnar border of the palm. Weakness may or may not bepresent and may vary in nature from a very mild clumsi-ness to a pronounced hand weakness. Pain and tendernessmay occur at the elbow and radiate toward the hand (75),but forearm muscles are often spared in lesions at the el-bow (76). Patients may notice a worsening of symptomsat night in relation to sleep position (68, 69).

Differential diagnosis of cubital tunnel syndromeand other upper-extremity musculoskeletaldisorders

It is not uncommon for compressive neuropathy at the el-bow to be associated with additional compression proxi-


lateral epicondyle

m supinator


olecranon

medial epicondyle

ulnar nerve passing cubital tunnel


retinaculum extensorum

mally in the neck or brachial plexus or distally in the Guy-on canal at the wrist. This phenomenon is known as the“double crush phenomenon” or “multiple crush phenom-enon”. Disease processes involving C8-T1 nerve roots orthe brachial plexus can be present in a similar manner andshould be considered in the differential diagnosis (70, 74).Thoracic outlet syndrome may involve compression of themedial cord in the brachial plexus and can produce thesame symptoms.


Provocative tests (elbow flexion test, Tinel’s test,elbow flexion plus pressure test)

Elbow flexion has been shown to increase pressure inthe cubital tunnel (77).

In their study of 204 elbows in 102 normal volun-teer subjects, Rayan et al (78) found that approximate-ly 10% of the elbows examined had a positive responseto the elbow flexion test when performed for 1minutewith the elbow fully flexed passively with both the wristand shoulder in neutral position; 24% of the elbows hada positive response when any 1 of 4 different shoulderand wrist posture positions were used. This same studyexamined volunteers’ response to the Tinel’s sign at theulnar nerve at the cubital tunnel with the elbow in 90 de-grees’ flexion (test defined as gentle percussion with 2fingers over the nerve in the cubital tunnel). Altogether31% of these asymptomatic subjects (24% of the el-bows) had a positive Tinel’s sign.


Sluiter et al

Rosati et al (79) replicated the Rayan et al (78) studyof the elbow flexion test with 216 elbows of 108 healthyvolunteer subjects [excluded were subjects with ulnaror other neuropathies, ulnar nerve dislocation at the cu-bital tunnel, cervicobrachialgias, sequelae of elbow frac-tures, axial deviations of the elbow or diabetes melli-tus]. These authors found a positive test for 66 of 216elbows (30.5%), but only 7 (3.6%) of the tests beingpositive after 1 minute, 24 (11.1%) being positive after2 minutes, and 35 (16.2%) being positive after 3 min-utes. In other words, the number of elbows with posi-tive responses increased as the duration of the test in-creased from 1 to 3 minutes — even when a combina-tion of tests with different positions were used.

Using abnormal nerve conduction studies as the goldstandard, Novak et al (80) compared 32 patients withcubital tunnel syndrome from a single surgical practicewith 33 referents with no history of numbness, pain, orparesthesias in the upper extremity in order to evaluatethe usefulness of the following provocative tests: Tinel’ssign, the pressure provocation test, the flexion test, andthe combined pressure and flexion provocative test.

As shown in table 4, the combined test at 30 sec-onds yielded the highest sensitivity, specificity, and pos-itive predictive value for this study population of pa-tients with cubital tunnel syndrome and controls. No fig-ures are known for the cluster properties of the Tinel’ssign plus flexion test plus pressure test, in comparisonwith the figures of the combined pressure and flexiontest. The authors recommend using the combined pres-sure and flexion test as the only test because of the ex-cellent properties of the test (Novak et al, personal com-munication 1999).

In their prospective study to correlate magnetic res-onance imaging (MRI), electrodiagnostic, clinical, andintraoperative findings in 31 elbows of 27 patients withulnar nerve entrapment at the elbow and 10 referents,Britz et al (74) reported the following physical exami-nation findings for the extremities of the patients: de-creased pin prick response of the 4th and 5th digits in27, positive 2-point discrimination of these digits in 5,mild weakness in 10, moderate weakness and atrophyin 2, moderate weakness with atrophy in 3, and severeweakness and atrophy in 5. Only 1 patient was normalin all these physical examination tests. The authors alsoreported the symptoms of the 31 extremities of the 27patients. They were paresthesias of the 4th and 5th dig-its in 20, numbness of these digits in 17, and complaintsof weakness in 9.

Ulnar electrodiagnostic and imaging studies

In a study of 21 patients with clinical symptoms andsigns of ulnar neuropathy at the elbow and 20 referents(73), the sensitivity of motor ulnar conduction studies

were 81% for the first dorsal interosseous muscle and71% for the abductor digiti quinti muscle. The sensitiv-ity of these ulnar motor studies was higher than that ofthe mixed ulnar nerve sensory study, which showed ab-normality in only 57% of the patients.

In their prospective study to correlate MRI, electro-diagnostic, clinical, and intraoperative findings for 31elbows of 27 patients with ulnar nerve entrapment at theelbow and 10 referents, Britz et al (74) found that thesensory and motor conduction velocities confirmed ul-nar neuropathy in 24 (77%) of the 31 elbows. Localiza-tion at the cubital tunnel was documented by nerve con-duction studies for 21 (68%) of the elbows. MRI showedan increased signal of the ulnar nerve for 30 (97%) el-bows and enlargement of the ulnar nerve for 23 (74%).No MRI abnormalities were found in the reference pop-ulation. Denervation on the basis of electromyographywas seen in 3 (10%) elbows. MRI, using a short tauinversion recovery (STIR) sequence, was more sensi-tive. An increased signal of the ulnar nerve as revealedby MRI was found for 30 (97%) elbows. MRI was alsospecific; 100% of the normal elbows had nonremarka-ble ulnar nerve configurations. The 12 patients who un-derwent surgery were found to have ulnar nerve com-pression.



Although cubital tunnel syndrome and Guyon’s canalsyndrome were not described separately, Palmer et al(81) assessed 153 gas distribution operatives and usedthe following symptoms to define ulnar nerve entrap-ment: a history of paresthesias, numbness, or both in apattern corresponding to ulnar nerve entrapment.

Table 4. Comparison of 32 patients with cubital tunnel syndromewith 33 referents with no history of numbness, pain, orparesthesias in the upper extremity [taken from Novak et al (80)].

Sensitivity Specificity Positive Negativepredictive predictivevalue value

Tinel's sign 0.70 0.98 0.94 0.87Flexion test

30 seconds 0.32 0.99 0.93 0.7460 seconds 0.75 0.99 0.97 0.89

Pressure test30 seconds 0.55 0.98 0.92 0.8160 seconds 0.89 0.98 0.95 0.95

Combined pressure andflexion test

30 seconds 0.91 0.97 0.93 0.9660 seconds 0.98 0.95 0.91 0.99



No occupational epidemiologic studies were foundthat used symptoms only as the basis for identifying cu-bital tunnel syndrome, but there is general agreementon the symptoms used in the studies based on symptomsand signs, as described in this section.


In an early epidemiologic and clinical study of neck andupper-limb disorders in slaughterhouse workers, Vii-kari-Juntura (82) used the following criteria for the clin-ical diagnosis of cubital tunnel syndrome: pain, par-esthesias or numbness in the 4th or 5th fingers, tender-ness to palpation at the cubital tunnel, Tinel’s sign atthe cubital tunnel possibly present, diminished sensationin the 4th and 5th fingers, and weakness of the interos-seii and the 3rd and 4th lumbricales possible (ulnarnerve entrapment at the Guyon’s tunnel, cervical syn-drome, and thoracic outlet syndrome excluded).

In a prospective study of the usefulness of provoca-tion tests in 44 extremities of 32 subjects with cubitaltunnel syndrome, Novak et al (80) based their diagno-sis of cubital tunnel syndrome on complaints of par-esthesia and numbness in the ulnar nerve distribution,confirmed by abnormal nerve conduction studies acrossthe cubital tunnel (a slowing of conduction velocity ofless than 50 m/s across the elbow and a decrease of 15%at the elbow).

In their study of female workers with highly repeti-tive jobs, Ranney et al (45) used the following as “min-imal clinical criteria” for diagnosing cubital tunnel syn-drome: numbness and tingling distal to the elbow in theulnar nerve distribution and tenderness over the ulnarnerve with a positive Tinel’s sign or elbow flexion testor both.

In their prospective study to correlate MRI, electro-diagnostic, clinical, and intraoperative findings for 27patients with ulnar nerve entrapment at the elbow, Britzet al (74) used the following criteria for subject inclu-sion: symptoms: numbness and paresthesias of the 4thand 5th digits and weakness and clumsiness of the hand;signs: sensory dysfunction in the 4th and 5th digits anddorso-ulnar aspect of the wrist and weakness of mus-cles innervated by the ulnar nerve, including the flexorcarpi ulnaris, flexor digitorum profundus of the 5th digit,the dorsal and palmar interossei, and the adductor pol-licus longus muscles.

In their clinical study of Swedish milkers, Stål et al(83) used the following criteria to diagnose cubital tun-nel syndrome: patient information about numbness inthe little finger, a selective weakness of the flexor digi-torum profundus V and the abductor digitii minimi, anda positive Tinel sign over the ulnar nerve at the elbowlevel.

In their published occupational medicine practiceguidelines, Harris et al (42) provide the following diag-nostic criteria for ulnar nerve entrapment at the elbow(ICD–9 354.2): symptoms: pain or paresthesias in me-dial ring and small fingers (palm-up position); signs: thereproduction of symptoms with percussion or compres-sion of the cubital tunnel, pain in the medial ring andsmall fingers on full elbow flexion, and weakness or at-rophy of the ulnar hand intrinsics (unusual or late sign).A nerve conduction velocity of <4.5 milliseconds fromelbow to hand (depending on the laboratory) is suggest-ed as an additional diagnostic criterion.

In developing a diagnostic instrument for cubital tun-nel syndrome, Sluiter et al (29) found the most weight-ed symptoms and signs that led to a “probable” diagno-sis of cubital tunnel syndrome to be intermittent painalong the medial aspect of the forearm or elbow and ra-diation into the ulnar part of the hand, along with twoof the following: a positive Tinel’s sign of the ulnarnerve at the elbow, a positive reversed Phalen’s test, andnotable loss of tonus or atrophy in hypothenar muscles,thenar muscles, or intrinsic hand muscles.


The literature suggests that paresthesias in the 4th and5th digits are a more common initial complaint than painand weakness. As has already been described, the com-bined elbow flexion-pressure provocation test has beenfound to be more sensitive and specific than Tinel’s signat the elbow, the elbow flexion test, and the pressureprovocation test at the cubital tunnel (80). The criteriarelating to time were selected according to the previ-ously discussed time rule for entrapment neuropathies.Paresthesia can include numbness, tingling, burning, andhypo- or hypersensitivity. Patients may also complainof pain or subjective weakness or clumsiness of thehands. Additional signs can include tenderness over thecubital tunnel, sensory disturbance in the dorso-ulnaraspect of the hand and the dorsum of the little finger,and muscle weakness. A positive Tinel’s sign over theulnar nerve in the cubital tunnel is a further diagnosticsign, but only if the response differs from that of theunaffected side (84). This finding helps distinguish ul-nar neuropathy at the elbow from compression at Guy-on’s canal. Further diagnostic testing may be necessarywhen clinical symptoms and findings are equivocal,when the site of nerve compression is uncertain, or whenmultiple sites are suspected. In such cases, motor andsensory nerve conduction studies may be helpful, al-though there is no consensus on the diagnostic value ofthe routine use of electrodiagnostic techniques in thediagnosis of cubital tunnel syndrome. Britz et al (74)found MRI to be both sensitive and specific,


Sluiter et al

correlating well with clinical and intraoperative diag-noses of compressive ulnar neuropathy at the elbow.Their study found MRI to be more sensitive than elec-trodiagnostic studies in the diagnosis of cubital tunnelsyndrome.

! Note ! When paresthesias are only present in the

fingers, the symptom case definition for cubital tunnelsyndrome may not differ from the symptom case defi-nition for Guyon’s canal syndrome (see pages 48—51)if pain is not present as a symptom in the latter. Then,however, the symptom case definitions can be used toregister this symptom case as ulnar nerve compression.

Case definition 1: cubital tunnel syndrome, based on symptoms only

Symptoms: • At least intermittent paresthesias in the 4th or5th digit or both or on the ulnar border of the forearm,wrist, or handAND



Case definition 2: cubital tunnel syndrome, based on symptoms and physical examination signs

Time rule: • Symptoms present now or on at least 4 days during thelast 7 days

AND Symptoms: • At least intermittent paresthesias in the 4th or 5th digit

or both or on the ulnar border of the forearm, wrist, orhandAND

Signs: • A positive combined pressure and flexion test

! Note ! : Descriptions and photographs of the tests involved, can be found in appendix A Photo 14



SYMPTOM CRITERIA FOR ULNAR NEUROPATHY AT THE ELBOW: CUBITAL TUNNELSYNDROME

SIGN CRITERIA FOR ULNAR NEUROPATHY AT THE ELBOW: CUBITAL TUNNEL SYNDROME

OR

no

yes

yes yes

no

• Symptoms in the elbow,forearm or wrist region

At least intermittent paraesthesiasin the 4th or 5th digit or both or onthe ulnar border of forearm, wrist,or hand

Deviant case: check criteriafor disorders 3, 5-12



= Latentsymptom caseor deviant casecheck criteria fordisorder 9

= Symptom case cubitaltunnel syndrome

= Symptom case cubitaltunnel syndrome

no

yes

yes

no

• Symptom case cubitaltunnel syndrome

Symptoms present now or presenton at least 4 days during the last 7days

Symptom case cubitaltunnel syndrome

Positive combined pressureand flexion test within 1minute

= Casecubital tunnel syndrome(ICD code G56.2[2])


Sluiter et al

5. Radial nerve compression: radial tunnel syndrome


The radial nerve arises from the posterior cord of thebrachial plexus; it contains motor, cutaneous sensory,proprioceptive, and autonomic fibers (84—86). Nearthe elbow (at some point between 3 cm above and be-low the elbow joint), the nerve divides into the deepmotor posterior interosseous nerve and the superficialsensory radial nerve (84, 85). The radial nerve is closeto the following structures that can compress it: the fi-brous arch at the origin of the supinator muscle (the ar-cade of Frohse), the origin of the extensor carpi radia-lis brevis muscle, and the vascular leash of Henry (thevessels arising from the radial artery to supply the mo-bile wad). The distal edge of the supinator muscle andan intramuscular fibrous band can also cause compres-sion (87). The nerve can be compressed in the radialtunnel, which extends from the radial head to the infe-rior border of the supinator muscle (88).

Entrapment of the radial nerve in the forearm canproduce a variety of symptoms and signs, depending onthe locus of the compression. One constellation ofsymptoms and signs is called radial tunnel syndrome(RTS), which is generally characterized by forearm painwithout motor weakness. Another constellation, poste-rior interosseous nerve syndrome (PINS), involves mus-cular paresis, with or without pain (84, 89, 90).


lateral epicondyle

m supinator(underneath extensors)


olecranon

medial epicondyle

ulnar nerve



radial nerve passingthrough m supinator

Differential diagnosis of radial nerve compressionand other upper-extremity musculoskeletaldisorders

The symptoms of radial nerve compression can be sim-ilar to those of lateral epicondylitis, chronic wrist pain,or tenosynovitis (86). In addition, extensor tendinitis,thoracic outlet syndrome, and cervical radiculopathyhave overlapping symptoms and signs, and therefore aclear diagnosis is difficult (91).


In a long-term follow-up study of 23 patients (24 ex-tremities) who had radial tunnel surgery, Jebson & Eng-ber (89) reported that all 23 of the patients had persist-ent pain in the proximal radial forearm and 6 had sub-jective sensory complaints in the distribution of the su-perficial branch of the radial nerve. Tenderness uponpalpation over the radial tunnel was found in all 24 ofthe extremities studied, pain with resisted forearm supi-nation in all 24, and pain with resisted middle-fingerextension in 19 of the 24. Nerve conduction velocitieswere normal in the 21 patients who underwent neuro-physiological testing. The surgical results suggested the



arcade of Frohse as the source of impingement for 20of the extremities, the extensor carpi radialis brevis(ECRB) for 6, and the radial recurrent vessels for 4. Sixpatients with ECRB impingement had positive resultson the resisted middle-finger extension test, but 11 ofthe patients with positive test results lacked evidence ofcompression by the ECRB. Thus this test was not a re-liable indicator of ECRB impingement specifically.

In their study to evaluate a potentially more sensi-tive nerve conduction study for confirming the presenceof clinically suspected radial tunnel syndrome, Kupferet al (92) examined 25 consecutive patients requiringradial tunnel decompression and 25 asymptomatic ref-erents. The diagnosis of radial tunnel syndrome wasbased on the criteria of Lister (84). Nerve conductionstudies were done with subjects’ arms in 3 positions, andthe provoked difference in the motor latencies betweenthe 3 positions was calculated as the differential laten-cy. All 25 of the cases had differential motor latenciesof ≥0.3 ms, while 24 had differential motor latencies of≤0.2 ms. Only 1 of the 25 referents had a differentiallatency of 0.3 ms. The difference between the 2 groupswas significant at P<0.001; the test subjects had a sig-nificantly greater differential latency than the referentsdid. In addition, the authors found close agreement be-tween the preoperative and postoperative changes in dif-ferential latency and the clinical response to surgery.The patient judged to be a clinical failure (in that thispatient did not return to the preoperative occupation) hada normal differential latency 30 days postsurgery, butan abnormal differential latency at 90 days postsurgery.The postoperative differential latencies were normal inthe 24 patients with successful outcomes.

Lawrence et al (86) and Kupfer et al (92) discussedfindings from previous studies on the role of conven-tional nerve conduction studies in the diagnosis of radi-al tunnel syndrome and concluded that these tests stillhave not been proved efficacious in the diagnosis ofradial tunnel syndrome.


Studies based on symptomsNo studies were found that were based solely on symp-toms, but there is general agreement on the symptomsused in the studies based on symptoms and signs.

Studies based on symptoms and signsIn her epidemiologic and clinical study of neck and up-per-limb disorders among 117 slaughterhouse workers,Viikari-Juntura (82) used the following criteria for theclinical diagnosis of posterior interosseous nerve entrap-

ment (Frohse’s syndrome): pain in the elbow during rest,radiating pain downward or upward and tenderness atthe edge of the superficial portion of the supinator mus-cle (the arcade of Frohse), and the extension force ofthe middle finger possibly diminished. The criteria not-ed specific exclusions for “epicondylitis syndrome, ten-osynovitis and peritendinitis of the wrist and forearm”and noted that “the rest of the neurological examination”must be normal.

In his classic textbook on hand disorders, Lister (84)describes radial tunnel syndrome as one of aching pain,possible weakness in extending the wrist and fingers,tenderness along the radial nerve over the radial head,middle finger test, full passive wrist and finger flexionwith elbow extension, and resisted supination of the ex-tended arm.

Toomingas (53) used the following as minimum cri-teria for supinator syndrome in his methodological studyto develop and evaluate different methods for measur-ing exposures and effects in epidemiologic studies ofwork-related musculoskeletal disorders: symptoms inthe elbow-forearm, and deep forearm pain on palpationof Frohse’s arc.

In a long-term follow-up study of 23 patients (24extremities) who had radial tunnel surgery, Jebson &Engber (89) used the following criteria to make the clin-ical diagnosis: symptoms: pain in the proximal radialforearm or elbow; signs: tenderness over the radial tun-nel, pain during resisted forearm supination, or pain dur-ing resisted middle-finger extension.

Kupfer et al (92) used the criteria of Lister to diag-nose radial tunnel syndrome in their study to evaluate anerve conduction study for confirming the presence ofclinically suspected radial tunnel syndrome. Lister (84)described the syndrome as one of aching pain, possibleweakness in extending the wrist and fingers, tendernessalong the radial nerve over the radial head, middle fin-ger test, full passive wrist and finger flexion with el-bow extension, and resisted supination of the extendedarm.

In their review of 26 cases of radial tunnel syndromein 25 patients in a hand surgeon’s practice, Sarhadi etal (88) used the following criteria for diagnosing radialtunnel syndrome: reproduction of the patient’s painsymptoms upon the application of pressure over tenderspots along the course of the radial nerve (just proximalto the lateral epicondyle to the dorsum of the forearm)identified by the patient upon stepwise palpation of thenerve by the examiner, pain on resisted supination ofthe forearm or resisted middle-finger extension; and sub-sidence of symptoms after infiltration of the area ofmaximal local tenderness with a local anesthetic.

In their study of treatment outcomes for 24 consec-utive patients with forearm pain exacerbated by repeti-tive tasks to the point that they were unable to continue


Sluiter et al

a prior level of activity, Barthel et al (26) used the fol-lowing clinical findings to categorize patients as hav-ing radial tunnel syndrome: pain on palpation of the ra-dial tunnel area identified over the proximal extensorsurface of the forearm and at the volar surface in thesupinator area over the arcade of Frohse and weaknessresisted middle-finger extension and resisted active wristsupination with the elbow fully extended and then at 90degrees. (Weakness with full extension but no weaknessat 90 degrees helped confirm the diagnosis of radial tun-nel syndrome.)

In their practice guidelines for occupational medi-cine, Harris et al (42) provided the following diagnos-tic criteria for radial tunnel syndrome (ICD-9 354.3):symptoms: aching pain in the extensor-supinator areaof the forearm; signs: reproduction of symptoms by per-cussion or compression of the radial tunnel, pain onstressing the extended middle finger (resisted extension),and maximum tenderness 4 fingerbreadths below thelateral epicondyle.


The case definitions and diagnostic criteria proposed inthis document have been drawn from and are consistentwith those of most of the described studies. All men-tion pain as a common symptom, and some mention sub-jective complaints of weakness (primarily associatedwith the posterior interosseous nerve syndrome associ-ated with the disorder). Tenderness to palpation over theradial nerve, distinct from the lateral epicondyle, is awidely used diagnostic test, as are both resisted fore-arm supination and resisted middle-finger extension.Similar to Sarhadi et al (88) and Jebson & Engber (89),our criteria require only 1 of the latter 2 tests to be pos-itive with the palpation test as described by Barnum etal (85). (See appendix A.) This practice seems appro-priate given Jebson & Engber’s findings (89) that theresisted middle-finger test was not a reliable indicator

of ECRB impingement in radial tunnel patients. Becauseresisted middle-finger extension may be positive withlateral epicondylitis as well, the site of complaints dur-ing testing determines whether the test is consideredpositive. The criteria relating to time were selected ac-cording to the previously described time rule.

Conventional diagnostic tools like nerve conductiontests are often normal with radial tunnel syndrome, al-though they may be helpful in confirming the diagnosisof PINS paresis.

! Note !: Descriptions and photographs of the tests involved can be found in appendix A Photos 13, 15, and 18

Case definition 2: radial nerve compression, based on symptoms and physical examination signs

Time rule: • Symptoms present now or on at least 4 days duringthe last 7 daysAND

Symptoms: • Pain in the lateral elbow region or forearm muscle massof the wrist extensors-supinatoror

• Weakness on extending the wrist and fingersAND

Signs: • Tenderness in the supinator area on palpation over theradial nerve 4-7 cm distal to the lateral epicondyleand

• At least one of the following tests positive:� resisted forearm supination� resisted middle finger extension

Case definition 1: radial nerve compression, based on symptoms only

Symptoms: • Pain in the lateral elbow region or forearm muscle massof the wrist extensors-supinator or

• Weakness on extending the wrist and fingersAND

Time rule: • Symptoms present now or on at least 4 days duringthe last 7 daysor

• Symptoms have been present on at least 4 days duringat least 1 week in the last 12 months



SYMPTOM CRITERIA FOR RADIAL NERVE COMPRESSION

SIGN CRITERIA FOR RADIAL NERVE COMPRESSION

OR

yesyes

yes no

Symptoms in theelbow-forearm region

Weakness on extendingthe wrist and fingers

Pain in the lateral elbow regionor forearm muscle mass ofwrist extensors-supinator

= Latentsymptom case

Deviant case: checkcriteria for disorders3, 4, 6, 11, 12

Symptoms are present nowor on at least 4 days duringthe last 7 days

Symptoms present on atleast 4 days during at least1 week in the last 12 months

= Symptom caseradial nervecompression

yes

no

OR

= Symptom caseradial nervecompression

•

OR

yes

yes yesno

no

yes


Symptom case radialnerve compression

Tenderness in supinator areaon palpation over the radialnerve, 4-7 cm distalto the lateral epicondyle

Positive resistedforearm supination

Positive resistedmiddle-finger extension

= Latent case ordeviant case:check criteriafor disorders6 & 12

= Caseradial nervecompression(ICD codeG 56.3[2])

no

= Caseradial nervecompression(ICD codeG 56.3[2])

• Symptom case radialnerve compression


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6. Flexor-extensor peritendinitis or tenosynovitis of the forearm-wrist region


Tendinitis, tenosynovitis, peritendinitis, paratenonitis,tendinosis, and tendinopathy are pathoanatomic termsthat are used and point to a pathological process in oraround the tendon (93). In medical dictionaries, tendin-itis is defined as inflammation of tendons and of ten-don-muscle attachments. In sports literature, this inflam-mation was earlier said to be caused by microinjuriesof tendon tissue as a result of repetitive mechanical load.Currently, the degenerative rather than inflammatoryfeatures of chronic tendon injuries are more clearly rec-ognized (93). Tenosynovitis is an inflammation-like re-action around the vagina synovialis of the tendonsheaths producing crepitus as a sign, whereas tendinitisoccurs in the part higher up on the tendon, where noextra surrounding tendon sheath is present.

Textbooks describe tendinitis of the flexor tendonsin the forearm or wrist region as characterized by inter-mittent pain on movement of the hand or wrist. In addi-tion, crepitus and local swelling of the tendon surround-ings are present. Most commonly, the tendons of thedeep flexors of digits II to IV are involved. In contrastto flexor tendinitis, the tendons of the wrist extensorscan be involved separately (94). The tendons of thewrist extensors are easy to observe because of their su-perficiality and because these tendons have relativelymore direct friction from the retinaculum extensorum.In addition, because the wrist extensors have beenshown to be more active than the flexors in wrist stabi-lization and because they adopt a different means of ac-

tion and biomechanics of the muscles, more tenosyno-vitis occurs at the dorsal aspect of the wrist.

Patients have pain when grasping or picking up ob-jects and when moving the wrist and hand (31).

Differential diagnosis of flexor-extensorperitendinitis or tenosynovitis in the forearm-wristregion and other upper-extremity musculoskeletaldisorders

Flexor-extensor peritendinitis or tenosynovitis in theforearm or wrist has to be differentiated from other up-per-extremity musculoskeletal disorders (UEMSD) thatmay give rise to the same kind of symptoms in the fore-arm or wrist area. Flexor tendinitis of the forearm mustbe distinguished from medial epicondylitis, carpal tun-nel syndrome, and ulnar nerve compression syndromes.Extensor tendinitis of the forearm must be distinguishedfrom De Quervain’s syndrome, lateral epicondylitis, andthe radial tunnel syndrome.


Baron et al (95) studied the reliability and validity ofthe Nordic musculoskeletal questionnaire and the sur-vey of the National Institute for Occupational Safety andHealth (NIOSH) in the United States using data of 852supermarket and telephone workers. During the physi-cal examination, the criterion of a tendon disorder,


medial epicondyle

median nerve

carpal tunnel

Guyons� canal

wrist-finger flexors

median nerve

ulnar nerve

m pronator teres

mm abductor pollicis longus

lateral epicondyle

m supinator


olecranon

medial epicondyle

ulnar nerve

wrist-finger extensors




defined as pain on resisted flexion or extension of thewrist and fingers, was positive for 25% of the subjects(N=287) who reported current hand pain.

Although not in an original study on test properties,but informative in this context, Toomingas (96) found asensitivity and specificity of 0.30 and 0.96, respective-ly, for self-reported pain in the resisted wrist-extensiontest (N=523) with a medical examination as the criteri-on. The subjects were a part of the Stockholm MUSIC Istudy for the different tests.

Franzblau et al (97) studied the test-retest reliabilityof self-reported symptoms in the forearm, wrist, orhands of 148 workers at a plant manufacturing sparkplugs and engine components. The questionnaire wasfilled out twice and the 2nd questionnaire was filled out3 weeks after the first. The subjects were instructed toreport a symptom if it had been present in at least 3 ep-isodes or if 1 episode had lasted >1 week in the 12months preceding the survey. Kappas of >0.75 werefound for any elbow or forearm symptoms, right or leftforearm symptoms or both, and wrist, hand or fingersymptoms. For reported pain or aching symptoms, thekappa was 0.63 and 0.68, respectively.



No studies were found which described flexor-extensorperitendinitis or tenosynovitis of the forearm-wrist re-gion on the basis of symptoms only without adding ac-tivity-dependent symptoms that are considered signs.However, the studies that based their diagnoses onsymptoms and signs highly agreed upon the symptomsinvolved.


Kuorinka & Koskinen (98) examined 93 scissor makersand compared them with 143 shop assistants. In diag-nosing tenosynovitis and peritendinitis, they used thefollowing criteria: localized tenderness and pain duringmovement, swelling of wrist tendons, and low gripforce.

Viikari-Juntura (82) studied upper-limb disordersamong slaughterhouse workers and used the followingcriteria for the clinical diagnoses of tenosynovitis andperitendinitis of the wrist and forearm under the assump-tion of the exclusion of other diagnoses: local ache orpain during movement and tenderness along the courseof the tendon or muscle-tendon junction.

Armstrong et al (99) assessed 652 workers from eachof 4 combinations of force and repetitiveness to which

they had been exposed to in their workplace. The diag-nostic criteria for tendinitis and tenosynovitis of thewrist-hand were as follows: symptoms: localized painor swelling or both over the muscle-tendon structure, thepain lasting at least 1 week; signs: increased pain by re-sisted motion, possibly fine crepitus in the passive rangeof motion, no pain in the passive range of motion, andpronounced asymmetric grip strength, more than 4 kg.

Byström et al (65) assessed 199 automobile assem-bly-line workers and 186 subjects of the general popu-lation and used the following symptoms and signs indiagnosing hand-wrist tenosynovitis or peritendinitis:pain at the tendon, peritendinous area or muscle-tendonjunction and swelling at the tendon sheath (peritendi-nous area), and pain during active movement at the mus-cle-tendon junction.

On the basis of what was found in the literature,Downs (100) described the signs and symptoms of flex-or or extensor tendinitis as pain, swelling, crepitus, min-imal paresthesias, and localized reproducible tendernessalong tendons.

In a practitioner’s guide of occupational overuse syn-drome (101), subacute tendinitis of the wrist is describedas dull ache over the dorsum of the wrists and forearm,exacerbated by certain repetitive activities, and sometenderness to touch. Diagnostic tests that should be in-cluded are passive and resisted wrist flexion and exten-sion and passive and resisted wrist ulnar and radial de-viation.

In their diagnostic classification system of work-re-lated upper-extremity musculoskeletal disorders(WRUEMSD), De Marco et al (31) used the followingrequirements for the clinical examination of tendinitisand degenerative disorders of the wrist and hand: con-tinuous pain continuous or occasional pain with pain-free intervals shorter than 30 days or pain occurring asa reaction to a specific triggering cause. [Physical ex-aminations require inspection of the wrist-hand and pos-itive tests (pain) of resisted wrist flexion and extension.]

Harrington et al (55) reached a multidisciplinaryconsensus over the following minimum diagnostic sur-veillance criteria for the diagnosis of tenosynovitis ofthe wrist: pain on movement localized to the affectedtendon sheaths in the wrist and reproduction of pain byresisted active movement of the affected tendons withthe forearm stabilized.

In practice guidelines for occupational medicine,Harris (42) provides the following diagnostic criteria forwrist or hand tendinitis or tenosynovitis (ICD-9 727.05):symptoms: pain localized to the muscle-tendon unit andtriggering; signs: tenderness over tendon unit and syno-vial thickening and triggering or locking and crepitus.

In the protocol used for the Southampton examina-tion schedule (48) in diagnosing tenosynovitis of thewrist, the following criteria were reported: symptoms:


Sluiter et al

pain on movement localized to the tendon sheathsin the wrist; signs: reproduction of pain by resisted ac-tive movement.


When the the case definitions from the aforementionedstudies are compared, most agree on the symptoms andsigns involved in flexor-extensor tendinitis of the fore-arm or wrist. In addition to the provocation of symp-

toms during testing by palpation, other tests are war-ranted for disorders of tendon-muscle junctions, andpain on active movement is a requirement that most ofthe studies included. Because of the difference in su-perficiality between the tendons of the wrist flexors andextensors, the reproduction of pain during palpation ofthe affected tendons or palpable crepitus or the obser-vation of local swelling should be added as a useful signwhen the symptoms are located at the dorsum of thewrist. The criteria related to time were selected accord-ing to the previously discussed time rule.

! Note ! : Descriptions and photographs of the tests involved can be found in appendix A Photo 16 and 17

Case definition 1: flexor-extensor peritendinitis or tenosynovitis in the forearm-wrist, based on symptoms only

Symptoms: • Intermittent pain-ache in the ventral or dorsal forearmor wrist regionAND

Time rule: • Symptoms now or on at least 4 days during the last7 daysor

• Symptoms present on at least 4 days during at least1 week in the last 12 months

Case definition 2: flexor-extensor peritendinitis or tenosynovitis in the forearm-wrist, based on symptoms and physical examination signs

Time rule: • Symptoms now or on at least 4 days during the last7 daysAND

Symptoms: • Intermittent pain-ache in the ventral or dorsal forearmor wrist regionAND

Signs: • Provocation of symptoms during resisted movement(s)of the muscles under the symptom areaand

• Reproduction of pain during palpation of the affectedtendons or palpable crepitus under the symptom area orvisible swelling of the dorsum wrist-forearm



SYMPTOM CRITERIA FOR FLEXOR-EXTENSOR PERITENDINITIS OR TENOSYNOVITIS OFTHE FOREARM-WRIST REGION

SIGN CRITERIA FOR FLEXOR-EXTENSOR PERITENDINITIS OR TENOSYNOVITIS OF THEFOREARM-WRIST REGION

no

yes

yes

yes

= Caseflexor-extensor peritendinitis ortenosynovitis in the forearm-wrist(ICD code M 70.0 / M 70.8)

Provocation of symptoms duringresisted movement(s) of themuscles under the symptom area

= Symptom case flexor-extensorperitendinitis or tenosynovitis inthe forearm-wrist

Reproduction of pain duringpalpation of the affected tendonsor palpable crepitus under thesymptom area or visible swellingof the dorsum wrist-forearm

Symptoms present now orpresent on at least 4 daysduring the last 7 days

Symptom case flexor-extensor peritendinitis ortenosynovitis in theforearm-wrist

no

no

•

OR

no

yes

yes yesno

Symptoms in theforearm or wristregion or both

Intermittent pain-ache in theventral or dorsal forearm orwrist region

Deviant case: check criteriafor disorders 4, 5, 8, 9, 12


Symptoms present on atleast 4 days during at least 1week in the last 12 months

= Latent symptomcase= Symptom case

flexor-extensorperitendinitis ortenosynovitis inthe forearm-wrist

= Symptom caseflexor-extensorperitendinitis ortenosynovitis inthe forearm-wrist

•


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7. De Quervain’s disease

Description of the disorder and clinical features

Textbooks and the literature describe De Quervain’s dis-ease as a relatively common upper-extremity muscu-loskeletal disorder (UEMSD), involving a stenosing ten-osynovitis or tendovaginitis of the 1st dorsal compart-ment of the wrist. This compartment contains the ten-dons and synovial sheaths of the abductor pollicis lon-gus (APL) muscle and the extensor pollicis brevis (EPB)muscle (102). Some people have, however, separate(sub)compartments for the abductor pollicis longus andthe extensor pollicis brevis. This anatomic anomaly mayplay a role in causation or help explain nonoperativetreatment failures (103). The disorder is characterizedby pain on the radial (thumb) side of the wrist and im-pairment in thumb function.

Differential diagnosis of De Quervain’s diseaseand other upper-extremity musculoskeletaldisorders

De Quervain’s disease must be distinguished from os-teoarthritis of the wrist or 1st carpometaphalangeal joint,

wrist ligament strains, and scaphoid nonunion (55).Compression of the superficial radial nerve or distalposterior interosseous nerve may also produce wristpain (104, 105).


In a test of the validity and repeatability of the South-ampton examination schedule for diagnosing muscu-loskeletal complaints of the upper limb in the UnitedKingdom, 43 patients (86 limbs) from rheumatology,orthopedic, and physiotherapy outpatient clinics weretested (48). The criteria for De Quervain’s disease ofthe wrist were pain over the radial styloid and tenderswelling of the 1st extensor compartment and eitherpain on resisted thumb extension or a positive Finkel-stein’s test. Using the opinion of a rheumatologist asthe standard, the authors found the sensitivity and spe-cificity of diagnosing De Quervain’s disease to be 71%and 100%, respectively. The interobserver reliability ofFinkelstein’s test was excellent (kappa = 0.79), and theinterobserver reliability of resisted thumb extension(kappa = 0.55) and radial wrist tenderness (kappa= 0.66)was good.


lateral epicondyle

m supinator


olecranon

medial epicondyle

ulnar nerve

wrist-finger extensorsl


first dorsal compartment



Although the sensitivity, specificity, and predictivevalue of Finkelstein’s test have not been studied veryoften, the test is widely accepted and used by clinicians.


Studies based on symptoms

No studies were found based solely on symptoms, butthere is general agreement on the symptoms used in thestudies based on symptoms and signs.

Studies based on symptoms and signs

In a general study of upper-limb disorders amongslaughterhouse workers, Viikari-Juntura (82) used thefollowing criteria for the clinical diagnosis of tenosyn-ovitis and peritendinitis of the wrist and forearm: localache or pain during movement, tenderness along thecourse of the tendon or muscle-tendon junction, and allother diagnoses excluded.

In their cross-sectional study to evaluate the relation-ship between repetitiveness, forcefulness, and selecteddisorders of the hand and wrist in 652 workers at 7worksites, Armstrong et al (99) used the following di-agnostic criteria for De Quervain’s disease: pain in theanatomic snuffbox that may radiate up the forearm, nohistory of fracture or radial wrist fracture, symptomsthat lasted for at least 1 week or occurred more than 20times in the last year, a physical examination that ruledout radial nerve entrapment, and a positive Finkelstein’stest with a pain score of ≥4 (range 1—8).

In their prospective study of nonoperative treatmentof De Quervain’s disease in 99 wrists of 95 patients seenconsecutively in an orthopedic surgery department, Wittet al (103) used the following as study inclusion crite-ria: pain radiating from the radial styloid process to thethumb and proximally into the forearm, increased painon passive movement of the thumb and wrist, swellingand tenderness over the 1st dorsal compartment, and apositive Finkelstein’s test.

In their retrospective cohort morbidity study ofUEMSD in association with 37 job categories in a porkprocessing plant, Moore & Garg (106) used the follow-ing case definition for De Quervain’s tenosynovitis:pain and tenderness localized to the radial aspect of thewrist and a positive Finkelstein’s test. (Of the 104 ob-served conditions, there were 3 cases of De Quervain’stenosynovitis).

Weiss et al (107) compared 3 treatment methods for93 wrists of 87 consecutive patients with De Quervain’s

disease and used the following criteria: pain in the radi-al wrist region, tenderness over the first dorsal compart-ment, and a positive Finkelstein’s test.

In their cross-sectional study of forearm and handdisorders among 199 automobile assembly-line work-ers and 186 referents, Byström et al (65) used the fol-lowing criteria for tenosynovitis or peritendinitis in thehand-forearm region: swelling with or without crepita-tion and tenderness to palpation along the tendon andpain at the tendon sheath, the peritendinous area of mus-cle-tendon junction during active movement of the ten-don. A diagnosis of De Quervain’s tendinitis also re-quired a positive Finkelstein’s test.

Ranney et al (45) used the following case definitionin their study of 146 female workers in 5 industries: painon the radial side of the wrist, tenderness over the 1stdorsal compartment, and a positive Finkelstein’s test.Twelve persons (8%) had 14 diagnoses of De Quer-vain’s tenosynovitis.

In their histopathological study of 23 consecutivecases of De Quervain’s disease treated surgically and24 control specimens, Clark et al (108) used the follow-ing clinical diagnostic criteria: a history of swelling lo-calized to the radial border of the wrist, pain over the1st extensor compartment on active extension of thethumb, and point tenderness and palpable thickeningover the 1st extensor compartment.

Working with a group of health care professionalsand a core group of experts from 9 different disciplines,Harrington et al (55) developed consensus surveillancecase definitions and criteria for De Quervain’s diseaseof the wrist. The criteria are pain centered over the ra-dial styloid and tender swelling of 1st extensor compart-ment and either pain reproduced by resisted thumb ex-tension or a positive Finkelstein’s test.

In developing a diagnostic instrument for De Quer-vain’s tenosynovitis, the most weighted symptoms andsigns of Sluiter et al (29) that minimally led to a “prob-able” diagnosis were intermittent pain in the wrist re-gion radiating into the thumb or radial part of the fore-arm and at least one of the following signs: positive re-sisted thumb extension or thumb abduction, a positiveFinkelstein’s test, palpable swelling in the 1st extensorcompartment of the wrist, or positive palpation of theprocessus styloideus radii.

In their practice guidelines for occupational medi-cine, Harris et al (42 pp 1-1—8-25) provided the fol-lowing diagnostic criteria for De Quervain’s tenosyno-vitis (ICD-9 727,04): symptoms: pain over radial sty-loid or first dorsal compartment; pain worse with ulnardeviation, thumb flexion, adduction or abduction, andtriggering; signs: tenderness over the radial styloid, massover the radial styloid, crepitus, a thick tendon sheath,and pain upon passive stretching of the 1st dorsal com-partment (Finkelstein’s test).


Sluiter et al


The case definitions and diagnostic criteria proposed inthis document have been drawn from and are consistentwith those of most of the described studies. All mentionpain or tenderness localized over the radial styloid, the ra-dial side of the wrist, or the 1st dorsal compartment. Somesuggest that the pain may radiate distally to the thumb orproximally to the forearm. Fewer include swelling or pal-

pable thickening of the first extensor compartment. Mostinclude a positive Finkelstein’s test, although an obviousleft-right difference should be stressed. The criteria ofPalmer et al (48) included resisted thumb extension, andthe criteria were demonstrated to have perfect specifici-ty. Sluiter et al (29) also included this test in their diag-nostic criteria. The temporal dimension of the symptomsincluded in this section follows the time rule describedearlier in this document.

! Note ! Descriptions and photographs of the tests involved can be found in appendix A Photos 19-21

Case definition 1: De Quervain’s disease, based on symptoms only

Symptoms: • Intermittent pain or tenderness localized over the radialside of the wrist; either may radiate proximally to theforearm or distally to the thumbAND

Time-rule: • Symptoms present now or on at least 4 days during thelast 7 daysor


Case definition 2: De Quervain’s disease, based on symptoms and physical examiation signs

Time rule: • Symptoms now or on at least 4 days during the last 7daysAND

Symptoms: • Intermittent pain or tenderness localized over the radialside of the wrist; either may radiate proximally to theforearm or distally to the thumbAND

Signs: • At least 1 of the following tests positive:� Finkelstein’s test� Resisted thumb extension� Resisted thumb abduction



SIGN CRITERIA FOR DE QUERVAIN’S DISEASE

OR

yes

yes yes

no

yes

•

no

Symptom caseDe Quervain’s disease

Symptoms present now or onat least 4 days during the last7 days

Symptom caseDe Quervain’s disease


Finkelstein’s test with distinctright-left difference

Resistedthumb extension orthumb abduction

= Case De Quervain’sdisease(ICD code M 65.4)

= Case De Quervain’s disease(ICD code M 65.4)

SYMPTOM CRITERIA FOR DE QUERVAIN’S DISEASE

OR

no

yes

yes yesno

• Symptoms in thewrist or hand region

Intermittent pain or tendernesslocalized over the radial side of thewrist; either may radiate to theforearm or distally to the thumb

Deviant case: checkcriteria for disorders6, 8-12

Symptoms now or on at least4 days during the last 7 days


= Latentsymptom case= Symptom case

De Quervain’s disease= Symptom caseDe Quervain’s disease


Sluiter et al

8. Carpal tunnel syndrome


Carpal tunnel syndrome (CTS) is a clinical disorder re-sulting from intermittent or continuous compression ofthe median nerve at the wrist. The carpal tunnel has itsboundaries by the carpal bones posteriorly, medially,and laterally, and the transverse carpal ligament (reti-naculum flexorum) anteriorly (109).

In textbooks and the literature, the clinical featuresof patients are described as a complex of symptoms suchas tingling, numbness, pain, or a burning feeling in themedian nerve distribution at the palmar side of the handand the 1st 3 fingers. Night complaints are common, anda subjective feeling of weakness and radiation of com-plaints can occur.

Differential diagnosis of carpal tunnel syndromeand other upper-extremity musculoskeletaldisorders

The characteristics of the main symptom (paresthesias)of carpal tunnel syndrome require differential diagno-sis from ulnar nerve compression syndromes, the tho-racic outlet syndrome, hand-arm vibration syndrome,and cervical nerve root compression.


Atterbury et al (110) clinically examined 25 symptoma-tic and 35 nonsymptomatic carpenters. Hand-wrist cas-es were selected on the basis of the case definition ofhand-wrist symptoms given by the National Institute forOccupational Health and Safety (NIOSH) in the UnitedStates. In addition to the symptoms, a positive Tinel’ssign or Phalen’s test was required for the clinical diag-nosis of carpal tunnel syndrome. Nerve conductionmeasures were used as the “golden test” and were per-formed for the median and ulnar nerve. A false-posi-tive rate of 21% was found for the reference group fortheir “golden” electrodiagnostic test for median neuro-pathy.

Schierhout & Meyers (111) presented an overviewon what is known about the test properties for carpaltunnel syndrome. Sensitivity in the Phalen’s test andTinel’s sign range from 25% to 75%, and estimates ofspecificity fall between 70% and 90%. Katz et al (112)reported low predictive values for both Phalen’s test andTinel’s sign [(the highest positive predictive value forTinel’s sign being 0.55 (95% CI 0.45—0.65 and thehighest negative predictive value for Phalen’s test be-ing 0.74 (95% CI 0.62—0.84)] in a study on 110 pa-tients referred to their laboratory.


medial epicondyle

median nerve

carpal tunnel

Guyons� canal


median nerve

ulnar nerve

m pronator teres

transverse carpalligament



Franzblau et al (97) evaluated the test-retest relia-bility of symptom reporting for 148 workers from a plantmanufacturing spark plugs and engine components andinvolved in low, medium, or high frequency repetitivemovements. A kappa value of 0.81 was found for symp-tom reporting of the following constellation of symp-toms: numbness, tingling, burning or pain in the wrists,hands, or fingers. For hand diagrams, the test-retest re-liability was 0.52, but the interobserver reliability forrating the hand diagrams was almost perfect (0.93).

del Pino et al (113) evaluated the test properties ofDurkan’s carpal compression test (CCT), which is per-formed by applying pressure with 2 thumbs over the ret-inaculum flexorum. The test is considered positive ifcomplaints occurred within 30 seconds. The CCT wascompared with Phalen’s test and Tinel’s sign for 200hands of 180 patients and 200 hands of 100 volunteers.The patients had had symptoms for at least 6 months. Asensitivity of 87% and a specificity of 95% were foundfor the CCT. For Phalen’s test, a sensitivity of 87% anda specificity of 90% were found, and for Tinel’s sign(only assessed for 129 wrists) a sensitivity of 33% anda specificity of 97% were found.

Inter- and intraobserver reliability was studied fortests of carpal tunnel syndrome by hand therapists, sur-geons, and occupational health workers of 12 patients,6 of whom actually had carpal tunnel syndrome (whenelectrophysiological tests were used as the gold stand-ard) in a study of Marx et al (114). There was substan-tial (0.61 < kappa < 0.81) interobserver reliability forPhalen’s test and Tinel’s sign. The intraobserver relia-bility of the 2 tests was found be moderate (kappa =0.53) for Phalen’s test and substantial (kappa = 0.80)for Tinel’s sign. However, occupational health workersperformed worse than hand therapists and surgeons.

Tetro et al (115) evaluated the test properties (sen-sitivity, specificity, positive predictive value (PPV), andnegative predictive value (NPV)) of Phalen’s test, Ti-nel’s sign, CCT, and a new test they called the “flexionand compression test” (table 5). This new test is per-formed by flexing the wrist and compressing the carpal

tunnel with 1 thumb for 20 seconds. Ninety-five wristsof patients with carpal tunnel syndrome (electrodiagnos-tic testing used as the “gold standard”) and 96 wrists ofreferents were tested. The figures for the positive andnegative predictive values were calculated on the as-sumption of a 5% prevalence of carpal tunnel syndrome.Compared with the sensitivity of the CCT, that of theflexion-compression test was significantly higher. Com-pared with the sensitivity and positive predictive valueof Tinel’s sign and Phalen’s test, those of the flexion-compression test were significantly higher.

Marx et al (49) performed a formal literature search,using 30 years of Medline (1966 to 1996), a snowballmethod, and expert references to evaluate the reliabili-ty and validity of a physical examination of the upperextremity. In studies on carpal tunnel syndrome, therange of the sensitivity of Phalen’s test and Tinel’s signwas 67—88% and 26—73%, respectively, in the differ-ent studies. The range of the specificity of these meas-ures was 32—86% and 55—94%, respectively, in thedifferent studies.

In evaluating the reliability and validity of the South-ampton examination schedule (48), 43 pairs (86 limbs)of interobserver data formed from 88 hospital outpa-tients with rheumatic and orthopedic complaints. Phys-ical examinations were performed by trained researchnurses or rheumatologists. The criteria for carpal tun-nel syndrome were pain or paresthesias or sensory lossin the median nerve distribution and one of the follow-ing tests positive: Tinel’s sign, Phalen’s test, nocturnalexacerbation of symptoms, motor loss with wasting ab-ductor pollicis brevis, or abnormal nerve conductiontime. The interobserver reliability of Phalen’s test wasexcellent (kappa = 1), and the interobserver reliabilityfor a light touch of the index finger was good (kappa =0.66). The sensitivity and specificity of the examinationschedule for carpal tunnel syndrome (with a rheumatol-ogist’s opinion as the gold standard) for the 2 observerswere 71% and 100%, respectively.

Examples of case defnitions and criteria proposedor used in different studies


In their cross-sectional study of hand-wrist symptomsamong 1058 female grocery checkers, Morgenstern etal (116) used self-reports of the following recent symp-toms as criteria for carpal tunnel syndrome: pain in thehands or wrists and nocturnal pain in the wrists or handsthat awakens the patient, numbness in the hands or fin-gers, and tingling in the hands or fingers. In their popu-lation, 12% reported all 4 symptoms.

Table 5. Sensitivity, specificity, positive predictive value (PPV),and negative predictive value (NPV) of 4 tests used for carpaltunnel syndrome by Tetro et al (115). (CCT = carpal compres-sion test)

Test property


Phalen’s test 0.61 0.83 0.16 0.98Tinel’s sign 0.74 0.91 0.29 0.99CCT 0.75 0.93 0.35 0.99Flexion-compression 0.82 0.99 0.47 0.99(20 seconds)


Sluiter et al

Rempel et al (117) assessed the properties of a CTSdiagnosis made by the following symptom characteris-tics alone: classic-probable symptom classification ac-cording to Katz’s and Franzblau’s hand diagram (numb-ness, tingling, burning, or pain in at least 2 of digits 1,2, or 3, palm pain, wrist pain, or radiation proximal tothe wrist being allowed). In data from a working popu-lation of 822 persons (not mentioned whether or not thepopulation was at risk), these criteria revealed a sensi-tivity and specificity of 22% and 90%, respectively, anda positive predictive value of 20% with the assumptionof electrodiagnostic findings as the gold standard and adisease prevalence of 10%.


In their cross-sectional study of forearm and hand dis-orders among 199 automobile assembly-line workersand 186 referents, Bystrom et al (65) used the follow-ing criteria for carpal tunnel syndrome [modified fromHagberg et al (118)]: nocturnal occurrence of paresthe-sias, tingling or numbness of the palmar side of the 3radial fingers at least once a week during the past 3months and a positive Tinel’s sign or Phalen’s test.

In their cross-sectional study among 146 female in-dustrial workers, Ranney et al (45) used the followingminimal clinical criteria for establishing worksite car-pal tunnel syndrome: symptoms: numbness or tingling(or both) in the thumb, index, or middle finger with par-ticular wrist postures or at night; signs: positive Phalen’stest or Tinel’s sign present over the median nerve at thewrist. In addition, they classified the severity of the dis-order as “mild” when the aforementioned criteria weremet, as “moderate” if there was sensory loss on testingor if it interfered significantly with day-to-day activi-ties, and as “severe” if motor sensory loss was present.

In a thesis based on 6 articles, Toomingas (53) usedthe following minimal diagnostic criteria for carpal tun-nel syndrome in his study, which was part of theMUSIC I study: symptoms: present ache, pain, or dis-comfort located at the wrist-hand; signs: positive Pha-len’s test (in one study) or positive Tinel’s sign (in an-other study).

In a nested case-referent study among carpenters,Atterbury et al (110) used the following diagnostic cri-teria for work-related carpal tunnel syndrome: sympto-matic work-related musculoskeletal disorder (ie, self-re-ported pain, aching, burning, numbness or tingling inthe hands or wrists during the past year and the onset ofthese symptoms after starting work as a carpenter andsymptoms occurring at least once a month or lasting atleast 1 week and no history of injury, pain being report-ed at least as “moderate”), and either a positive Phalen’stest or a positive Tinel’s sign and minimal electrodiag-nostic criteria.

In practice guidelines for occupational medicine,Harris (42 p 11-7) provides the following diagnostic cri-teria for carpal tunnel syndrome (ICD-9 354.0): symp-toms: numbness or tingling in the thumb, index, middlefingers, especially at night or with activity, and handpain radiating into the forearm and decreased gripstrength and difficulty picking up small objects; signs:atrophy or decreased strength of the abductor pollicisbrevis, opponens (advanced cases) and decreased sen-sation in the median nerve distribution and positive Ti-nel’s sign and positive Phalen’s test.

In the development of a diagnostic instrument forcarpal tunnel syndrome, the most weighted symptomsand signs of Sluiter et al (29) that minimally led to a“probable” diagnosis were intermittent paresthesias,pain, or numbness in digits I to III, nocturnal symptoms,and minimally two of the following: positive Phalen’stest, positive Tinel’s sign, observable thenar atrophy,weakness on resistance thumb abduction, or sensory lossin the median nerve distribution.

Harrington et al (55) reached a multidisciplinaryconsensus on the following minimum diagnostic crite-ria for diagnosing carpal tunnel syndrome [these crite-ria were taken over by Davis (56) as well]: pain, par-esthesias or sensory loss in the median nerve distribu-tion and one of the following positive tests: Tinel’s sign,Phalen’s test, nocturnal exacerbation, motor loss withwasting of the abductor pollicis brevis, or abnormalnerve conduction time.

Rempel et al (117) reached a multidisciplinary con-sensus on the following symptoms and signs and addi-tional tests in diagnosing carpal tunnel syndrome forepidemiologic studies. They emphasized that no perfectgold standard for carpal tunnel syndrome exists and that,in the absence of electrodiagnostic findings, the mostaccurate CTS diagnosis should be made by combiningsymptom characteristics and physical examination find-ings as follows: classic or probable symptom classifi-cation according to Katz’s hand diagram and nightsymptoms and a positive physical examination (com-prising either Tinel’s sign, Phalen’s test, 2-point dis-crimination, or CCT). In data from a working popula-tion of 822 persons, these criteria revealed a sensitivityand specificity of 7% and 99%, respectively, and a pos-itive predictive value of 44%, with the assumption ofelectrodiagnostic findings as the gold standard, and adisease prevalence of 10%.

In the Southampton examination schedule (48), thefollowing diagnostic criteria are used for carpal tunnelsyndrome: symptoms: pain or paresthesias or sensoryloss in the median nerve distribution and one of the fol-lowing tests positive: Tinel’s sign, Phalen’s test, noc-turnal exacerbation of symptoms, motor loss withwasting of the abductor pollicis brevis muscle, or ab-normal nerve conduction time.




The decisions for the case definitions for this documentwere based mainly on the expertise and results of the 2latest consensus-based studies of Rempel et al (117) andHarrington et al (55). However, the duration of symp-toms is considered in the case definition (based on the

previously discussed time rule) as is the feasibility ofperforming physical examination tests by most (occu-pational) physicians. The CCT and the flexion-compres-sion test are included on the basis of their test proper-ties (115).

With further diagnostic testing, abnormal nerve con-duction time might also be taken into account.

Case definition 1: carpal tunnel syndrome, based on symptoms only

Symptoms: • Intermittent paresthesias or pain in at least 2 of digits I,II, or III; either may be present at night as well (allowingpain in the palm, wrist, or radiation proximal to thewrist)AND



! Note ! Descriptions and photographs of the tests involved can be found in the appendix A Photos 20, 25—28

Case definition 2: carpal tunnel syndrome, based on symptoms and physical examination signs

Time rule: • Symptoms present now or on at least 4 days during the last 7 daysAND

Symptoms: • Intermittent paresthesias or pain in at least 2 of digits I,II, or III; either may be present at night as well (allowingpain in the palm, wrist, or radiation proximal to thewrist)AND

Signs: • At least one of the following tests positive:� Flexion compression test� Carpal compression test� Tinel’s sign� Phalen’s test� Two-point discrimination test� Resisted thumb abduction or motor loss with

wasting of abductor pollicis brevis muscle

SYMPTOM CRITERIA FOR CARPAL TUNNEL SYNDROME

OR

no

yes

yes yesno

• Symptoms in thewrist or hand regionor both

Intermittent paresthesias orpain in at least 2 of digits I, II,or III; either may be present atnight as well

Deviant case: check criteriafor disorders 5–7, 9–12


Symptoms present on atleast 4 days during atleast 1 week in the last 12months

= Latentsymptom case = Symptom case

carpal tunnelsyndrome

= Symptom casecarpal tunnelsyndrome


Sluiter et al

SIGN CRITERIA FOR CARPAL TUNNEL SYNDROME

OR

yes

yes

yes

no

no

yes

•

Symptom casecarpal tunnel syndrome

Symptoms present now or on atleast 4 days during the last 7 days


Flexion compression test

Carpal compression test

Tinel’s sign

Phalen’s test

Two-point discrimination

Resisted thumb abduction oratrophy of the abductorpollicis brevis muscle

Symptom casecarpal tunnel syndrome

= Case carpaltunnel syndrome(ICD code G 56.0)

= Case carpaltunnel syndrome(ICD code G 56.0)

OR

OR

OR

OR

yes

yes

yes

yes



9. Ulnar nerve compression at the wrist: Guyon canal syndrome

possibly diurnal as well (84, 120, 122,). Hand or fore-arm pain can be present. Ulnar nerve entrapment in Guy-on’s canal does not affect dorsal ulnar hand sensationbecause the dorsal branch rises proximal to the tunnel.If such a sensory disturbance is found, it suggests an-other site of compression (84, 119, 120, 123, 124). De-pending on the site of the entrapment, motor functioncan be impaired in the hypothenar muscle and other in-trinsic muscles of the hand, including the first dorsal in-terosseous muscle and the thumb adductor muscle (120).Patients with motor symptoms may complain of clum-siness in the precision pinch (119).

Differential diagnosis of Guyon’s canal syndromeand other upper-extremity musculoskeletaldisorders

Other potential sites of ulnar nerve compression mustbe ruled out, such as involvement in C8-T1 cervical pa-thology, thoracic outlet syndrome, and cubital tunnelsyndrome. Symptoms in patients with carpal tunnel syn-drome may be referred to the 4th and 5th digits in theabsence of specific ulnar nerve entrapment (120).

Description of the disorder and clinical features

Compression of the ulnar nerve can occur in Guyon’scanal, which lies ulnar to the carpal tunnel between thehook of the hamatum bone and the pisiform bone. Onlythe ulnar nerve and artery pass through the canal, and itcontains no tendons (119).

The canal has been divided into 3 anatomic zones –one containing both sensory and motor fibers, one withmotor fibers only, and one with sensory fibers only(119—121). The motor branch innervates the hypothe-nar muscles, the 2 ulnar lumbricals, the adductor polli-cis muscle, and part of the flexor pollicis brevis muscle(119). The pattern of sensory and motor symptoms as-sociated with ulnar nerve compression at the wrist de-pends on the actual site of the compression within thecanal. Souquet & Mansat (119) suggested that most cas-es with sensory only symptoms are associated with mi-crotrauma.

Ulnar nerve entrapment at the wrist occurs infre-quently. In textbooks and the literature, the clinical fea-tures of ulnar neuropathy at the wrist are described asfollows: patients may complain of numbness or par-esthesias of the 4th and 5th digits, often nocturnal but


medial epicondyle

median nerve

carpal tunnel

Guyons� canal


median nerve

ulnar nerve

m pronator teres


Sluiter et al

Information on test propertiesNetscher & Cohen (124) reviewed clinical informationon 8 patients (11 extremities) with documented ulnarnerve entrapment at the wrist requiring surgery. Sevenof the 8 patients had both sensory and motor findings.The other patient had isolated compression of the deepulnar motor branch and exhibited marked wasting andweakness of the 1st dorsal interosseous muscle andthumb adductor muscle, but not sensory abnormality.

Although the clinical literature often describes theuse of such tests as Tinel’s sign and Phalen’s test, noinformation was found on the diagnostic value of thesetests for ulnar nerve entrapment at the wrist. Netscher& Cohen (124) described 8 patients with 11 instancesof wrist-level ulnar nerve entrapment from his hand sur-gery practice. In his discussion, he noted that a positivepressure provocative test applied just proximal to Guy-on’s canal will produce numbness in the little finger andon the ulnar aspect of the ring finger and that Phalen’stest may produce numbness in these same 2 fingers.

Because the electrophysiological localization of ul-nar entrapment at the wrist is often difficult, severalstudies have reported results of electrodiagnostic tech-niques that may supplement the routine dorsal ulnar sen-sory studies and ulnar motor studies often performed todiagnose ulnar nerve compression at the wrist. Kothariet al (125, 126) studied the difference (Diff) in distalmotor latencies to the medial-innervation 2nd lumbri-cal (2L) muscle and the ulnar-innervated palmar inter-osseous (PI) muscle — Diff 2L-PI — in 2 patients withclinically definite ulnar neuropathy at the wrist. Theycompared the results with those of 51 normal referentsand 12 patients with clinical and electrophysiologicalulnar neuropathy at the elbow (disease referents). Theyfound that the Diff 2L-PI was essentially the same inthe disease referent and normal subjects, but the Diff2L-PI in the 2 patients with ulnar neuropathy at the wristwas well below the range for the normal and diseasereference groups. In these patients, that distal motor la-tency to the PI was significantly longer than to the 2L.

McIntosh et al (127) evaluated 2 patients with clini-cal ulnar neuropathy at the wrist, 10 normal subjects,and 1 disease referent (with ulnar neuropathy at the el-bow) using short-segment incremental studies (SSIS)across the wrist, recording from the 1st dorsal interos-seous muscle, in addition to the Diff 2L-PI already de-scribed, as well as routine electrodiagnostic studies.They used the findings from their normal subjects toestablish normal and abnormal values for the maximalchange in latency and amplitude over each of 7 1-cmsegments. The 1 disease referent was shown to havenormal SSIS at the wrist, and the 2 patients with ulnarneuropathy at the wrist had clearly abnormal values. TheSSIS precisely localized the ulnar nerve lesion in bothpatients.


Studies based on symptoms

No studies were found which were based on symptomsalone, but there is general agreement on the symptomsused in the studies based on symptoms and signs.

Studies based on symptoms and signs

Very few epidemiologic studies were found that specif-ically considered ulnar nerve entrapment at the wrist(Guyon’s canal) as a specific outcome variable.

In an early epidemiologic and clinical study of neckand upper-limb disorders among slaughterhouse work-ers, Viikari-Juntura (82) used the following criteria forthe clinical diagnosis of ulnar nerve entrapment at Guy-on’s tunnel: pain, paresthesias, numbness or weaknessof the 5th finger, tenderness to palpation at the Guyon’stunnel possible, Tinel’s sign at the Guyon’s tunnel pos-sible, diminished sensation in the 4th and 5th fingers orweak abduction of the 5th finger.

Ranney et al (45) used the following minimum clin-ical criteria for establishing a worksite diagnosis of ul-nar tunnel syndrome in their study of 146 female work-ers in 5 industries: symptoms: numbness and tingling inthe ulnar nerve distribution in the hand distal to thewrist; signs: positive Tinel’s sign over the ulnar nerveat the wrist.

In proposing a protocol for a structured anamnesticsurvey of upper-limb disorders, Menoni et al (54) de-scribed Guyon’s canal syndrome as paresthesias local-ized in the 4th and 5th digits, onset usually nocturnal(but diurnal onset also posssible), possible radiation ofpain to the forearm, and, in the more advanced stages,possible development of hypoesthesia and impaired ab-duction of the fingers.

In the development of a diagnostic instrument forGuyon’s canal syndrome, the most weighted symptomsand signs of Sluiter et al (29) that minimally led to a“probable” diagnosis were intermittent pain or eithernumbness or paresthesias in the ulnar border of the handand symptoms in the little finger and a minimum of oneof the following: a positive Tinel’s sign of the ulnarnerve at the wrist, a positive reversed Phalen’s test, ornotable loss of tonus or atrophy in hypothenar muscles,thenar muscles, or intrinsic hand muscles.


Textbooks and clinical studies consistently include par-esthesias or numbness or both in the 4th and 5th digitsas primary sensory symptoms of ulnar nerve entrapment



at the wrist. At the same time, they note ulnar nervecompression at the wrist will spare sensation in the dor-sal sensory branch of the hand and that, if such symp-toms can be provoked, the compression is proximal toGuyon’s canal. Pain is mentioned, although less often.The literature clearly notes that the constellation ofsymptoms may vary, depending on the site of compres-sion, and that symptoms may be sensory-motor, senso-ry, or motor in nature. Leclercq (123) has suggested thatintrinsic muscle paresis may not be appreciated if theclinical examination is performed too quickly and thatit is important to perform a comparative examination ofthe other side, measuring muscle motor strength andevaluating the strength of the different forms of pinchand grasp. Although used, most studies agree that Ti-nel’s sign and a positive Phalen’s test may not alwaysbe present. For this reason and according to the discus-sion in Netscher & Cohen (124), the positive pressuretest over the Guyon canal is included as another possi-ble diagnostic sign. The temporal criteria in the follow-ing case definition follow the earlier-described time rule.Nerve conduction and electromyographic studies mayconfirm and help localize the entrapment.

! Note ! When pain is not present, it has to be notedthat the symptom case definition of Guyon’s canal syn-drome may not differ from the symptom case definitionof cubital tunnel syndrome (see pages 43—47). In sucha case, however, the symptom case definitions can beused to register this symptom case as ulnar nerve com-pression.

Case definition 1: Guyon’s canal syndrome, based on symptoms only

Symptoms: • Intermittent paresthesias in the palmar ulnar nervedistribution of the hand, distal to the wristor

• Pain in the ulnar innervated area of the hand; the painmay radiate to the forearmAND



Case definition 2: Guyon’s canal syndrome, based on symptoms and physical examination signs


Symptoms: • Intermittent parasthesias in the palmar ulnar nervedistribution of the hand, distal to the wristor

• Pain in the ulnar innervated area of the hand, which mayradiate to the forearmAND

Signs: • At least one of the following tests positive:� Weakness or atrophy in the ulnar-innervated

intrinsic hand muscles� Tinel’s sign� Reversed Phalen’s test� Pressure test over the Guyon canal

! Note ! Descriptions and photographs of the tests involved can be found in appendix A Photos 22 & 23


Sluiter et al

SYMPTOM CRITERIA FOR ULNAR NERVE COMPRESSION AT THE WRIST: GUYON’S CANALSYNDROME

OR

yesyes

yesno

yes

no

OR

Intermittent paresthesiasin the palmar ulnar nervedistribution of the hand,distal to the wrist

Pain in the palmar ulnarinnervated area of the hand;pain may radiate to theforearm

= Deviant case: checkcriteria for disorders7, 8, 10–12



= Latentsymptomcase=Symptom case

Guyon’s canalsyndrome

=Symptom caseGuyon’s canalsyndrome

Symptoms inthe wrist-handregion

•

SIGN CRITERIA FOR ULNAR NERVE COMPRESSION AT THE WRIST: GUYON’S CANALSYNDROME

yes

yes

no•

OR

OR

OR

yes

yes

yes


Reversed Phalen’s test

Pressure test over theGuyon’s canal

Case Guyon’scanal syndrome(ICD codeG 56.2 [4])

yes

no

Weakness or atrophy in theulnar-innervated intrinsichand muscles


Tinel’s sign at the Guyon’scanal

Symptom caseGuyon’scanal syndrome

Symptom caseGuyon’scanal syndrome

saltsa.pdf

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