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Occupational Medicine Advance Access originally published online on November 23, 2006
Occupational Medicine 2007 57(1):67-74; doi:10.1093/occmed/kql127
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© The Author 2006. Published by Oxford University Press on behalf of the Society of Occupational Medicine. All rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.org

Compensating occupationally related tenosynovitis and epicondylitis: a literature review

Keith T. Palmer, E. Clare Harris and David Coggon

MRC Epidemiology Resource Centre, University of Southampton, Southampton, UK

Correspondence to: Keith T. Palmer, MRC Epidemiology Resource Centre, Southampton General Hospital, Tremona Road, Southampton SO16 6YD, UK. Tel: +44 23 8077 7624; fax: +44 23 8070 4021; e-mail: ktp{at}mrc.soton.ac.uk


   Abstract
Top
 Abstract
Introduction
 Method
 Results
 Discussion
 Conflicts of interest
 Appendix
 References
 
Objectives To assess occupational associations with tenosynovitis and epicondylitis, we conducted a systematic literature review. We focused particularly on evidence that might support compensation of these disorders ‘on the balance of probabilities’.

Methods We searched the MEDLINE and EMBASE electronic biomedical databases to 1 January 2005 using combinations of keyword and medical subject headings, and also the references cited in two state-of-the-art reviews from the 1990s. Primary research reports were retrieved and checked for further relevant citations. From each paper, we abstracted a standardized set of information on study populations, exposure contrasts and estimates of effect.

Results We found and summarized 18 papers. In the main, these based analysis on job titles rather than on directly assessed physical activities. Few occupations were studied more than once, however, and there was little consistent evidence of jobs or work activities that carried more than a doubling of risk for either disorder.

Conclusion Compensation of occupational illness can be problematic for disorders that are not specific to work and for which there are no distinctive clinical features in occupationally related cases. Attribution can, however, be made on the balance of probabilities if there is convincing evidence that risk is at least doubled in an occupational group. Our review highlights the relative lack of data to support such attribution for tenosynovitis and epicondylitis, and discusses the difficulty of compensating upper limb disorders.

Keywords      Compensation; epicondylitis; risk factors; tenosynovitis


   Introduction
Top
 Abstract
 Introduction
Method
 Results
 Discussion
 Conflicts of interest
 Appendix
 References
 
Pain in the neck and upper limb is common in the general population. In a large community-based survey across Britain, some 20% of people complained of pain in the neck during the past 7 days [1], and 17% of shoulder pain [2], while 13% had consulted a general practitioner about arm pain in the past year [3]. Symptoms become more common with increasing age and often defy clinical classification. Distinct clinical disorders such as epicondylitis and carpal tunnel syndrome may each affect some 1–3% of older people [4,5], but in many cases arm pain is ‘non-specific’ (i.e. without identifiable underlying pathology). Often the symptom is attributed to work. For example, the Health & Safety Executive estimated that in 2001/2, there were 396 000 people in Britain with upper limb or neck complaints which they believed were caused or made worse by their work [6]. The same survey indicated that, nationally, >4 million working days were lost per year because of work-attributed upper limb and neck disorders.

Against this background, a small number of upper limb disorders (ULDs) are currently recognized for social security compensation in the UK under the regulations of the Industrial Injuries Benefits (IIB) Scheme [7]. The terms of ‘prescription’ (circumstances in which employed earners can claim benefit) (Table 1) may seem quite limited given the apparent scale of work-related ill-health, but several factors restrict the scope for wider coverage.


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  		Table 1 Current prescription relating to WRULDs

 
One constraint, imposed by legislation, is that a prescribed occupational disease (i) ‘ought to be treated, having regard to its causes and incidence and any other relevant considerations, as a risk of the occupation and not as a risk common to all persons’, and (ii) should be ‘such that, in the absence of special circumstances, the attribution of particular cases to the nature of the employment can be established or presumed with reasonable certainty’ [8,9]. The first criterion has been interpreted as demanding evidence that the disease can be caused by occupation and the second as a requirement that occupational attribution can be established as ‘more likely than not’ in at least some individual claimants [9]. Satisfying the second condition may be less than straightforward where diseases are common in the absence of relevant occupational exposures, and occupational cases are clinically indistinguishable from those that are unrelated to work. However, the Industrial Injuries Advisory Council (IIAC), which is the independent committee that advises the UK Government on the IIB Scheme, has determined that the condition may be met where a reasonable body of epidemiological data indicates an attributable fraction in an exposed population of >50% [10,11]. This corresponds to a relative risk (RR) of >2 in exposed versus non-exposed people (an appendix explains the rationale for this further) [9].

In addition, a number of other practical issues must be weighed before a disease can be recommended for prescription [12]. In particular the disorder must be serious and long-lasting, it must be capable of diagnosis with reasonable confidence and without recourse to expensive or invasive testing and it should be feasible for a lay adjudicator to confirm the causal occupational exposures within the limits imposed by a high-volume, low-cost compensation scheme.

In applying these principles to the prescription of work-related upper limb disorders (WRULDs), several particular challenges emerge [13–16]. These include the wide mix of diagnoses, the inconsistent use of diagnostic labels by researchers and clinicians, the limited availability of objective tests to resolve diagnostic uncertainties and the problem of how to assess and classify complex patterns of physical exposures.

Against this background, the authors were commissioned by IIAC to review the evidential basis for prescription in relation to three ULDs identified by an expert workshop as those for which there appeared to be a relatively high measure of agreement on diagnostic criteria: epicondylitis, tenosynovitis and carpal tunnel syndrome. We here set out our findings on epicondylitis and tenosynovitis. Those on carpal tunnel syndrome are presented in a separate report [17]. The views expressed are our own, while the position of IIAC, based in part on our review, has been published elsewhere [18].


   Method
Top
 Abstract
 Introduction
 Method
Results
 Discussion
 Conflicts of interest
 Appendix
 References
 
The method of investigation is described more fully elsewhere [17]. In brief, we conducted a systematic search of the MEDLINE and EMBASE electronic bibliographic databases in OVID, from the inception of the electronic record to 1 January 2005. Keywords and medical subject headings for each outcome and exposure of interest were combined using Boolean strings. The outcomes terms included epicondylitis, medial/lateral (golfer's elbow, tennis elbow); tenosynovitis; tendonitis, tendinitis (of hand–wrist) and De Quervain's. Those for exposures included ‘work-related’, ‘occupation’, ‘occupational’, ‘repetitive’, ‘repetitious’, ‘RSI’, ‘cumulative trauma disorder’, ‘CTI’, ‘CTD’ and a list of specific occupational titles [17]. The titles and abstracts of papers were screened independently by two researchers, KTP and ECH, to decide on relevant inclusions, and any differences of opinion were resolved by consensus. Duplicates, non-English language publications, studies that did not include a control group and those that only considered compensation cases were excluded. In addition, we obtained all of the unique references to epicondylitis and tenosynovitis from two comprehensive reviews of WRULDs published by the National Institute for Occupational Safety and Health (NIOSH) [19] and Taylor & Francis (editors Kuorinka and Forcier [20]) in the mid to late 1990s. Reports were retrieved and their references checked for further relevant research in a ‘snowballing’ exercise. For each paper that was finally reviewed, we abstracted a standardized set of information on study populations, exposure contrasts, effect estimates and control for potential confounding.


   Results
Top
 Abstract
 Introduction
 Method
 Results
Discussion
 Conflicts of interest
 Appendix
 References
 
In total, 36 references were identified from the NIOSH and Kuorinka reports, including 10 listed under non-specific diagnostic headings. Of these, 13 proved eligible for review. Additionally, after eliminating non-relevant reports, duplicates, non-English language publications, reviews, case-only series and papers that did not provide risk estimates for the outcomes of interest (or the data from which they could be calculated), the computerized search identified a further five primary research papers that were read in detail and summarized. No further papers of relevance were identified from the snowballing exercise.

The studies reported fell into two groups: those that compared risks according to job title and those that assessed risks according to occupational physical activities.

Risk of tenosynovitis by job title
As Table 2 shows, although tenosynovitis is already prescribed as an occupational disease in the UK in relation to repetitive work, the number of studies published on this topic and indexed in MEDLINE or EMBASE (the former covering papers since 1966) was quite limited. Moreover, several of the studies included only small numbers of cases and some took only limited account of possible confounding.


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  		Table 2 Studies that report the risks of tenosynovitis or epicondylitis by occupational title and in comparison with a less exposed occupation

 
RRs exceeded 2 (with P < 0.05) in four studies of assembly and packing—one in the shoe industry [prevalence ratio (PR) 3.7, 95% confidence interval (CI) 1.9–7.3] [21], one in automobile workers (PR 2.5, 95% CI 1.0–6.2) [24], one of assembly line packers (PR 4.1, 95% CI 2.6–6.5) [30] and one of meat packers (RR 36) [28]. In addition, we found two surveys of meat cutters, both of which were positive. A longitudinal study by Kurppa et al. [28] found an incidence rate ratio (IRR) of 13.9, while an odds ratio (OR) of 3.1 (95% CI 1.4–6.7) was reported in a smaller investigation by Roto and Kivi [34] The first of these studies also indicated a high RR (24.1) in women making sausages [28], but we found no other investigation of tenosynovitis in this trade. Raised risks were reported for a few categories of textile worker (PRs 2.1–3.0, P < 0.05) [31], but only in one investigation.

Risks of tenosynovitis by physical activity
Armstrong et al. [37] examined cross-sectional associations of hand–wrist tendonitis with the repetitiveness of occupational tasks involving the hand and the degree of grip force entailed. Their study base comprised 652 workers from various industries, whose exposures were assessed by observation. In jobs with high repetition (cycle time <30 s or >50% of the cycle time involved in the same fundamental activities) but low grip force (<1 kg), the PR relative to those with low repetition and grip force was 5.5 (95% CI 0.7–46.3). When the average grip force exceeded 4 kg with a similar degree of repetition, the PR rose to 17.0 (95% CI 2.3–126.2).

Risk of epicondylitis by job title
Epicondylitis is not currently prescribed within the IIB Scheme. The main data we found on which to assess the case for prescription are again summarized in Table 2. One small but careful cross-sectional study in vibration-exposed workers provided some support for a raised risk—Bovenzi et al. [23] found that foresters had an OR of almost 5 in comparison with a mixed population of blue-collar workers. This finding accorded with that from a survey of pipe fitter and water/gas suppliers (some of whom may have had exposure to hand-transmitted vibration), in which the OR was 3.8 (95% CI 1.1–12.8) among those who had worked in this job for >15 years as compared with never [33]. These associations could reflect an effect of vibration or of other mechanical stresses in the occupations studied. To check for any additional evidence on vibration, we conducted a supplemental search, using the terms ‘epicondylitis’ + ‘vibrat$’ as text words. However, this failed to identify any further relevant reports.

We also found three investigations of meat cutters, all with RRs >2 (P < 0.05). In Finland, a cross-sectional survey by Viikari-Juntura et al. [35] and a follow-up survey by Kurppa et al. [28] were based upon the same study population and setting. In the former, an OR of 2.4 (95% CI 1.2–8.7) was reported, while in the latter, the IRR exceeded 7. A smaller cross-sectional study of meat cutters by Roto and Kivi [34] also indicated an elevated risk (OR 6.4) in construction foremen—but with relatively wide confidence limits (95% CI 1.0–40.9).

The two Finnish studies also investigated sausage makers and meat packers. Among the former, risks were elevated both cross-sectionally (OR 2.4, 95% CI 1.2–5.2) [35] and longitudinally (IRR 10.3) [28]; but for packers the findings were inconsistent—with more than a 6-fold elevation of risk in the prospective investigation [28] but no increase in the cross-sectional analysis of prevalence (OR 0.8, 95% CI 0.3–2.0) [35].

In addition, Leclerc et al. [29] reported a materially higher prevalence of epicondylitis in packers (from various industries) than in cashiers (10.5% versus 2.5%), although not much different from clothing, food or assembly workers. No unexposed group was designated for analysis, all groups being classed as repetitive, physically stressful jobs. Finally, a higher OR (of 5.1, 95% CI 2.3–11.3) was found for epicondylitis in Japanese nursery school cooks as compared with sex-matched social welfare workers, but in only a single study [32].

Risks of epicondylitis by physical activity
We identified two studies of epicondylitis that provided risk estimates according to physical activities in jobs.

Haahr and Andersen [38] compared occupational exposures in 267 cases and 388 referents, recruited from general practices in Ringkjoebing County, Denmark. Risk estimates were adjusted for various factors, including age, body mass index and occupational psychosocial stressors. Positive associations (RR > 2, P < 0.05) were found with various activities performed for three-quarters or more of the time versus never/almost never—namely, arms lifted in front of the body (OR 4.0, 95% CI 2.0–8.3 for women); hands bent or twisted (OR 7.4, 95% CI 2.9–18.7 for women and OR 3.2, 95% CI 1.3–7.9 for men); repetitive movements of the arm (OR 3.7, 95% CI 1.7–8.3 for women) and work requiring precise movements of the upper limb (OR 5.2, 95% CI 1.5–17.9 for men). In men, a relation was also found to use of hand-held vibratory tools, but this was stronger in the intermediate duration band (1/4 to 1/2 of the time, OR 2.9, 95% CI 1.3–6.3) than in the highest band (3/4+ of the time, OR 1.4, 95% CI 0.4–5.3).

Leclerc et al. [29] reported on risk factors for incident epicondylitis among workers from various occupations involving repetitive use of the arm and hand. For jobs that involved repetitive turning and screwing (of unstated duration), an OR of 2.1 (95% CI 1.2–3.7) was found after adjustment for age, sex, depressive symptoms and number of other upper limb diagnoses.


   Discussion
Top
 Abstract
 Introduction
 Method
 Results
 Discussion
Conflicts of interest
 Appendix
 References
 
Our search suggests that the epidemiological evidence based on occupational activity and tenosynovitis is comparatively limited. Existing terms of prescription under the UK IIB Scheme may owe more to clinical case reports in which the onset of classical tenosynovitis was well documented following exceptional hand–wrist work. Many such cases occurred in the 1940s when people were required to undertake unaccustomed work in factories and in agriculture as part of the war effort [39]. Attribution to work was favoured by the clinical time course: typically symptoms appeared following return to work after a long lay off, or following a change to unfamiliar work requiring new, rapid movements. Classically, cases would develop shortly after such exposures and resolve within a few weeks. Acute tenosynovitis is well documented under such circumstances.

When viewed in these terms and relative to the literature described, the current prescription of ‘traumatic inflammation of the tendons or forearm or of the associated tendon sheaths’ in association with ‘manual labour or frequent repeated movements of the hand or wrist’—still seems appropriate. The Guide to Industrial Injuries Benefits [7] cites routine assembly work as an example of a qualifying occupation and this is supported by several research reports. However, we found little evidence that could justify extension of the coverage to other occupations.

The situation for epicondylitis is not dissimilar. While prescription as an occupational disease might be entertained, direct support for this at present seems limited. The strongest case is for meat cutters (three studies), followed by sausage makers (two studies), and there is also a little evidence for sufficiently elevated risks in workers using hand-held powered vibratory tools.

In addition to the papers reviewed, we also found two reports comparing rates of compensation for epicondylitis by occupation [40,41]. These were excluded because of problems of interpretation. In particular, the extent to which an occupation attracts payments depended not only on the incidence of disease in the job but also on the rules of the compensation scheme and awareness of the opportunity to claim. Moreover, such risk estimates were presented only for broad industrial or occupational groupings, making it impossible to define precisely those occupations at excess risk, and the analyses had only limited scope to address possible confounding.

Of greater potential significance, our search did not include non-English language publications or the grey literature. Nor did we actively contact researchers in the field (although IIAC advertised for further evidence in the UK medical press without success). Thus, the findings may not be entirely comprehensive. Nevertheless, we believe them to have been adequate for purpose. IIAC aims to avoid recommending prescription of a disease as occupational in circumstances where new data could easily emerge that would render the prescription inappropriate. Thus, the evidence supporting extensions of coverage must be robust in quantity as well as in quality. It seems unlikely that an important volume of positive evidence on which to base compensation will have been overlooked in our review.

Perhaps unsurprisingly, the NIOSH review that we used as a source for some of our material concluded similarly that for epicondylitis there was ‘insufficient evidence’ in relation to repetitive work and posture and ‘evidence’ (meaning limited evidence) for an association with force. ‘Strong evidence’ was reported for a combination of risk factors, although largely based on the work in meat cutters. Regarding hand–wrist tendonitis, the same report concluded there was evidence for associations with repetition, force and posture when considered separately, but strong evidence for their effect in combination, the most compelling evidence coming from the work of Armstrong et al. [37].

Nine years on this still appears a useful and valid summary of the position. Thus, as we assess the evidence, it does not make a compelling case for compensating any specific group of workers ‘on the balance of probabilities’ in terms other than those that already apply to tenosynovitis in the UK IIB Scheme. Our review illustrates the limitations of the current evidence base in facilitating compensation for tenosynovitis and epicondylitis, despite the substantial research effort that they have attracted.


   Conflicts of interest
Top
 Abstract
 Introduction
 Method
 Results
 Discussion
 Conflicts of interest
Appendix
 References
 
None declared


   Appendix
Top
 Abstract
 Introduction
 Method
 Results
 Discussion
 Conflicts of interest
 Appendix
References
 
Although terminology varies, an attributable fraction represents the proportion of cases attributable to an exposure or equivalently the proportion that might be prevented by removing the exposure. Such a fraction may be expressed in relation to the group with exposure (attributable fraction in the exposed or AFe) or in the population as a whole (population attributable fraction).

The AFe can be estimated by the standard formula:

Formula
where RR is the relative risk arising from exposure.

Formula

Formula

Thus, within the exposed group, if RR >2 the disease can be considered ‘more likely than not’ attributable to the exposure. (More strictly, this approach applies when an exposure causes a disease in an all or none fashion for some of the population, rather than advancing the onset of disease for all by a certain amount.)


   Acknowledgements
 
Financial support to conduct this review was provided (to DC) by the IIAC. The views expressed are those of the authors and not necessarily those of the Council. We thank Denise Gould who prepared the manuscript.


   References
Top
 Abstract
 Introduction
 Method
 Results
 Discussion
 Conflicts of interest
 Appendix
 References
 

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