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(continued)
Initial assessment to rule out serious knee problems is discussed, but definite diagnosis and treatment of serious disorders is beyond the scope of this guideline. This guideline does not deal with issues of legal causation or work-relatedness. Treatment guidelines are designed to assist providers by providing an analytical framework for the evaluation and treatment of the more common problems of injured workers. These guidelines are educational and descriptive of generally accepted parameters for the assessment and treatment of knee injuries. The guidelines are intended to assure appropriate and necessary care for injured workers diagnosed with these types of industrial conditions. Due to the many factors which must be considered when providing quality care, health providers shall not be expected to always provide care within the stated guidelines. Treatment authorization, or payment for treatment, shall not be denied based solely on a health care provider's failure to adhere to the IMC guideline. The guidelines are not intended to be the basis for the imposition of civil liability or professional sanctions. They are not intended to either replace a treating provider's clinical judgment or to establish a protocol for all injured workers with a particular condition. It is understood that some injured workers will not fit the clinical conditions contemplated by a guideline.
For the purpose of this document, a provider is defined as any health care provider acting within the scope of his/her practice, including those to whom an injured worker has been referred or whose treatment has been prescribed by a treating physician.
All health care providers acting within the scope of their practice, including those to whom an injured worker has been referred or whose treatment has been prescribed by a treating physician, shall be allowed to bill and be reimbursed in accordance with the Official Medical Fee Schedule.
A provider may vary from these guidelines, if in his or her judgment, variance is warranted to meet the health care needs of the injured worker and that variance remains within the standards of practice generally accepted by the health care community, and the provider documents the need for the variance in the evaluation report or the medical treatment record in the manner that is generally accepted by the health care community.
Not every medical situation can be addressed in these regulations and medical standards change constantly. The documentation required of the provider is necessary to monitor and explain the use of variances.
In all cases, the provider shall document no later than 6 months from the date of injury, whether further treatment is warranted and whether the injured worker has significant subjective and objective evidence of the condition not having reached maximum medical improvement (i.e. Permanent and Stationary status).
1.0 Initial Assessment
1.1 Purpose
The purpose of the initial assessment is to define the structural abnormality, in particular knee stability and intra articular abnormalities. Initial evaluation of an acute knee injury focuses on avoiding missed diagnoses. Early diagnoses of repairable abnormalities will speed return to work.
1.2 Appropriate initial assessment methods
1.2.1 History and physical
The history focuses on defining the nature of the injury, the duration of the knee complaint, and the past history of effusion. A history of previous knee injuries or other workplace injuries is important. Pain in the knee may be from the hip, the back, the thigh or the lower leg.
Clinical diagnosis of knee problems can usually be made on history and physical examination with the help of x-rays.
The presence of hemarthrosis suggests a more serious injury. Aspiration of a tense knee effusion may reduce pain and allow a more appropriate evaluation on physical examination. Injection of a local anesthetic may also be indicated.
The usual complaint of individuals with ligament insufficiencies is 'giving away'. Definition of the problem by physical examination is the first step in appropriate care. Appropriate tests should be used to identify ligamentous incompetence, disruption of a meniscus, articular surface irregularity and other soft tissue injury. Many injuries such as meniscus and ligament damage can be established by physical examination and may not require further tests.
1.2.2 X-rays (Mail Survey =4) (Consensus Panel=) [4]
Appropriate indications for radiography in acute knee injuries include:
Tenderness at the head of fibula
Isolated tenderness of the patella (no other bone tenderness of the knee)
Inability to fully extend the knee
Inability to weight bear both immediately and in the provider's office (four steps regardless of limping)
Tense effusion
Acute direct trauma to the knee
Inability to flex beyond 90 degrees
1.2.3 Diagnostic arthroscopic examination
Arthroscopic examination may be necessary on very rare occasions when clinical evaluation is not diagnostic. (M=4) (C=) [2]
Arthroscopy allows examination of the under surface of the patella, meniscus tears, cruciate ligament status, synovitis, loose bodies, and the status of the tibial and femoral articular surfaces.
1.2.4 Vascular studies
Vascular studies are indicated if the injury is associated with vascular disruption/damage, a secondary vascular complication, or a dislocation of the knee.(M=4) (C=4) [4]
1.3 Inappropriate initial assessment methods
1.3.1 MRI/CT
MRI/CT is not usually appropriate at the initial evaluation or within the first month. (M=1) (C=) [1]
Exceptions include suspected subarticular stress fracture or bone bruise, any evidence of a mass, a tear of the patellar tendon or a locked knee.
1.3.2 Arthrogram
An Arthrogram is not usually appropriate at the initial evaluation or within the first month. (M=1) (C=) [1]
2.0 Initial Treatment
2.1 Purpose
The purpose of the initial treatment is to return the worker to their pre-injury status and to facilitate sustained return to work.
2.2 Appropriate initial treatment methods may include:
2.2.1 Aspiration of a tense, painful effusion. (M=4) (C=) [4]
2.2.2 Ice, compression and elevation of a painful knee. Immobilization of an unstable knee, including functional bracing. (M =4) (C=) [4]
2.2.3 Initial treatment for primary patellofemoral dislocation includes immobilization. (M=4) (C=4) [4]
2.2.4 Medications
2.2.4.1 Anti-inflammatory and non-narcotic analgesic medications (M=4) (C=) [3]
2.2.4.2 Narcotic analgesics are usually not required. (M=1) (C=) [2]
2.2.5 Physical medicine modalities may enhance early rehabilitation (M=4) (C=) [4]
2.2.6 Progressive exercise program (M=4) (C=4) [4]
Progressive exercises should be performed to prevent weakness, stiffness and other forms of deconditioning.
2.2.7 Manual medicine/modalities (M=4) (C=) [4]
2.2.8 Surgery (M=4) (C=) [4]
Surgery may be needed to remove loose bodies or to correct major soft tissue or bony disruption.
2.2.9 Ligament injuries
Immediate repair of anterior cruciate ligaments in many situations is not necessary. (M=1) (C=) [1]
Primary, multiple structural repairs require additional documentation because of a less predictable outcome. (M=1) (C=) [1]
Isolated tears of the medial collateral and/or lateral collateral ligament usually do not require surgical repair. (M=1) (C =) [1]
Although the prognosis is not good, combined repair of cruciate and lateral collateral ligaments may be needed. (M=1) (C=) [1]
2.3 Inappropriate initial treatments
2.3.1 A TENS unit is inappropriate in the initial phase. (M=1) (C =) [1]
2.3.2 Psychotropic medications are seldom needed. (M=1) (C=) [1]
2.4 Case management
Management during the first 4 weeks of treatment will be determined by the clinician's evaluation of the injured worker's response to therapy. Generally, re-evaluation of the problem, determination of treatment effectiveness and work status should be performed every 1-2 weeks until return to modified or full work is achieved. At each visit, the initial diagnosis should be confirmed or modified and the treatment plan adjusted if necessary. If symptoms continue to increase despite adequate conservative therapy, or if there is significant disability due to pain, referral to a provider trained and experienced in the evaluation and treatment of occupational disorders is warranted in the initial treatment phase. Once the acute pain is controlled, the treatment should focus on progressive rehabilitative exercises to increase strength and endurance, and activity modification. This approach minimizes the chance of recurrence once normal occupational duties are resumed.
3.0 Secondary Assessment
3.1 Purpose
The purpose of reassessment is to determine the reason for delayed recovery in patients who have not functionally improved. It is often difficult initially to assess the severity of the damage and/or instability. Therefore, reassess any individual who remains symptomatic after a trial of rehabilitation.
3.2 Appropriate secondary assessment methods, if clinically indicated, include:
3.2.1 Use of mechanical devices to test strength and stability.
Appropriate tests may be performed with initiation of the rehabilitation process and particularly post operatively and may be necessary to be repeated upon conclusion of rehabilitation. (M=4) (C =) [3]
Special equipment which isolates the knee and measures strength may be helpful.
3.2.2 Diagnostic imaging testing may be appropriate if the worker remains symptomatic, the diagnosis elusive and/or surgery is planned. (M=4) (C=) [4]
Testing may include an x-rays, MRI, CT, and arthrogram.
Clinical indications:
Joint instability or obvious ligamentous damage determined by the physical exam that is not responsive to conservative treatment and the decision to do arthroscopy has not yet been made.
Post-traumatic hemarthrosis or persistent effusion (over 4 weeks).
Acute trauma with unexplained persistent pain of over four weeks that is not responsive to conservative treatment and the decision to do arthroscopy has not yet been made.
Findings suggestive of a defect in the alignment of the patella.
Indications previously mentioned under initial evaluation (suspected subarticular stress fracture or bone bruise, any evidence of a mass, or tear of the patellar tendon).
3.2.3 Functional capacity evaluation may be indicated in situations of ligament reconstruction or other major knee surgery. [3]
3.3 Inappropriate secondary assessment methods
3.3.1 EMG unless muscle weakness is thought to be secondary to nerve damage. (M=1) (C=) [1]
3.3.2 Vascular studies are not indicated unless there is associated vascular disruption/damage or a secondary vascular complication. (M=1) (C=) [1]
3.3.3 Bone scan (M=1) (C=) [1]
4.0 Secondary Treatment
4.1 Purpose
The purpose of secondary treatment is to help the injured worker who is slow to recover.
4.2 Appropriate secondary treatment methods (for the specific clinical indications as noted)
4.2.1 Progressive physical exercise program
4.2.1.1 Individuals without full range of motion and strength can benefit from a progressive exercise program. (M=4) (C=) [4]
4.2.1.2 Rehabilitation therapy is important following surgery. (M =4) (C=) [4]
4.2.1.3 Functional bracing for unstable knees under non-surgical care. (M=) (C=4) [4]
4.2.2 Surgery
4.2.2.1 Arthroscopic surgery may be indicated if a clinically significant, surgically correctable abnormality is documented. (M=4) (C=) [4]
4.2.2.2 Reconstruction of ligaments is best done after appropriate rehabilitation to restore range of motion. (M=) (C=4) [4]
4.3 Inappropriate secondary treatments
4.3.1 Surgery
4.3.1.1 Total removal of the meniscus (M=1)(C=) [1]
The meniscus is an important component of knee mechanism. Even a mild degenerative meniscus is more useful than an absent meniscus. Excision of the total meniscus leads to a significant amount of problems. The modern approach is to remove as little as possible and try for repair in the younger individual.
4.3.1.2 Multiple ligament repairs performed at the same time as repairs to the meniscus (M=1) [1]
Multiple ligament repairs performed at the same time meniscus repairs may lead to a stiff joint.
4.3.1.3 Collateral ligament repair for injuries without instability (M=1) (C=) [1]
4.3.2 Prolonged immobilization (M=1) (C=) [1]
4.3.3 Multiple steroid injections into the knee joint (> 3), or into the ligament or tendon is rarely indicated. Direct steroid injections in the ligament or tendons of the knee is rarely indicated. Steroid injections of the bursae of the knee may be indicated. (M=1) (C=) [1]
4.3.4 Routine prescription of pain or sedative medication is not recommended and when prescribed for severe pain, should be limited in duration and quantity. (M=1) (C=) [1]
4.4 Case management
If the injured worker has not resumed near normal work duties after 8 weeks of full conservative therapy including adherence to a graded exercise program, a referral to a physician trained and experienced in the evaluation and treatment of occupational disorders or an orthopedic surgeon is recommended. Consultation should include a complete evaluation and recommendations for treatment and return to appropriate work. If the condition becomes chronic or disabling despite full conservative treatment including appropriate medical, rehabilitative, and ergonomic interventions (and surgery if indicated), the injured worker should be rated for permanent disability. If psychosocial issues are judged to contribute delayed recovery heightened disability, it may be appropriate to have a psychiatric evaluation.
5.0 Prevention
5.1 Purpose
The purpose of preventive measures is to avoid reoccurrence of the knee problems.
5.2 Appropriate preventive measures
5.2.1 Exercises which maintain/improve strength, range, and endurance (M=4) (C=) [4]
5.2.2 Functional bracing for ACL/PCL unstable knees (M=) (C=4) [4]
5.3 Inappropriate preventive measures
5.3.1 Prolonged total immobilization. (M=4) (C=) [1]
6.0 Primary References
1. Bonamo JJ et al.: The conservative treatment of the anterior cruciate deficient knee. Am J Sports Med 1990;18:618-23.
2. Casscells SW: Arthroscopy: Diagnostic and Surgical Practice, Ed. by SW Casscells. Lee & Febiger, Philadelphia, 1984;59-63.
3. Daniel DM, Stone ML: KT-1000 Anterior-posterior displacement measurements in Knee Ligaments: Structure, Function, Injury and Repair. Eds. DM Daniel, et al., Raven Press, New York, 1990.
4. Fischer SP, et al.: Accuracy of diagnosis from magnetic resonance imaging of the knee. J Bone Jt Surg 1991;71A:2-10.
5. Griffin LY: The Patellofemoral Joint, Eds. JM Fox, WD Pizzo, McGraw-Hill, New York, 1993;279-290.
6. Indelicato PA, Hermansdorfer J, Huegel M: Non-operative management of complete tears of the medial collateral ligament of the knee in intercollegiate football players. Clin Orthop 1990;256:174-7.
7. Jones RE, Henley MB, Francis P: Non-operative management of isolated grade III collateral ligament injury in high school football players. Clin Orthop 1986;213:137-40.
8. Kannus P: Long-term results of conservatively treated medial collateral ligament injuries of the knee joint. Clin Orthop 1988;226:103-12.
9. Kannus P: Non-operative treatment of grade II and III sprains of the lateral ligament compartment of the knee. Am J Sports Med 1989;17:83-6.
10. Paulos LE, Payne FC, Rosenberg TD: Rehabilitation after ACL surgery in The Anterior Cruciate Deficient Knee. Eds. DW Jackson, D Drez. C.V. Mosby Co., St Louis, 1987;291-313.
11. Polly DW, et al.: The accuracy of selective magnetic resonance imaging compared with the findings of arthroscopy of the knee. J Bone Jt Surg 1988; 70A(2):192-8.
12. Schutzer SF, Rasmby GR, Fulkerson JP: The evaluation of patellofemoral pain using computerized tomography. Clin Orthop 1986;204:286-93.
13. Scott WN: Arthroscopic diagnosis and treatment of patellofemoral disorders in Arthroscopy of the Knee. Ed. EH Wickland W.B. Saunders Co., Philadelphia, 1990;163-73.
14. Scuderi G, Cuomo F, Scott WN: Lateral release and proximal realignment for patellar subluxation and dislocation. J Bone Jt Surg 1988;70A(60:856-61.
15. Simpson LA, Barrett JP: Factors associated with poor results following arthroscopic subcutaneous lateral retinacular release. Clin Orthop Rel Res 1984;186:165-71.
16. Wilcox PG, Jackson DW: Factors affecting choices of anterior cruciate ligament surgery in The Anterior Cruciate Deficient Knee. Eds. DW Jackson, D Drez. C.V. Mosby Co., St Louis, 1987;27-141.
17. Wilson WJ, et al.: Combined reconstruction of the anterior cruciate ligament in competitive athletes. J Bone Jt Surg 1990;72A;742-7.
18. Davis JM. Rehabilitation of knee injuries in Techniques in Sports Medicine. Eds. WE Prentice, et al. C.V. Mosby Co., St Louis, 1990;294-315.
Appendix 7.0 Description of IMC Appropriateness Levels


Level 4 Level 3 Level 2 Level 1
Good Research Yes No No No
Based Evidence
Clinical Evidence Yes Yes Some No
Consensus Of The Yes Yes Partial No
Health Care Community
Clinical Utility Approp- Accepta- Appropriate
riate ble
Of Appropriateness and or appr- in uncommon Inappropriate
opria-
te
Level For Common recomm- in most individual cases.
ended
Shoulder cases Document the
case-specific

Problems clinical factors circumstances
or which make this
procedure
reasonable and
necessary for this
injured worker.






Note: Authority cited: Section 139(e)(8), Labor Code. Reference: Section 139(e)(8), Labor Code.








s 76.5. Treatment Guideline for Elbow Problems.
The method of treating industrial injury to the elbow shall be as set forth below in the "Treatment Guideline for Elbow Problems" as adopted by the Industrial Medical Council on May 15, 1997.
ELBOW PROBLEMS

Introduction
Elbow problems are a common musculoskeletal disorder. Acute 'strain' or blunt trauma may precipitate elbow problems such as medial and lateral epicondylitis, bursitis, nerve entrapment, and tendinitis.
Scope of this guideline: This guideline is intended for use in the diagnosis and management of working aged people with a primary complaint of elbow or extensor forearm pain and whose occupational activities put them at risk for elbow problems. The condition of lateral epicondylitis will be used throughout this guideline as an example.
Treatment guidelines are designed to assist providers by providing an analytical framework for the evaluation and treatment of the more common problems of injured workers. These guidelines are educational and descriptive of generally accepted parameters for the assessment and treatment of elbow problems. The guidelines are intended to assure appropriate and necessary care for injured workers diagnosed with these types of industrial conditions. Due to the many factors which must be considered when providing quality care, health providers shall not be expected to always provide care within the stated guidelines. Treatment authorization, or payment for treatment, shall not be denied based solely on a health care provider's failure to adhere to the IMC guideline. The guidelines are not intended to be the basis for the imposition of civil liability or professional sanctions. They are not intended to either replace a treating provider's clinical judgment or to establish a protocol for all injured workers with a particular condition. It is understood that some injured workers will not fit the clinical conditions contemplated by a guideline.
Symptom duration is defined as acute (< one month), subacute (one - three months) and chronic (> three months).
For the purpose of this document, a provider is defined as any health care provider acting within the scope of his/her practice, including those to whom an injured worker has been referred or whose treatment has been prescribed by a treating physician. This guideline does not address the evaluation and management of chronic elbow problems including chronic pain syndrome.
All health care providers acting within the scope of their practice, including those to whom an injured worker has been referred or whose treatment has been prescribed by a treating physician, shall be allowed to bill and be reimbursed in accordance with the usual practices.
A provider may vary from these guidelines, if in his or her judgment, variance is warranted to meet the health care needs of the injured worker and that variance remains within the standards of practice generally accepted by the health care community, and the provider documents the need for the variance in the evaluation report or the medical treatment record in the manner that is generally accepted by the health care community.
Not every medical situation can be addressed in these regulations and medical standards change constantly. The documentation required of the provider is necessary to monitor and explain the use of variances.
In all cases, the provider shall document no later than 6 months from the date of injury, whether further treatment is warranted and whether the injured worker has significant subjective and objective evidence of the condition not having plateaued.
1.0 Initial Assessments (First Month)
1.1 Purpose
The purpose of the initial assessment is to establish a specific diagnosis. For the diagnosis of occupational elbow problems, a work-related etiology should be established, and relevant non-occupational home, hobby and sports activities should be ruled out as contributing or causative factors. When considering diagnoses other than those involving the elbow, the provider should refer to the appropriate treatment guideline.
1.2 Appropriate initial assessment methods
1.2.1 History and physical examination
A detailed history addressing all pertinent complaints should be obtained including the characteristics of the pain, its onset and location, radiation, provocative and relieving factors. Hand dominance should be recorded. Any antecedent symptoms, trauma, fall, or new activities should be documented.
Typical symptoms of lateral epicondylitis include pain in the lateral aspect of the elbow with pain or burning radiating to the forearm (and occasionally proximal radiation). There may be loss of grip strength due to forearm pain with hand grip. Pain is usually insidious in onset but may be provoked by an acute trauma or strain. Initial complaints may be vague, such as a dull forearm ache. Any history of similar symptoms in the past, including diagnosis and treatment strategies should be recorded.
Documentation of probable work-relatedness should be made, including the injured worker's job title and occupational tasks. Specific attention should be directed towards confirming occupational risk factors such as repetitive, sustained or forceful wrist dorsiflexion, power grip, exposure to vibration, repetitive extended elbow reach with forceful pulling, and repetitive pronation and supination of the forearm against resistance. Record any recent changes in work duties, overtime, and work station or process design. Document any relationship of the symptoms to the work day, work week, particular task, and the use of any specific tools and equipment. A history of lost work days due to these symptoms, and other work-related musculoskeletal diagnoses should be recorded. Any functional impairment or current activity or work modifications should be noted.
Rule out non occupational activities that could be causing or aggravating the condition, such as activities that require gripping or hyperextending the wrist.
Olecranon bursitis may be secondary to systemic illness.
Past medical history and current health status should be documented. Routine screening questions for cervical or shoulder pain or injury should be asked.
A physical examination should be performed with documentation of the following findings:
Inspection for: deformity, swelling or erythema.

Provocative maneuvers: such as the presence or absence of pain with resisted dorsiflexion of the wrist, passive wrist flexion with the elbow in full extension, resisted supination of the forearm, and Tinel's sign.
Range of motion: elbow flexion and extension, pronation and supination, wrist flexion and extension. Note any flexion contracture deformity of the elbow.
Palpation: Document the presence or absence of the following: elbow deformity, tenderness, heat or crepitus (including olecranon process and medial epicondyle). Also check the forearm for deformity, heat or tenderness.
Muscle strength testing of the entire upper extremity should be performed as relevant.
Appropriate distal extremity exam should include neurological testing. A routine examination of the shoulder, neck, and wrist, and hand (palpation, range of motion, strength testing) should be performed.
A differential diagnosis should be considered at this point: such as radiculopathy, or shoulder pathology with referred pain.
1.2.2 Diagnostic imaging (M=4) [4]
Radiographic studies of the elbow and forearm should be obtained when clinically indicated.
As a rule, the diagnosis of elbow problems does not require an imaging study.
1.2.3 Laboratory studies
Appropriate laboratory studies should be considered if there is evidence of an infectious or diffuse inflammatory process as a contributing or causative factor. (M=4) [4]
1.2.4 Electromyography/Nerve conduction studies (EMG/NCS)
Nerve conduction studies may be indicated for elbow problems associated with neurological deficits. (M=4) [4]
1.2.5 Aspiration of the olecranon bursa is not routinely indicated unless there is suspicion of infection or metabolic disease.
1.3 Inappropriate initial assessment methods
1.3.1 Routine diagnostic imaging (M=2) (C=1) [1]
1.3.2 Routine laboratory studies (M=2) (C=1) [1]
1.3.3 Routine nerve conduction studies (M=2) (C=1) [1]
1.3.4 Arthroscopy, arthrogram (M=1) [1]
1.3.5 Ultrasound (M=1) [1]
1.3.6 MRI scan (M=1) [1]
2.0 Initial Treatment
2.1 Purpose
The purpose of the initial treatment is to reduce, symptoms, optimize healing/function and increase work with appropriate modifications to minimize the risk factors that contributed to the injury.
2.2 Appropriate initial treatments
2.2.1 Education (M=4) [4]
All injured workers should receive instruction concerning the nature of their condition, its risk factors, preventive measures and goals of initial therapy.
This information should be provided by the physician or by a Physical or Occupational Therapist as part of a referral for treatment (see Physical Treatments and Passive Modalities section). The injured worker should be instructed on how to eliminate or modify any aggravating non-occupational activities and sports during treatment.
2.2.2 Ergonomic modification (M=4) [4]
Work restrictions or modifications which reduce the injured worker's exposure to the etiologic or aggravating activity are of central importance.
Examples of such restrictions include preclusion from or reduction in time performing tasks requiring repetitive, sustained or repetitive forceful wrist or hand activities, repetitive elbow motion, prolonged elbow positioning or prolonged exposure to vibration. Be specific about work preclusions and avoid terms such as "light duty". The physician should discuss with the employer appropriate tasks for the injured worker to perform while undergoing treatment, and to discuss task modification once the injured worker resumes full and unrestricted employment, in order to reduce the chance of recurrence. Initial treatment of elbow problems need not involve lost work time. A job evaluation by an experienced specialist trained in ergonomics may be considered in order to identify appropriate modifications to the tasks, tools, or workstation.
2.2.3 Medications
a. Nonsteroidal antiinflammatory agents can be used. (M=3) (C=4) [3]
The choice of specific drug is discretionary. The injured worker should be screened for contraindications to their use and warned of the common potential side-effects.
b. Acetaminophen is an analgesic which may be used as an adjunct or alternative to NSAIDs. (M=3) (C=4) [3]

c. Opioids may be necessary if the pain is refractory to treatment with non-opioid analgesics. (M=3) (C=4) [3]
2.2.4 Physical treatments and passive modalities
If there is no improvement after 2 weeks the treatment should be modified.
a. Use of thermal modalities in conjunction with physical treatment may be useful.
b. Physical treatments for pain management splinting and/or functional retraining and instruction in a graded exercise program. (M=4) [4]
Appropriate exercises may include, but are not limited to,: 1) gentle muscle stretching; 2) flexibility; and 3) graduated strengthening. Care should be taken while incrementing exercises so that the condition is not aggravated.
c. Appropriate manual therapies may include manipulation, or joint or soft tissue mobilization, supplemented by physical modalities and exercise.[3]
d. Acupuncture

Use of acupuncture in the first 4 weeks of treatment as a part of an overall treatment plan. (C=3) [2]
2.2.5 Protective devices
The use of an elbow and/or wrist support for immobilization may be indicated for a brief period. (M=4) [4]
The use of a splint at work must be carefully considered as it may put the injured worker at risk for further musculoskeletal injury by forcing the adoption of awkward compensatory postures. A forearm strap can be aggravating in the acute stage so its use should be individualized. It is contraindicated in the presence of nerve compression symptoms. Night splinting may be indicated for nerve entrapment syndromes.
2.2.6 Local corticosteroid injection
Local corticosteroid injections of the myofascial areas or bursae may be appropriate, especially if the pain is moderate to severe. (M =4) [4]
Before the injection, it is important to be aware that the olecranon bursa may be the site of infection. In such an instance, an steroid injection would be contraindicated.
2.3 Inappropriate initial treatments
1. Medications-Systemic corticosteroids, and/or muscle relaxant. (M=1) [1]
2. Exclusive use of passive modalities (M=1) (C= 1) [1]
3. Surgery is rarely indicated (M=1) [1]
2.4 Case management
Management during the first 4 weeks of treatment will be determined by the clinician's evaluation of the injured worker's response to therapy. Generally, re-evaluation of the problem, determination of treatment effectiveness and work status should be performed every 1-2 weeks until return to modified or full work is achieved. At each visit, the initial diagnosis should be confirmed or modified and the treatment plan adjusted if necessary. If symptoms continue to increase despite adequate conservative therapy, or if there is significant disability due to pain, referral to a provider trained and experienced in the evaluation and treatment of occupational disorders is warranted in the initial treatment phase. Once the acute pain is controlled, the treatment should focus on progressive rehabilitative exercises to increase strength and endurance, and activity modification. This approach minimizes the chance of recurrence once normal occupational duties are resumed.
3.0 Secondary Assessment
3.1 Purpose
Most workers with elbow injuries will respond to initial treatment with reduction of pain and near or full return to occupational duties. The purpose of secondary assessment after conservative treatment is to determine the cause of delayed recovery. This may be due to misdiagnosis, non-compliance with the treatment regimen, inappropriate work modifications or other perpetuating factors. A reconsideration of the initial diagnosis is necessary at this stage and a differential diagnosis should be reviewed: cervical radiculopathy, shoulder pathology with referred pain and nerve entrapment. Work status and disability should be determined.
3.2. Appropriate secondary assessment methods
3.2.1 History and physical examination
An interval history and physical examination should be performed. Particular attention should be paid to compliance with and response to therapy. The development of any new symptoms should be documented as well as side effects of treatment modalities. The appropriateness of the prescribed work restrictions should be reviewed, including how they were accommodated by the employer.
3.2.2 Diagnostic imaging
Radiographic studies of the elbow and forearm may be considered if, on re-evaluation, the physician suspects morphologic pathology. (M=4) [4]
The use of MRI and arthrography is rarely indicated except for the evaluation of intraarticular pathology.
3.2.3 Laboratory studies
Laboratory studies may be performed if there is evidence of an infectious or diffuse inflammatory process as a contributing pathology. (M=4) [4]
3.2.4 EMG/NCS
Electrodiagnostic studies should be considered if there is clinical evidence of nerve entrapment or cervical radiculopathy as alternative diagnoses. (M=4) [4]
3.3 Inappropriate secondary assessment methods
3.3.1 Arthroscopy or arthrogram (M=1) [1]
3.3.2 Ultrasound (M=1) [1]
4.0 Secondary Treatment
4.1 Purpose
Secondary treatment options should be selected on the basis of the injured worker's response to initial conservative treatment for 4 weeks. If specific causes of delayed recovery are determined, they may be addressed in this phase. The purpose of secondary treatment is to reduce symptoms and optimize the return to normal arm function and a graded resumption of full and unrestricted employment.
4.2 Appropriate secondary treatments
4.2.1 Continued conservative management
a. Occupational activities should be advanced and modifications to the work environment reviewed to prevent exacerbation of symptoms. (M=4) [4]
An ergonomic assessment of the workstation may be necessary to facilitate this.
b. The injured worker's progress in the progressive exercise program should be reviewed. (M=4) [4]
c. Medication
NSAID's or acetaminophen may be used periodically.
Non steroidal anti-inflammatory agents should be discontinued as soon as possible. (M=4) [4]

A trial of 6-8 weeks maximum is recommended. They may be re-instituted briefly for symptom flare. Periodic acetaminophen may be used also.
Opioids may be necessary if the pain is refractory to treatment with non-opioid analgesics. (M=3) (C=4) [3]
Use of thermal modalities in conjunction with physical treatment may be useful.
d. Bracing or supports may be continued if beneficial. (M=4) [4]
It may be uncomfortable and exacerbate symptoms, especially if worn inappropriately (i.e. overlying the trigger point).
e. Various manual and/or passive modalities may be used but, not standing alone as a sole treatment. [3]
f. Acupuncture (M=3) (C=3) [3]
g. Biofeedback [3]
4.2.2 Local injection including corticosteroids during the secondary phase may be indicated.
If there is partial or transient relief with the first injection, local injections may be repeated (up to a total of three). (M=3) (C=4) [3]
Complications of injection include local infection, hematoma, skin discoloration and subcutaneous fat atrophy. Injection must be accompanied by the activity and workplace modifications discussed above.
4.2.3 Surgical referral
Surgical consultation is recommended if any of the following criteria are met: (C=4) [4]
a. Failure of conservative treatment and indication of a surgically correctable condition.
4.3 Inappropriate secondary treatments
4.3.1 Medications.
Systemic corticosteroids and/or delivery of medications by ionto or phonophoresis. (C=1) [1]
4.4 Case management
If the injured worker has not resumed near normal work duties after 8 weeks of full conservative therapy including adherence to a graded exercise program, a referral to a physician trained and experienced in the evaluation and treatment of occupational disorders or an Orthopedic or Hand Surgeon is recommended. Consultation should include a complete evaluation and recommendations for treatment and return to appropriate work. If psychosocial issues are judged to contribute to the disability, it may be appropriate to have a psychologic evaluation. If the condition becomes chronic or disabling despite full conservative treatment including appropriate medical, rehabilitative, and ergonomic interventions (and surgery if indicated), the injured worker should be evaluated for permanent disability.
5.0 Primary References
1. American Academy of Orthopedic Surgeons: Clinical policies - lateral epicondylitis of the elbow. AAOS 1-3, 1992.
2. Day, DE: Preventive and return to work aspects of cumulative trauma disorders in the workplace. Sem in Occ Med 2(1):57-63, 1987.
3. Dijs J, Mortier G, Driessens M, DeRidder A, Willems J, De Vroey T: A retrospective study of the conservative treatment of tennis elbow. Medica Physica 13:73-77, 1990.
4. Fillion PL: Treatment of lateral epicondylitis. Am J Occ Ther 45:340-343, 1991.
5. Kasdan ML: Occupational hand and upper extremity injuries and diseases. Hanley and Belfus Inc., 1991.
6. Kurppa K, Pekka W, Rokkanen P: Tennis elbow; lateral elbow pain syndrome. Scand J Work Environ Health 5(suppl3):15-18, 1979.
7. Nirschl RP: Elbow tendinosis/tennis elbow. Clin Sports Med 11(4):851-870, 1992.
8. Rempel DM, Harrison RJ, Barnhart S: Work-related cumulative trauma disorders of the upper extremity. JAMA 267(6):838-842, 1992.
9. Thorson EP, Szabo RM: Tendonitis of the wrist and elbow. Occ Med State of the Art Rev 4(3):419-431, 1989.
10. Wadsworth CT, Nielsen DH, Burns LT, Krull JD, Thompson CG: Effect of the counterforce armband on wrist extension and grip strength and pain in subjects with tennis elbow. JOSPT 11(5):192-197, 1989.
Appendix 7.0 Description of IMC Appropriateness Levels

Level 4 Level 3 Level 2 Level 1
Good Research Yes No No No
Based Evidence
Clinical Evidence Yes Yes Some No
Consensus Of The Yes Yes Partial No

Health Care Community
Clinical Utility Approp- Accepta- Appropriate
riate ble
Of Appropriateness and or appr- in uncommon Inappropriate
opria-
te
Level For Common recomm- in most individual cases.
ended
Knee cases Document the
case-specific
Problems clinical factors circumstances
or which make this
procedure
reasonable and
necessary for this
injured worker.






Note: Authority cited: Section 139(e)(8), Labor Code. Reference: Section 139(e)(8), Labor Code.








s 77. Treatment Guideline for Problems of the Hand and Wrist.
The method of treating industrial injury to the hand and wrist shall be set forth below in the "Treatment Guideline for Problems of the Hand & Wrist" as adopted by the Industrial Medical Council on May 15, 1997.
PROBLEMS OF THE HAND AND WRIST

Introduction
Conditions affecting the hand and wrist are common among workers with tasks requiring intensive use of the upper extremity. Evaluation can be difficult, given the anatomical and functional complexity of the region. However, a systematic assessment of upper extremity symptoms contributes to accurate, timely and cost-effective diagnosis and treatment.
Scope of this guideline
This guideline is intended for use in the diagnosis and management of hand and wrist tendinitis, de Quervain's tenosynovitis, nerve entrapment syndromes and wrist pain in working aged adults whose occupational activities put them at risk for these problems. Guidelines for initial assessment (first 4 weeks) and subsequent secondary assessment (1 to 3 months) are presented here. This guideline does not address all conditions causing hand & wrist symptoms such as fractures. This guideline does not deal with legal issue of causation or work relatedness. Treatment guidelines are designed to assist providers by providing an analytical framework for the evaluation and treatment of the more common problems of injured workers. These guidelines are educational and descriptive of generally accepted practices for the assessment and treatment of wrist pain, nerve entrapment syndromes, de Quervain's tenosynovitis and hand and wrist tendinitis. Due to the many factors which must be considered when providing quality care, health providers shall not be expected to always provide care within the stated guidelines. Treatment authorization, or payment for treatment, shall not be denied based solely on a health care provider's failure to adhere to the IMC guideline. The guidelines are not intended to be the basis for the imposition of civil liability or professional sanctions. They are not intended to either replace a treating provider's clinical judgment or to establish a protocol for all injured workers with a particular condition. It is understood that some injured workers will not fit the clinical conditions contemplated by a guideline.
Symptom duration is defined as acute (< one month), subacute (one - three months) and chronic (> three months).
For the purpose of this document, a provider is defined as any health care provider acting within the scope of his/her practice, including those to whom an injured worker has been referred or whose treatment has been prescribed by a treating physician.
All health care providers acting within the scope of their practice, including those to whom an injured worker has been referred or whose treatment has been prescribed by a treating physician, shall be allowed to bill and be reimbursed in accordance with usual practices.
A provider may vary from these guidelines, if in his or her judgment, variance is warranted to meet the health care needs of the injured worker and that variance remains within the standards of practice generally accepted by the health care community, and the provider documents the need for the variance in the evaluation report or the medical treatment record in the manner that is generally accepted by the health care community.
Not every medical situation can be addressed in these regulations and medical standards change constantly. The documentation required of the provider is necessary to monitor and explain the use of variances.
In all cases, the provider shall document no later than 6 months from the date of injury, whether further treatment is warranted and whether the injured worker has significant subjective and objective evidence of the condition not having plateaued.
1.0 Initial Assessment (First month)
1.1 Purpose
The purpose of the initial assessment of hand and wrist is to establish specific diagnosis(es). These may include hand and wrist tendinitis/ tenosynovitis, and nerve entrapment syndromes. An additional purpose of the initial assessment is to identify and document any medical, mechanical or psychosocial factors which are contributing to the symptoms and/or may influence the response to treatment. At the discretion of the physician, a shorter, less detailed evaluation may be acceptable.
1.2 Appropriate Initial Assessment Methods
1.2.1 History
As appropriate, the initial history should contain the following basic information for the medical record: the injured worker's age, hand dominance, job description, pre-injury limb function, daily physical activities, previous limb injuries and relevant medical/surgical history. A detailed symptom history may be documented, including characteristics of pain (type, location, duration, severity, radiation), associated symptoms, exacerbating and relieving movements and other factors, and the impact on function at home or work. Information concerning recent trauma and previous diagnostic or treatment procedures (including home treatments) may be obtained. The initial evaluation must address the possible presence of mechanical factors which are causing, aggravating, or precipitating the painful condition, including occupational and nonoccupational physical activities. The relationship of the symptoms to the performance of specific activities may be sought and recorded (e.g. symptoms experienced during work tasks, time off, hobbies, sports or other activities). Inquiry into any history of similar symptoms, previous diagnoses and treatments should be made. The initial history may also note any psychosocial factors which are potentially relevant to the clinical course of the condition, including work status, economic or psychological effects of the condition, and unresolved litigation or workers' compensation issues.
If tendinitis/tenosynovitis is suspected, ask about the typical symptom of localized pain aggravated by direct pressure over or use of the affected muscle-tendon unit. The discomfort may radiate in a proximal or distal direction when force is applied to the tendon. Initially intermittent discomfort may be experienced, but can progress to become a persistent burning or sharp pain. Associated symptoms descriptive of triggering, crepitus, weakness and/or limited motion may be present.
An example of a common tenosynovitis is de Quervain's tenosynovitis. The classic presentation of this condition is pain over the radial styloid; local swelling may also be present. The injured worker may describe symptoms of proximal and distal radiation of pain from this site and/or weakness of pinch or grip strength. The discomfort is exacerbated by ulnar wrist deviation and thumb flexion and adduction. Triggering may be present if the condition is chronic.
If Nerve Entrapment Syndromes are suspected, inquire about the typical symptoms - insidious onset of hand paresthesias in the thumb, index, middle and/or radial aspect of ring fingers (median nerve inervation). Many injured workers will describe paresthesias more diffusely, in all fingers. Nocturnal paresthesias, if present, are particularly characteristic. Dull aching hand pain, subjective grip stiffness, weakness of grip or pinch, hand clumsiness and impaired manual dexterity are other presenting complaints. Symptoms may be vague or atypical, and non-specific wrist and hand symptoms in a manual worker should prompt consideration of CTS in the differential diagnosis.
Self-administered hand symptom diagrams have been developed and may be useful in obtaining a detailed description of the distribution and severity of hand symptoms. They may serve as an aid in the history and physical examination.
Documentation of activities as they relate to hand should be made, including the injured worker's job title and a description of tasks performed Note the use of each hand in work tasks. Record any recent changes in work duties, overtime, tool design and patterns of tool use or any loss of function, lost work time, or limitation of activity or modification of work due to symptoms. Work station design and adjustability, as well as any prior ergonomic assessment or recent modifications should be noted. Record the onset of symptoms in relation to the work day, work week and specific work tasks or equipment. Any history of previous work related musculoskeletal diagnose be recorded.
Consider non-occupational activities and medical conditions that could cause or aggravate the presenting symptoms, i.e. hobbies, child handling, sports, and musical pursuits.
When the clinical picture is confusing, screening questions should be asked about neck or other upper extremity injury or symptoms. In the case of an atypical presentation of nerve entrapment syndromes, other pathologies may be considered. These include:
a. Cervical radiculopathy (especially C-6 or C-7)
b. Neurovascular compression syndromes such as:
Thoracic outlet syndrome
Anterior scalene syndrome

Costoclavicular syndrome
Hyperabduction syndrome
c. Other nerve compression syndromes:
Radial nerve entrapment: Posterior interosseus entrapment, radial tunnel syndrome
Ulnar nerve entrapment: At the elbow or in the Canal of Guyon
Median nerve entrapment: Pronator teres syndrome, anterior interosseus syndrome
d. Other conditions: Reflex sympathetic dystrophy, Raynaud's syndrome inflammatory, or degenerative joint diseases.
Past medical history and current health status may be elicited and should be evaluated for possible clinical significance. These may include, but are not limited to:
1. Pregnancy
2. Diabetes mellitus
3. Hypothyroidism
4. Fluid retention / edema
5. Rheumatoid arthritis/degenerative joint disease of the wrist and hand
6. Gout
1.2.2 The initial physical examination will be focused upon the affected part but may also include a basic examination of both upper extremities, including the cervical spine, shoulder, upper arm, elbow, forearm and hand. General physical signs of underlying medical diseases may also be sought. This approach can identify more distant causes of pain such as cervical radiculopathy and/or non-work related disorders contributing to or causing the symptoms (e.g. myxedema). Examination of the contralateral extremity is useful for comparison and to identify any bilateral abnormalities. Basic elements of the wrist and hand examination may include:
Inspection for swelling, erythema, thenar muscle atrophy, nodules, signs of trauma, surgical scars, arthritic bony changes, soft tissue masses, hyper/hypohydrosis, altered hair pattern, edema, cyanosis, guarding, abnormal posture or other deformities of joints or soft tissues.
Palpation of osseous and soft tissue structures for tenderness, swelling, skin temperature asymmetry, abnormal sweating, synovial thickening, masses, ganglion cysts, nodules, bony deformity, pulses, muscle spasm, myofascial trigger points, or crepitus. (continued)