Lateral epicondylitis, often called “tennis elbow,” is a musculoskeletal condition characterized by pain around the lateral elbow and adjacent forearm with resisted wrist extension or passive terminal wrist flexion with the elbow in full extension, plus tenderness over and/or just distal to the lateral epicondyle. The name is a misnomer because the pathology is neither inflammatory nor located in the lateral epicondyle but rather represents a chronic tendinosis with disorganized tissue and neovessels of the tendon originating from the extensor carpi radialis brevis muscle and less commonly the extensor digitorum communis muscle, which originate on the lateral epicondyle. Clinical assessment involves understanding the chronology, precipitating activities, current symptoms, and interference with activities of daily living. Physical examination is performed bilaterally and includes palpitation provocative testing, measuring elbow and wrist motions, and neurological evaluation. Many treatments have been proposed, but little quality evidence supports any specific approach; more than 90% of cases are managed nonoperatively. Severe cases that have failed at least months of nonoperative management may warrant surgical assessment, but studies of surgical results for treatment of lateral epicondylitis are limited. Impairment rating may be necessary in a minority of cases and involves using the AMA Guides to the Evaluation of Permanent Impairment ( AMA Guides ), Sixth Edition, based on diagnosis-based impairment and using Table 15-4, Elbow Regional Grid: Upper Extremity Impairments.

The rotator cuff comprises four muscles and their tendons, the supraspinatus, infraspinatus, teres minor, and subscapularis. Rotator cuff tears (RCTs) are common and most frequently involve the supraspinatus, and usually occur through tendon rather than muscle. Clinical manifestations vary depending on the size and age of the tear, the individual's physical demands, psychosocial factors, and other variables; tears may range from the asymptomatic to large, full-thickness, and retracted tears that cause pain, weakness, and at least partial disability. Individuals involved in rear-end motor vehicle collisions (MVCs) may complain of “shoulder” pain, and magnetic resonance imaging may reveal the presence of shoulder cuff tears, high-energy trauma can cause rotator cuff tears, but the tensile forces encountered in rear-end MVCs almost certainly do not cause rotator cuff tears de novo. Because rear-end collisions and RCTs are common and often involve claims or lawsuits, physicians may be asked to assess the causation of the RCTs. Treatment should be based on clinical findings and not the results of imaging; the same applies to causation analysis: Involvement in a rear-end MVC does not establish causality for a rotator cuff tear. The medical literature is devoid of evidence indicating that rear-end collisions cause RCTs, but compelling evidence in the biomechanical literature shows that low-speed rear-end MVCs do not cause RCTs.

The first four editions of the AMA Guides to the Evaluation of Permanent Impairment ( AMA Guides ) used the range of motion (ROM) method and derived impairment percentages. This method is reliable and works well to rate finger joint injuries such as fractures or sprains that cause reduced finger joint ROM, but it frequently underestimates the functional difficulty (impairment) caused by tendon injuries that restrict the excursion of tendons. For this reason, the AMA Guides, Fifth Edition, introduced a second method to rate ROM in fingers, the total active motion (TAM) method. When an evaluator calculates the patient's impairment using the traditional method from the first four editions of the AMA Guides, the impairment percentage is likely to underestimate the patient's “real world” difficulty or function; the TAM method measures flexion when the metacarpophalangeal, proximal interphalangeal, and distal interphalangeal joints are in full simultaneous flexion, and it measures extension when all three joints are in full simultaneous extension. Based on an example and using the Combined Values Chart in the Fifth Edition and the traditional method (the only method allowed in the first four editions), one would assess a 16% impairment of the digit; using the TAM method now available in the Fifth Edition, the impairment is more appropriately estimated at 61%.

This article discusses situations in which an evaluating physician may find rating according the AMA Guides to the Evaluation of Permanent Impairment ( AMA Guides ) cumbersome, including fingertip injuries, transection of flexor digitorum sublimis tendon, medial and lateral epicondylitis, upper extremity amputations, and recurrent shoulder dislocation. On finding decreased motion at a finger distal interphalangeal joint (DIP) or thumb interphalangeal (IP) joint, the examiner should carefully assess the functional consequences and ensure the rating adequately addresses the impairment but does not rate the same problem twice. Laceration of the distal palm or proximal phalanx of a finger resulting in isolated transection of the flexor digitorum sublimis tendon (flexor digitorum profundus tendon remains intact) is a challenging scenario. Medial and lateral epicondylitis are not mentioned in the AMA Guides because usually they resolve with time. Grip strength loss usually is not an appropriate way to rate epicondylitis because pain limits grasp in this condition. Impairment ratings for upper extremity amputations may not be consistent in terms of the location where the procedure is used. Recurrent shoulder dislocation may complicate an initial traumatic dislocation, particularly in younger patients and must be medically documented rather than anecdotally reported. When faced with a situation that is not covered in the AMA Guides, the rating physician should consider analogous situations, consult other manuals or guidelines, or discuss the case with other experienced evaluators.