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Brief Summary

GUIDELINE TITLE

Elbow disorders.

BIBLIOGRAPHIC SOURCE(S)

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

GUIDELINE STATUS

This is the current release of the guideline.

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

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

** REGULATORY ALERT **

FDA WARNING/REGULATORY ALERT

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

BRIEF SUMMARY CONTENT

 ** REGULATORY ALERT **
 RECOMMENDATIONS
 EVIDENCE SUPPORTING THE RECOMMENDATIONS
 IDENTIFYING INFORMATION AND AVAILABILITY
 DISCLAIMER

 Go to the Complete Summary

RECOMMENDATIONS

MAJOR RECOMMENDATIONS

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

General Summary of Recommendation

Recommendations for Assessing and Treating Patients with Elbow Disorders

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

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

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

Clinical Measure Treatment with Evidence Rating/Recommendation Level
Recommended No Recommendation Not Recommended
History/physical exam Occupational and non-occupational activity history (C)

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

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

Acetaminophen (I)

Aspirin (I)

Ketamine gel for neuropathic pain (I)

NSAIDs for ulnar neuropathies (I)

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

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



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

Acupuncture for epicondylalgia (I) 		Manipulation (I)

Massage (I)

Friction massage (I)

Soft tissue mobilization (I)

TENS (I)

Biofeedback (I)

Electrical stimulation (I)

Magnets (I)

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

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

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

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

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

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

Epicondylalgia supports for epicondylalgia (I)

Dynamic extensor brace for lateral epicondylalgia (I)

Wrist splinting for epicondylalgia (I)

Wrist splinting for radial tunnel syndrome (I)

Nocturnal elbow splinting for ulnar neuropathy (I)

Daytime padding for ulnar neuropathies at the elbow (I)

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

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

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

Posterior splint for elbow dislocation (I)

Shoulder sling for elbow sprain (I)

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

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

Stretching (I)

Aerobic exercise (I)

Activity modification (I)

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

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

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

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

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

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

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

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

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

Surgery for biceps rupture (I)

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

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

Medical epicondylectomy for ulnar neuropathy (I)

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

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

Elbow Condition Treatment with Evidence Rating/Recommendation Level
  Recommended No Recommendation Not Recommended
Contusion Protection, rest, ice, compression, elevation, and mobilization (I)    
Olecranon Bursitis (Aseptic) Soft padding of the elbow (I)

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

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

Avoid direct pressure (I)

Aspiration and antibiotics(I)

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

Posterior splint for 10 days (I)

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

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

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

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

NSAIDs (I)

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

Elbow padding (I)

Avoid leaning on elbow (I)

NSAIDs (I)

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

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

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

Confirmatory electro-diagnostic study helpful (I)

Wrist splint for periodic daytime use (I)

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

Activity modifications (I)

Confirmatory electrodiagnostic study helpful (I)

Wrist brace (I)

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

Aspirin (I)

Heat or cold packs (I)

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

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

Home exercise (I)

Epicondylalgia supports (I)

Activity modification (I)

Workstation modifications (I)

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

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

Acupuncture (I)

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

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

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

Massage (I)

Friction massage (I)

Soft tissue mobilization (I)

Biofeedback (I)

Transcutaneous electrical neurostimulation (TENS) (I)

Electrical stimulation (I)

Magnets (I)

Diathermy (I)

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

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

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

Autologous blood injections (I)

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

Activity modification (I)

Workstation modification (I)

Iontophoresis (Nirschl et al., 2003) (C)

Corticosteroid injections (Stahl & Kaufman, 1997) (B)

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

Definitions:

Strength of Evidence Ratings

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

B: Moderate evidence-base: At least one high-quality study, a well-conducted systematic review or meta-analysis of lower quality studies,2 or multiple lower-quality studies relevant to the topic and the working population.

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

I: Insufficient evidence: Evidence is insufficient or irreconcilable.

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

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

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

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

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

Categories of Evidence-based Recommendations

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

CLINICAL ALGORITHM(S)

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

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

REFERENCES SUPPORTING THE RECOMMENDATIONS

References open in a new window

TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

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

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IDENTIFYING INFORMATION AND AVAILABILITY

BIBLIOGRAPHIC SOURCE(S)

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

ADAPTATION

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

DATE RELEASED

1997 (revised 2007)

GUIDELINE DEVELOPER(S)

American College of Occupational and Environmental Medicine - Medical Specialty Society

SOURCE(S) OF FUNDING

American College of Occupational and Environmental Medicine

GUIDELINE COMMITTEE

American College of Occupational and Environmental Medicine Practice Guidelines Committee

COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

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

Elbow Panel Chair: Harold E. Hoffman, MD, FACOEM, FRCPC

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

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

FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Roger Belcourt, MD, MPH (Panel Member)

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

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

Guidelines Related Professional Activities—None

Research Grants/Other Support—None

Financial/Non-Financial Conflict of Interest—None

Kevin Byrne, MD, MPH (Panel Member)

Associate Area Medical Director, USPS

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

Guidelines Related Professional Activities—None

Research Grants/Other Support—None

Financial/Non-Financial Conflict of Interest—None

Jed Downs, MD, MPH (Panel Member)

President, Occupational & Manual Medicine of Duluth, Ltd.

National, Regional, Local Committee Affiliations—None

Guidelines Related Professional Activities—None

Research Grants/Other Support—None

Financial/Non-Financial Conflict of Interest—None

Lee Glass, MD, JD (Panel Member)

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

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

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

Research Grants/Other Support—None

Financial/Non-Financial Conflict of Interest—None

Kurt Hegmann, MD, MPH (Editor-in-Chief)

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

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

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

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

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

Financial/Non-Financial Conflict of Interest—None

Harold Hoffman, MD (Chair of Panel)

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

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

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

Research Grants/Other Support—None

Financial/Non-Financial Conflict of Interest—None

J. Mark Melhorn, MD (Panel Member)

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

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

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

Research Grants/Other Support—None

Financial/Non-Financial Conflict of Interest—None

Jack Richman, MD (Panel Member)

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

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

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

Research Grants/Other Support—None

Financial/Non-Financial Conflict of Interest—None

Bruce Sherman, MD (Managing Editor-Technical)

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

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

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

Research Grants/Other Support—None

Financial/Non-Financial Conflict of Interest—None

Phillip Zinni, DO (Panel Member)

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

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

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

Research Grants/Other Support—None

Financial/Non-Financial Conflict of Interest—None

GUIDELINE STATUS

This is the current release of the guideline.

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

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

GUIDELINE AVAILABILITY

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

AVAILABILITY OF COMPANION DOCUMENTS

None available

PATIENT RESOURCES

None available

NGC STATUS

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

COPYRIGHT STATEMENT

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

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All guidelines summarized by NGC and hosted on our site are produced under the auspices of medical specialty societies, relevant professional associations, public or private organizations, other government agencies, health care organizations or plans, and similar entities.

Guidelines represented on the NGC Web site are submitted by guideline developers, and are screened solely to determine that they meet the NGC Inclusion Criteria which may be found at http://www.guideline.gov/about/inclusion.aspx .

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

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