SUMMARY OF MAJOR SUBSTANTIVE CHANGES BETWEEN THE CURRENTLY
EFFECTIVE RULE 17, EXHIBITS #2 AND #5-CARPAL TUNNEL SYNDROME AND
CUMULATIVE TRAUMA DISORDER MEDICAL TREATMENT GUIDELINES AND
PROPOSED EXHIBIT #5 CUMULATIVE TRAUMA CONDITIONS
Below is a Summary of Major Substantive Changes between the 2007 and 2006 Cumulative Trauma Disorder and Carpal Tunnel
Syndrome (respectively) Medical Treatment Guidelines and the Proposed 2010 Cumulative Trauma Conditions Medical
Treatment Guidelines. The changes that are listed below comprise mainly the following: some general comments about the
guidelines as a whole; diagnoses/procedures not addressed previously; diagnoses/procedures no longer addressed in the proposed
rule; procedures that have been specifically stated as, 'not recommended’ where no such statement was in the previous guidelines;
procedures which no longer have a notation of, ‘not recommended;’ and interventions/procedures specifically listed as needing
prior authorization. Please refer to the Cumulative Trauma Conditions Medical Treatment Guidelines (as proposed June 30th
2010) for specific and complete substantive and non-substantive changes.
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SUBSTANTIVE CHANGE
General Comments
The Cumulative Trauma Conditions Medical Treatment Guidelines replaces two
other guidelines, the Carpal Tunnel Syndrome and Cumulative Trauma Disorder.
Language has been updated according to changes in the medical literature.
The Cumulative Trauma Conditions Medical Treatment Guidelines has been
organized and formatted similarly to the Shoulder Disorder and the Lower
Extremity Medical Treatment Guidelines. It has two sections devoted to Specific
Diagnosis, Testing and Treatment Procedures (Musculoskeletal and
Neurological). This allows the reader to look up specific diagnoses and learn the
Division position on the continuum of care, from diagnosis to Post-Operative
Procedures.
Inclusion of language related to FDA-approval.
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SUBSTANTIVE CHANGE
General Comments (cont)
Operative Sections for each specific disorder have been enveloped into Specific
Diagnostic Testing and Treatment Procedures. Therefore, there is no separate
section for Operative Procedures.
Section C: Definitions and Mechanisms of
Injury
Section D: Initial Diagnostic Procedures
Section E: Follow-up Diagnostic Procedures
Changes in recommendations regarding causation assessment, diagnosis, testing,
and treatment procedures.
Acknowledgement that in some cases, the normal working-age population may
have non-specific pain complaints. Therefore, guidance provided that in cases
where there is no specific diagnosis and corresponding work-related etiology,
work-up should generally be performed outside the Workers’ Compensation
system.
This section greatly expanded to include more specific guidance regarding
causation assessment. It includes: foundations for occupational relationships,
specific directions on using risk factors to determine causation, and tables on
specific risk factor definitions and diagnosis-based risk factors.
Insertion of: Computerized Axial Tomography (CT scan)
Prior authorization for: Functional Capacity Evaluations performed during
treatment (not needed initially for determination of baseline status or at case
closure when patient unable to return to work).
Insertion of:

Section E: Follow-up Diagnostic Procedures
(cont)
joint aspiration
Changes in Recommendations:
Magnetic Resonance Imaging (MRI): Previously effective guidelines stated as ‘not
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SUBSTANTIVE CHANGE
recommended.’ Proposed guidelines specify that although routine use for CTC is
not recommended, that MRI may be helpful to diagnose triangular fibrocartilage
complex tear (TFCC) or other suspected ligament/bone pathology when clinical
findings suggest.
Section F: Specific Musculoskeletal
Diagnosis, Testing, and Treatment
Procedures
Insertion of:

'Initial Treatment' subsections into most non-operative sections of specific
disorders.

Discussion and related recommendations for smoking cessation where
applicable
Insertion on text related to the complete continuum care (Description to PostOperative Treatment)

Aggravated osteoarthritis of the wrist

De Quervain’s Disease*

Epicondylitis – Lateral*

Epicondylitis – Medial*

Extensor Tendon Disorders of the Wrist*

Flexor Tendon Disorders of the Wrist*
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Section F: Specific Musculoskeletal
Diagnosis, Testing, and Treatment
Procedures (cont)
SUBSTANTIVE CHANGE

Triangular Fibrocartilage Complex Tear

Trigger Finger*
*Denotes that treatment strategies related to this disorder are addressed in the
currently effective Cumulative Trauma Disorder and/or Carpal Tunnel Syndrome
Medical Treatment Guideline, but on a much less extensive level.
Deleted: Hand/Arm Vibration Syndrome
Stated as ‘not recommended’:
Section G: Specific Peripheral Nerve
Diagnosis, Testing, and Treatment
Procedures

s-adenosyl methionine (SAM-e)

continuous passive motion after metacarpal-phalangeal joint arthroplasty

polidocanal injections for lateral/medial epicondylitis

magnets or diathermy for lateral/ medial epicondylitis

radiofrequency microtenotomy for lateral epicondylitis
Insertion of:

'Initial Treatment' subsections into most non-operative sections of specific
disorders.

Discussion and related recommendations for smoking cessation where
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Section G: Specific Peripheral Nerve
Diagnosis, Testing, and Treatment
Procedures (cont)
SUBSTANTIVE CHANGE
applicable

Hatha yoga therapy for carpal tunnel syndrome
Insertion of text related to the complete continuum of care(Description to PostOperative Treatment:

Cubital Tunnel Syndrome*

Guyon Canal (Tunnel) Syndrome*

Pronator Syndrome*

Radial Tunnel Syndrome*

Posterior Interosseus Nerve Entrapment (PIN)
*Denotes that treatment strategies related to this disorder are addressed in the
currently effective Cumulative Trauma Disorder and/or Carpal Tunnel Syndrome
Medical Treatment Guideline, but on a much less extensive level.
Stated as ‘not recommended’:

MRI, imaging, and sonography for carpal tunnel syndrome unless a spaceoccupying lesion is suspected.

magnets for carpal tunnel syndrome
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Section G: Specific Peripheral Nerve
Diagnosis, Testing, and Treatment
Procedures (cont).
SUBSTANTIVE CHANGE

laser acupuncture for carpal tunnel syndrome

chiropractic for carpal tunnel syndrome
Changes in Recommendations:

Section H. Therapeutic Procedures – NonOperative
Oral steroids: still stated as not recommended for carpal tunnel syndrome.
However may occasionally be used for patients with severe symptoms who
refuse injections and who have no risk factors for adverse effects.
Insertion of text regarding:

autologous whole blood injections;

platelet-rich plasma injections;

botulinum toxin injections(prior authorization required);

viscosupplementation/intracapsular acid salts;

expanded text on topical drug delivery
 topical salicylates and nonsalicylates
 capsaicin

paraffin bath

manipulation (a separate section now separated from manual therapy
techniques)
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Section H. Therapeutic Procedures – NonOperative (cont).
Deletion of text regarding:

tramadol

microcurrent transcutaneous electrical nerve stimulation (TENS)
Stated as ‘not recommended:’

prolotherapy

NSAIDs for routine use for prevention of heterotopic bone formation

benzodiazepines on a routine basis due to habit-forming potential

topical glyceryl trinitrate for epicondylitis

topical lidocaine patches, but may in some cases be used when primary
complaint is pain and the patient refuses a steroid injection
Changes in Recommendations:

oral steroids: limited use but are accepted in cases requiring potent
inflammatory drug effect. May be considered for patients who have
frequent flare-ups of arthritic joints.

extracorporeal shock wave therapy (ESWT)- now an accepted treatment
for lateral and medial epicondylitis.
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