Lateral epicondylitis: New evidence for work relatedness.

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JointBoneSpine82(2015)5–7

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Editorial

Lateral epicondylitis: New evidence for work relatedness

a r t i c l e i n f o

Keywords:

Epicondylitis Elbowtendionitis Epicondylalgia Occupational Work Cohortstudy Causation

Lateralepicondylitisis oneofthemostcommonupper-limb musculoskeletaldisordersingeneralpractice[1]andinworking population[2]withanestimatedincidencerangingfrom0.3–1.1 per100person-years[3].Its descriptionbyRungein 1873and Majorin1883as“Lawn-tenniselbow”wasduetoitsassociation withthebiomechanicalinjuriesinthissport[4].Recentsystem- aticreviewsconcluded thattherewasmoderateevidenceofan associationbetweenepicondylitisandoccupational exposureto forcefulandrepetitivehandactivities[5,6].However,theevidence forthisassociationwasprimarilybasedoncross-sectionalstudies.

Astherewasonlyoneprospectivestudyavailable[7],thecausality ofthereportedassociationbetweenoccupationalexposureandthe occurrenceoflateralepicondylitishasbeendebated[6].

Threelarge,longitudinalstudiesonmusculoskeletaldisorders wererecentlycompletedwhichaddresstheissuesofworkplace exposuresandriskforlateralepicondylalgiawithgreaterpreci- sion.Inthispaper,wehavesummarizedthesestudiesanddrawn conclusionsfromtheirﬁndings.

Allthreestudieswerepublishedin2013;twowereconducted intheUnitedStates,andoneinEurope[8–10].Lateralepicondylal- giaisthetermusedforoutcomesinceeachstudyusedastandard definitionforpossibleepicondylitisthatincludedspecificsymp- tomsand/orphysicalexaminationmanoeuvre[11,12](Table1).In theFrenchCosalistudy(PrincipalinvestigatorY.Roquelaure),3710 workers,representativeoftheworkforce,wereidentified by83 occupationalphysicians;thecohortincluded1394workerswith- outelbowpainwhowerefollowedonaveragefor5.5years[8].

Theincidenceoflateralepicondylalgiawas1.0/100person-years.

Self-reportedhighphysicalexertion(Borg₂₀rating>13)combined withreportedelbowﬂexionandextension,orwithextremewrist bendingfor>2h/day,wasassociated withlateralepicondylalgia withan estimated relative risk of 3.2 in men (95% conﬁdence interval[1.5–6.4])and3.3[1.4–7.6]inwomen.ThePrediCTSstudy (PrincipalinvestigatorB.Evanoff)included1107newlyemployed

workersfrom8companiesand3constructiontradeunionsinthe Saint-Louisarea;699workerswithoutelbowpainatbaselinewere followedonaveragefor2.8years[10].Theincidenceoflateralepi- condylalgiawas1.7/100person-years.Self-reportedexposureto wristbending≥4h/dayandforearmtwisting≥2h/daywasassoci- atedwithlateralepicondylalgia,withanestimatedrelativeriskof 2.5[1.1–5.3].InastudyfromWashingtonState(Principalinvesti- gatorB.A.Silverstein),733workerswereincludedfrom12different manufacturing and service sector industries, with611workers (withoutepicondylitis)followedonaveragefor1.5years[9].The incidenceoflateralepicondylalgiawas4.9/100person-years,and wasassociatedwithforearmpronation≥45^◦for40%ofthetime andpowergrip(bothassessedbyobservation),withanestimated relativeriskof2.8[1.4–5.8].

Although the deﬁnitions of lateral epicondylalgia, exposure assessment,inclusioncriteriaandstatisticalmodelsweresome- what different, strenuousmanual tasks involving theelbow or hand wereconsistently foundtobeassociated withthe occur- renceofnewcasesof lateralepicondylalgiain allthree studies.

Thesestudiesdidnotincludedetailedphysicalexaminationsofthe elbowtodifferentiatebetweenepicondylitis,tendinitisandtendi- nosis(andrelatedterms),sothetermlateralepicondylalgiawas preferred.Differentlimitationswerereportedforeachstudy,e.g.

lackofrepresentativenessofnationalworkforce[9,10],attrition [8],self-reportedassessmentofdiagnosis[8]orworkplacephysi- calexposures[8,10],andconfoundingfactors[9].However,oneof thestudieshadarepresentativesample[8],twohadlowattrition ratesandconﬁrmatoryphysicalexamination[9,10],onehadobser- vationsofexposure[9],andoneacompleteanalysisofconfounders [10].

Thesethreeprospectivestudiesprovidenewevidenceforfourof theHillcriteriaforcausalityinobservationalstudies[13]:tempo- ralsequence,consistencybetweenstudies,strengthofassociation (similarestimationsofrelative risk,between2.5and3.3),anda biologicalgradient increasingwithexposure.Thereisalsogood compatibilitywithﬁndingsfrompreviousworkplacestudies[6,7]

andwithwhathasbeenobservedinathletes[14]fromoveruse oftheforearmextensormusclesandtheresultantmicrotrauma thatleadstoangioﬁbroblastictendinosis(biologicalplausibility) [14,15].

Inconclusion,theserecentcomplementaryprospectivestud- iesprovidenewinsights andstrongevidencefor arelationship betweenlateralepicondylalgiaandoccupationalexposuretohigh handforceand non-neutralelbowandwristpostures.Compen- sationguidance,managementandpreventionshouldincorporate

http://dx.doi.org/10.1016/j.jbspin.2014.10.013

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6Editorial/JointBoneSpine82(2015)5–7

Table1

Detailsofthethreelongitudinalstudies.

Nameofthecohort(andthe Principalinvestigator)

Country Inclusionandnumber ofworkersfollowed

Deﬁnitionoflateral epicondylalgia

Deﬁnitionofmain exposure

Incidencerates (per100workers)

RelativeRisk

Cosali(Y.Roquelaure)[8] France 3710workers

examinedby83 occupational physicians, 1394workerswere followedonaveragefor 5.5years

Painaroundlateral epicondylefor≥4days overaperiodonone weekinthelast 12months,orlocal painonresistedwrist extension

Self-report,high physicalexertion (Borg20rating>13) combinedwithelbow movements(elbow ﬂexionandextension, orextremewrist bending,>2h/day)

Men:1.0 Women:0.9

MenIRR=3.2[1.5;6.4];

WomenIRR=3.3[1.4;

7.6]

Predi-CTS(BAEvanoff)[10] UnitedStated 1107newlyemployed workerswithoutcarpal tunnelsyndromefrom 8companiesand3 tradeunions,699 workerswithoutelbow painwerefollowedon averagefor2.8years

Elbowsymptomsand (eitherone):

a)Painaroundlateral epicondyleatpalpation or

b)Painonresisted wristextension

Self-report, bending≥4h/dayand twisting≥2h/day

1.7 OR=2.5[1.1;5.3]

Washingtonstudy(BA Silverstein)[9]

UnitedStates 733workersfrom12 different

manufacturingand servicesector employers,611 workerswerefollowed onaveragefor3.5years

Anyelbowpaininthe past7days,and symptomsoccurring morethan3timesin thelastyear,ANDno previouselbowinjury ANDpainonresisted wristextension

Observed,forearm pronation≥45^◦for40%

timeandpowergrip

4.9 HR=2.8[1.4–5.8]

IRR:incidentrateratio(adjustedonage,repetitivetask;stratiﬁedongender);OR:oddsratio(adjustedongender,age,socialsupportlevelofeducation,medicalhistoryofdiabetes,osteoarthritis,rheumaticarthritisandobesity);

HR:hazardratio(adjustedongenderandage).

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Editorial/JointBoneSpine82(2015)5–7 7 thesenewﬁndingsandpractitionersfromprimarytosecondary

careshouldnotestrenuousbiomechanicalhandandelbowexpo- suresforpatientswithlateralepicondylalgia.

Disclosureofinterest

Thiseditorialreceivednospecificfunding.Norelevantconflict ofinterest(ICMJEfilled).

Theauthorsdeclarethattheyhavenoconﬂictsofinterestcon- cerningthisarticle.

Acknowledgment

We are particularly thankful to Annette Leclerc, Bradley A Evanoff,and Z Joyce Fanfor theirhelp in theredaction of this editorial.

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AlexisDescatha^a,b,c,∗

AnnMarieDale^d BarbaraA.Silverstein^e YvesRoquelaure^f DavidRempel^g

aUniversitédeVersaillesSaint-Quentin,78035 Versailles,France

bInserm,UMS011,94807Villejuif,France

cAP–HP,PoincaréUniversityHospital,Occupational HealthUnit,92380Garches,France

dDivisionofGeneralMedicalSciences,Washington UniversitySchoolofMedicine,Saint-Louis,MO,USA

eSafetyandHealthAssessmentandResearchfor Prevention(SHARP),WashingtonStateDepartmentof LaborandIndustries,Olympia,WA,USA

fLUNAMUniversité,Universitéd’Angers,Laboratoire d’ergonomieetd’épidémiologieensantéautravail (LEEST),49045AngersCedex01,France

gDepartmentofMedicine,UniversityofCalifornia, SanFrancisco,CA,USA

∗Correspondingauthor.InsermUMS011,UVSQ, unitédepathologieprofessionnelle,CHUde Poincaré,104,boulevardPoincaré,92380Garches, France.Tel.:+33147107764;

fax:+33147107768.

E-mailaddress:[email protected] (A.Descatha) Accepted22October2014 Availableonline29December2014