1081
ORIGINAL ARTICLE
The Effects of Splinting on Outcomes for Epicondylitis
V. Jane Derebery, MD, Jenny N. Devenport, PhD, Geneva M. Giang, MBA, W. Tom Fogarty, MD
ABSTRACT. Derebery VJ, Devenport JN, Giang GM,
Fogarty WT. The effects of splinting on outcomes for epicon-
dylitis. Arch Phys Med Rehabil 2005;86:1081-8.
Objective: To evaluate the effects of splinting on outcomes
for injured workers with epicondylitis.
Design: Retrospective cohort study using propensity score
methodology to statistically control for all observed pretreat-
ment differences between patients with and without splints.
Setting: Nationwide network of 253 occupational medicine
clinics.
Participants: All injured workers (N⫽4614) receiving pri-
mary care for lateral or medical epicondylitis (International
Classification of Diseases, 9th Revision, codes 726.31 or
726.32).
Interventions: Not applicable.
Main Outcome Measures: Physician-prescribed rates of
duty restrictions and lost time, treatment duration, specialist
referrals, and medical and physical therapy (PT) visits and
charges.
Results: Overall, patients with splints had higher rates of
limited duty (P⬍.001), more medical visits and charges
(P⬍.001), higher total charges (medical and PT, P⬍.001), and
longer treatment durations (P⬍.01) than patients without
splints. Evaluating differences for patients who did and did not
receive PT, significant differences remained for rates of limited
duty (P⬍.05), medical visits (P⬍.01), and medical charges
(P⬍.01).
Conclusions: Splinting patients with epicondylitis may not
optimize outcomes, including rates of limited duty, treatment
duration, and medical costs.
Key Words: Epicondylitis; Occupational medicine; Reha-
bilitation; Splints.
© 2005 by the American Congress of Rehabilitation Medi-
cine and the American Academy of Physical Medicine and
Rehabilitation
PPER-EXTREMITY DISORDERS believed to result
U from repetitive and/or forceful work activity are of major
concern in occupational medicine and workers’ compensation.
According to the US Bureau of Labor Statistics, between 1988
and 1992 the number of repeated trauma cases reported in-
creased by 144%, compared with a 3% increase for all other
injuries and illnesses.1,2 By 2001, repeated trauma accounted
for 4% of the 5.2 million total workplace injuries and illnesses
and 65% of occupational illnesses, with work-related upper-
extremity disorders (WRUEDs) accounting for most of these.3
Epicondylitis is one of the common WRUED diagnoses.
There are conflicting studies on the cause of epicondylitis and,
From Concentra Inc, Addison, TX.
No commercial party having a direct financial interest in the results of the research
supporting this article has or will confer a benefit upon the authors(s) or upon any
organization with which the author(s) is/are associated.
Reprint requests to Jenny N. Devenport, PhD, Concentra Inc, 5080 Spectrum Dr,
Ste 400, West Tower, Addison, TX 75001, e-mail: Jenny_Novotny@concentra.com.
0003-9993/05/8606-9367$30.00/0
doi:10.1016/j.apmr.2004.11.029
in particular, its work-relatedness.4-13 A review of epidemio-
logic studies of workplace factors by the US National Institute
of Occupational Safety and Health (NIOSH) determined that
there was insufficient evidence for (1) an association between
repetitive work and elbow musculoskeletal disorders and (2) an
association between postural factors and epicondylitis.14 Both
findings are contrary to common assumptions of both workers
and physicians, which include, for instance, belief in a causal
link between keyboarding and epicondylitis.15 The NIOSH
review concluded that there was evidence for an association
between forceful work and epicondylitis and strong evidence
for a relationship between exposure to a combination of risk
factors (force, repetition, posture) and epicondylitis.14
Most patients with epicondylitis are managed by primary
care physicians, and common treatments include rest, ice, non-
steroidal anti-inflammatory drugs (NSAIDs), corticosteroid
injections, range of motion exercises, stretching and strength-
ening exercises, counterforce bracing and splinting, ionto-
phoresis, acupuncture, and ergonomic adjustments or training.
Less commonly, refractory cases may be treated surgically.16-18
The long-term prognosis for epicondylitis is good, with 80% of
patients recovering within a year.19,20 However, there is no
strong consistent evidence to support any one treatment as
being more efficacious in the long term than any other, includ-
ing “wait and see.”12,18,20-23 Recent research18,20 suggests that,
in the short term (4 – 6wk), corticosteroid injections may out-
perform physical therapy (PT), NSAIDs, and wait-and-see
treatments, but with longer follow-up, most patients improve
regardless of treatment.
Study results for splinting, a commonly prescribed treat-
ment, are also equivocal, with some studies yielding findings
that conflict with the proposed therapeutic mechanisms of
splints. Presumably, splints are offered to patients to provide
short-term support to weakened or sore muscles, to reduce
pain, and to cushion the injured area—thereby promoting re-
turn to activity. But in a randomized study24 of patients with
unilateral epicondylitis, none of the bracing conditions (includ-
ing no brace) was associated with significant differences in
pain-free grip strength. In another randomized experimental
study of nonimpaired patients,25 researchers found that wearing
a forearm band increased rather than reduced extensor muscle
fatigue, as measured by wrist extension force and peak grip
isometric force. Such findings suggest that splints might hinder
activity and potentially contribute to deconditioning, contrary
to indications. Most recently, a randomized clinical trial26 of
brace-only, PT, and combination treatment found mixed re-
sults, with different conditions achieving superior results on
different outcomes at 6 weeks and no significant differences
between groups at 26 and 52 weeks.26
Despite the paucity of evidence to suggest that relative rest,
immobilization, or splinting is indicated in the treatment of
epicondylitis, it is common for patients to be restricted from
certain activities at work, as well as to be braced or splinted at
least initially, to rest the wrist and/or elbow. Such treatment is
prescribed even when the job activities are not necessarily
forceful or excessive, which raises the concern of overuse or
misuse of a medical treatment for a condition that might
resolve more quickly without restrictions, rest, or immobiliza-
tion in many cases.20 It is quite possible, for example, that once
Arch Phys Med Rehabil Vol 86, June 2005
1082 SPLINTING AND EPICONDYLITIS OUTCOMES, Derebery

Table 1: Initial Differences Between Treatment Groups, Splint Versus No Splint

Splint No Splint Comparisons†
Mean ⫾ SD Mean ⫾ SD Standardized
Variable (n⫽3236) (n⫽1378) Diff in %‡

% with high severity ¶

89.7⫾30.4 84.0⫾36.7 ⫺16.95*
Patient age (y) 41.42⫾9.29 41.32⫾9.54 ⫺1.00
Sex (% male) 57.8⫾49.4 61.2⫾48.7 7.12*
Marital status (% married)储 50.1⫾50.0 47.8⫾50.0 ⫺4.66
% with lateral epicondylitis 82.4⫾38.1 78.3⫾41.2 ⫺9.38*
% treated within 1wk of injury 59.9⫾49.0 55.2⫾49.7 ⫺10.16*
% initial provider⫽physician 71.9⫾44.9 73.3⫾44.3 3.04
% with prior case 37.2⫾48.3 35.1⫾47.7 ⫺4.42
% with initial drug screen 26.3⫾44.0 22.0⫾41.4 ⫺10.15*
2
Region (4: midwest/east, south, west, southeast) ␹3 test⫽36.21 *

Abbreviation: SD, standard deviation.

*P⬍.05.
†
The Fisher exact test used to compare means for all variables except age and region; t test used for age; chi-square used for region.
‡
The standardized difference is the mean difference between groups divided by the average standard deviation: 100(ms⫺mns)/公[(ss2 ⫹ sns 2
)/2], where for
each covariate ms and mns are the subclass means for the splinted and not splinted cases, respectively, and ss2 and sns
2
are the corresponding variances.
¶
Internal rating given by initial treating provider (original scale: no objective findings, mild, moderate, severe; used moderate ⫹ severe vs mild
⫹ no objective findings based on frequency analysis, suggesting dichotomous variable more reflective of use).
储
N⫽3219 and 1376 for splinted and not splinted, respectively, because of missing data.

a patient becomes symptomatic of epicondylitis, certain routine
activities cause an increase in symptoms, misleading the pa-
tient (and doctor) to think that the activity “caused” the disor-
der and should be avoided even when use of the arm, despite
pain, may in actuality lead to a more rapid recovery.
The primary goal of treatment of epicondylitis should be the
patient’s rapid and enduring return to full functioning. For
splinting to be recommended in the context of evidence-based
medicine, it would be prudent to show that patients with splints
show faster and more sustained improvements in pain and/or
function than patients without splints. Specific to occupational
medicine and workers’ compensation, patients with splints
would need to have less time off work, less duty restrictions,
shorter treatment durations, and lower medical costs than pa-
tients without splints. To date, we know of no studies that
address each of these work-related outcomes relative to splint-
ing.
The purpose of this article was to evaluate the effects of
splinting on outcomes for injured workers with epicondylitis.
Specifically, retrospective analyses of patients were undertaken
to identify pretreatment differences in splinted and nonsplinted
patients on background and initial injury characteristics, to
statistically control for these differences, and to estimate the
effects of splinting on functional and treatment outcomes most
relevant to occupational medicine.
METHODS
Participants
The patient population in this study consisted of patients
receiving primary care for lateral or medial epicondylitis (In-
ternational Classification of Diseases, 9th Revision, codes
726.31 or 726.32) at any clinic within a nationwide network of
253 occupational medical centers. This network, owned and
operated by Concentra Inc, sees approximately 7% of US
workers’ compensation patients. Patient records were retrieved
from the proprietary internal information management system,
which contains patient demographic and injury information, as
well as transaction-level treatment, diagnostic, billing, and
outcomes information. All patients who were of legal working
age (at least 16 years old) and who received primary injury care
at the centers with treatment episodes beginning in calendar
year 2002 and ending by July 31, 2003, were eligible for the
study. Fifty-one patients were excluded because of concurrent
treatment for complicating injuries not involving the elbow. A
total of 4614 patients remained for inclusion in subsequent
analyses.
Splinting
Splinting was identified from the electronic records for pa-
tient visits. A variety of restraints was provided to these pa-
tients, at their treating provider’s discretion, to reduce move-
ment and apply supportive tension to the elbow/wrist and
associated extensor muscles. Because the comparison of inter-
est in this study was splints versus no splints (rather than
comparisons of splints applied to the elbow versus both the
elbow and wrist), patients were counted as receiving a splint if
they received any restraint to the elbow, forearm, or wrist
areas—including braces, splints, straps, and wrap bandages.
Evaluation of Splinting Differences
To control for pretreatment differences between patients
who did and did not receive splints, the first step was to identify
and quantify observed differences. Table 1 presents summary
information on available background characteristics and initial
condition for patients who did and did not receive splints.
Independent t tests and chi-square tests were conducted to
assess group differences. No significant differences were ob-
served for patient age (measured in years), the type of initial
treating provider (primary care physician [MD or DO] vs
physician assistant), patient marital status (single, married),
and the existence of any prior injury claim within the network
(yes, no). Significant differences were observed for severity
ratings by the initial treating provider (patients with moderate
to severe ratings were more likely to receive splints than
patients with mild ratings), gender (higher rates of splinting for
females versus males), diagnosis (higher rates of splinting for
patients with lateral versus medial epicondylitis), for treatment
lag (higher rates of splinting for patients treated within 1wk of
injury vs those treated ⬎1wk), for drug screen (higher rate of
splinting for patients who received a drug screen, an optional
service provided during the initial visit at the discretion of the
employer or governing laws of the area), and for geographic
region (patients in the west and southeast regions received

Arch Phys Med Rehabil Vol 86, June 2005

 SPLINTING AND EPICONDYLITIS OUTCOMES, Derebery
splints more than patients in the south, midwest, and east
regions).
Statistical Control of Pretreatment Differences
In a retrospective study of usual care patterns, it is not
reasonable to presume that splinting decisions were made at
random, that patients had an equal chance of having a splint
versus not having a splint, or that pretreatment differences
among patients were uncorrelated with outcome prognoses. In
our example, patients with more severely rated injuries were
more likely to receive splints, but we might also expect patients
with more severe injuries to miss work, to require more duty
restrictions, to incur more medical charges, and to have longer
treatment durations than less severe cases even before splinting
decisions. Thus, an immediate comparison of these outcomes
for patients with and without splints would be misleading.
Propensity score methodology is a statistical approach used
in observational studies to control simultaneously for multiple
pretreatment covariates to create equivalent groups of patients
who did and did not receive a particular treatment.27-31 The
propensity score represents the conditional probability of re-
ceiving a particular treatment—in our study, a splint— given
observed covariates. Simply put, the propensity score reduces
the differences between patients on several variables to a
one-number summary. If 2 patients, one who received a splint
and one who did not, have the same propensity to receive a
splint (predicted from a set of potential confounding variables),
then they would not systematically differ with respect to the
predictor variables.29,31 That is, these variables would not help
predict which of these 2 patients received the splint. As in a
randomized experiment, the treatment assignment would be
independent of these predictor variables. Thus, observed dif-
ferences in outcomes for these patients could not be attributed
to the pretreatment differences on the predictors because they
were balanced at the start. Similarly, if patients are divided into
equally sized subclasses based on the magnitude of their pro-
pensity scores, it has been shown that the average treatment
effect within subclasses (the difference between splinting and
not splinting within a given range of propensity scores) will be
an unbiased estimate of the true treatment effect.27-28,32
Estimating Propensity Scores and Treatment Effects
In our study, the propensity to receive a splint was estimated
by using a logistic regression model with splint (yes, no) as the
dichotomous dependent variable and the demographic and pre-
treatment covariates described earlier as predictors. Modeling
proceeded iteratively. Once a solution was estimated, the re-
sulting propensity scores (conditional probability of receiving a
splint) were divided into 5 equally sized subclasses based on
their rank (ie, patients with the lowest propensity scores in the
first subclass, patients with the highest propensity scores in the
fifth subclass). Then the success of the model at achieving
balance on the covariates was evaluated by looking at within-
and across-subclass differences between splinted and non-
splinted patients for each covariate (using analysis of variance
or logistic regression as appropriate). The initial main effects
model that included all the covariates alone (and no interac-
tions) did not result in balance— defined as no significant main
effects for splinting or interaction effects of splinting and
subclass on all covariates. This model was refined by adding
clinically reasonable and/or statistically significant covariate
interactions. The final model, presented in table 2, includes all
significant main effects, plus the main effects used in the
included interactions. By using this model, balance was
achieved on all covariates, meaning that, within propensity
1083
score subclasses, there were no remaining statistically signifi-
cant differences between splinted and nonsplinted patients on
any of the covariates. Figure 1 displays side-by-side boxplots
of the propensity scores for splinted and nonsplinted patients
within each of the 5 subclasses. The degree of symmetry in the
medians, the similarity in the size of the boxes, and the length
of the whiskers further support the adequacy of the final pro-
pensity score model for reducing pretreatment differences on
observed covariates.
Finally, to estimate outcome differences between splinted
and nonsplinted patients while controlling for background co-
variates, the within-subclass means and standard errors (SEs)
for the 2 groups were calculated and then used to compute
overall differences and standard errors.28,33 The outcomes of
interest were the percentage of cases put on limited duty or
taken off work by the treating provider (as distinct from the
percentage of patients who elect to take off work or are taken
off work by their employers), treatment duration (from the first
date of service to the last date of service), the percentage of
patients who completed their care in the network (eg, released
from care to full duty by the network vs opting out), and the
percentage of paients referred to specialists. Limited duty rates,
lost time rates, and treatment durations are standard measures
of the effectiveness of medical management in workers’ com-
pensation cases. Treatments that minimize these measures
while improving patient function and symptoms are preferred.
Referral to a specialist generally indicates the failure of con-
servative treatment efforts to yield adequate improvement. The
final outcome, completion rate, is potentially indicative of
patient and/or employer satisfaction with care, in addition to
success of care. If large disparities in completion rates exist
between treatment groups, the treatment with the higher com-
pletion rate would be preferred (assuming the treatment is
effective).
In addition to the main hypothesis, splinting versus not
splinting, the effect of PT was also assessed. The medical
model of the network in our study favors aggressive therapeutic
interventions—including strength training, patient education,
manual therapy, and electrotherapeutic modalities—so the
splinting effect needed to be measured in the presence or
absence of PT interventions. Propensity scores for splinting
were reestimated separately for patients who did and did not
receive PT. For patients who received therapy, the lag from
initiation of the episode of care to the initiation of PT was also
included as a covariate in the model. Models were estimated
and evaluated for adequacy of covariate and overall score
balance by using the methods described earlier for the main
comparison. Not all the same main effects and interactions
were included in these models, although balance on all the
covariates and the resulting estimated propensity scores were
verified. The within-subclass means and SEs were then calcu-
lated and used to assess the splinting effect for patients with
and without PT.
RESULTS
Splinting Main Effect
Table 3 summarizes differences in outcome measures for
patients with and without splints. Means and SEs for each
outcome measure are presented for splinted versus nonsplinted
patients within propensity score subclasses and averaged across
subclasses. Significance test results, noted in the last row of the
table, refer to the overall mean difference observed for splint-
ing versus not splinting (calculated as a 2-tailed z test, signif-
icant at P⬍.05).
Arch Phys Med Rehabil Vol 86, June 2005
1084 SPLINTING AND EPICONDYLITIS OUTCOMES, Derebery

Table 2: Logistic Regression Model Estimates for Propensity to Receive Splint

Covariate Estimate SE Wald z Score df P

% with high severity (SEV) .69 .13 26.96 1 .00

Patient age (AGE) .00 .00 0.40 1 .53
Marital status (MSAT) .38 .18 4.64 1 .03
Gender (% male) ⫺.14 .07 4.41 1 .04
% treated within 1wk of injury .16 .07 5.72 1 .02
% with lateral epicondylitis .26 .08 9.78 1 .00
% initial provider⫽physician (TYPEPROV) ⫺.25 .10 6.18 1 .01
% with prior case (PREVIOUS) .16 .09 3.25 1 .07
REGION 10.88 3 .01
REGION (1) .17 .20 0.76 1 .38
REGION (2) .43 .20 4.48 1 .03
REGION (3) .94 .33 8.13 1 .00
% with initial drug screen (DRUGSCRN) .72 .35 4.18 1 .04
AGE by DRUGSCRN ⫺.01 .01 1.74 1 .19
TYPEPROV by REGION 11.58 3 .01
TYPEPROV by REGION (1) ⫺.59 .24 6.36 1 .01
TYPEPROV by REGION (2) ⫺.01 .23 0.00 1 .97
TYPEPROV by REGION (3) ⫺.88 .36 5.86 1 .02
PREVIOUS by REGION 9.16 3 .03
PREVIOUS by REGION (1) ⫺.74 .30 5.81 1 .02
PREVIOUS by REGION (2) ⫺.80 .35 5.12 1 .02
PREVIOUS by REGION (3) .28 .52 0.30 1 .58
TYPEPROV by REGION by PREVIOUS 6.32 3 .01
TYPEPROV by REGION (1) by PREVIOUS .92 .37 6.06 1 .01
TYPEPROV by REGION (2) by PREVIOUS .48 .40 1.42 1 .23
TYPEPROV by REGION (3) by PREVIOUS .04 .54 0.00 1 .95
MSTAT by SEV ⫺.33 .19 2.93 1 .09
Constant ⫺.02 .24 0.01 1 .94

NOTE. Hosmer and Lemeshow goodness of fit: ␹82 test⫽4.39, P⫽.820. Omnibus model ␹23
2
test⫽140.46, P⬍.001.
Abbreviation: SE, standard error.

Overall significant differences between splint groups were
found for rate of limited duty, number of medical visits, med-
ical charges, total primary care charges (includes PT), and
treatment duration. Patients with splints had higher rates of
limited duty within each subclass and overall (range, 7%–20%)
than nonsplinted patients. Typical duty modifications and re-
strictions prescribed by the treating physician involved lifting
restrictions and limitations on time spent doing forceful or
repetitive tasks. Patients with splints also had an average of 1
more medical visit within and across all subclasses, higher
medical charges (expected given the additional medical visit),
higher total charges (PT plus medical), and treatment durations
that were an average of 12 days longer than patients without
splints. Differences in rates of lost time, the percentage of
patients completing care, and the percentage of patients re-
ferred out to specialists were not statistically significant.
These results do not suggest an advantage for splinting from
an outcomes perspective. With the adjustments included for
pretreatment differences, these results suggest that splinted
patients had worse outcomes in terms of treatment duration,
return to activity, and medical costs without improving rates of
care completion than did patients without splints. However, the
significant differences in total charges (which include therapy
charges) do suggest a need for further investigation of the
hypothesis that therapy interventions contribute to higher costs
and longer treatment durations.

Splinting and Therapy

Fig 1. Boxplot showing balance of propensity scores within sub-
classes. Confidence interval is 99%.
Table 4 exhibits outcome differences for splinting and not
splinting in patients who did not receive PT. Means with SEs
are presented within and across subgroups for each outcome
measure. Overall significance results are presented in the bot-
tom row for each outcome variable. Significant differences

Arch Phys Med Rehabil Vol 86, June 2005

 SPLINTING AND EPICONDYLITIS OUTCOMES, Derebery 1085

Table 3: Estimated Outcome Differences Between Groups, Splint Versus No Splint*

%
Completed
Care (full
No. of Avg MD Avg MD Avg Total duty Avg Treatment % Refd Out
Subclass Splint Patients % Ltd Duty % Lost Time Visits Charges ($) Charges ($) release) Duration to Specialist

1 No 383 48.3⫾2.6 1.3⫾0.6 2.88⫾0.12 321.21⫾13.50 709.20⫾35.74 53.0⫾2.6 24.31⫾2.14 18.0⫾2.0

Yes 536 68.5⫾2.0 0.9⫾0.4 4.03⫾0.11 459.38⫾13.06 1108.39⫾41.77 56.7⫾2.1 36.11⫾2.36 22.0⫾1.8
2 No 305 60.3⫾2.8 1.6⫾0.7 3.46⫾0.15 406.60⫾20.70 899.82⫾53.30 56.0⫾2.8 30.66⫾3.31 16.4⫾2.1
Yes 614 76.1⫾1.7 1.1⫾0.4 4.37⫾0.10 510.48⫾13.57 1205.58⫾36.97 57.8⫾2.0 41.73⫾2.73 21.2⫾1.6
3 No 283 62.5⫾2.9 1.8⫾0.8 3.42⫾0.14 413.35⫾16.30 843.41⫾40.33 54.1⫾3.0 35.05⫾3.55 20.5⫾2.4
Yes 636 79.9⫾1.6 1.4⫾0.5 4.56⫾0.12 563.38⫾18.74 1285.71⫾47.53 59.0⫾2.0 40.63⫾2.57 20.1⫾1.6
4 No 226 74.3⫾2.9 0.9⫾0.6 3.72⫾0.17 449.24⫾23.32 895.24⫾49.45 60.2⫾3.3 34.28⫾3.87 17.7⫾2.5
Yes 693 81.5⫾1.5 1.4⫾0.4 4.90⫾0.13 596.57⫾17.28 1283.01⫾39.06 59.7⫾1.9 47.72⫾2.57 26.7⫾1.7
5 No 179 68.2⫾3.5 2.2⫾1.1 3.78⫾0.23 421.28⫾24.89 819.10⫾58.62 60.3⫾3.7 36.26⫾4.75 19.6⫾3.0
Yes 740 79.3⫾1.5 1.6⫾0.5 5.15⫾0.13 606.98⫾17.36 1274.17⫾37.78 62.4⫾1.8 54.38⫾2.89 27.4⫾1.6
Overall No 1376 62.7⫾2.9 1.6⫾0.8 3.45⫾0.16 402.33⫾20.20 833.36⫾48.22 56.7⫾3.1 32.11⫾3.63 18.4⫾2.4
Yes 3219 77.0⫾1.7 1.3⫾0.4 4.60⫾0.12 547.36⫾16.16 1231.37⫾40.80 59.1⫾2.0 44.11⫾2.63 23.5⫾1.7
P⬍.01 NS P⬍.01 P⬍.01 P⬍.01 NS P⬍.01 NS

NOTE. Values mean ⫾ SE unless otherwise indicated. N⫽4595. Marital status, which was included in the propensity score estimation, was not
provided by 19 patients. Thus, their propensities were not estimated and included in this set, although they were included in later analyses.
Abbreviations: Avg, average; Ltd, limited; NS, not significant; Refd, referred.
*Subclasses of equal size were created according to the ranked propensity score; within subclasses, patients with and without splints have
similar propensity scores; overall estimates were produced using direct standardization methods with subclass total weights.34,41

were again observed for rates of limited duty, number of
medical visits, and medical charges. As with the overall results,
outcome differences did not favor splinting. Patients without
splints were less likely to have limited duty, had fewer medical
visits, and had lower medical charges than their splinted coun-
terparts. However, no differences in treatment duration were ob-
served, in contrast with the overall results presented in table 3.
Table 5 presents analogous comparisons for splinting and
not splinting in patients who received PT. Again, statistically
significant differences in limited duty rates, medical visit
counts, and medical charges were observed, and worse out-
comes for splinted patients were shown. In addition, splinted
patients received an average of 1 more therapy visit than
nonsplinted patients and had higher overall charges for therapy.
The total treatment duration difference was not significant,
which suggests that additional therapy, either alone or in com-
bination with additional medical visits, may be responsible for
the differences in treatment duration observed in the overall
population. But the consistency of results independent of ther-
apy suggests that splinting does not promote, and may even
impede, optimal outcomes.
DISCUSSION
A treating provider’s main reasons for prescribing a splint
are, presumably, to rest the arm and to alleviate pain or dis-
comfort. However, no good correlation between a patient’s
subjective pain ratings and his/her ability to work or to perform
certain physical activities has been established, nor has a cor-
relation been found between the decrease in symptoms and the
rate of return to work.34,35 In addition, prescribing a splint is
likely to necessitate movement restrictions that may further
impede recovery and contribute to disability in those cases in
which the job activities, which may lead to discomfort, do not
actually cause the condition. Such restrictions can have an

Table 4: Estimated Outcome Differences Between Groups, Splint Versus No Splint for Cases Without PT*
% Completed
No. of Avg MD Charges Care Avg Treatment % Refd Out
Subclass Splint Patients % Ltd Duty % Lost Time Avg MD Visits ($) (full duty release) Duration to Specialist

1 No 154 24.7⫾3.5 1.3⫾0.9 2.14⫾0.14 249.70⫾14.03 49.35⫾4.04 18.18⫾2.80 13.6⫾2.8

Yes 105 39.0⫾4.8 1.0⫾1.0 2.89⫾0.20 348.00⫾24.36 55.24⫾4.88 21.30⫾3.60 10.5⫾3.0
2 No 115 33.9⫾4.4 0.9⫾0.9 2.49⫾0.27 323.54⫾33.26 43.48⫾4.64 22.15⫾4.56 14.8⫾3.3
Yes 143 58.7⫾4.1 0.0⫾0.0 3.31⫾0.18 395.36⫾21.10 51.75⫾4.19 25.17⫾3.25 15.4⫾3.0
3 No 103 37.9⫾4.8 0.0⫾0.0 1.99⫾0.13 265.67⫾16.59 43.69⫾4.91 22.96⫾4.63 11.7⫾3.2
Yes 158 55.7⫾4.0 0.0⫾0.0 3.29⫾0.19 391.21⫾22.78 47.47⫾3.99 27.47⫾3.90 20.3⫾3.2
4 No 87 41.4⫾5.3 1.1⫾1.1 2.40⫾0.20 319.52⫾23.57 48.28⫾5.39 20.90⫾4.14 18.4⫾4.2
Yes 172 58.7⫾3.8 0.6⫾0.6 3.19⫾0.17 418.37⫾21.12 51.74⫾3.82 27.37⫾4.34 15.7⫾2.8
5 No 69 59.4⫾6.0 4.3⫾2.5 2.93⫾0.29 339.54⫾34.44 56.52⫾6.01 20.07⫾5.97 15.9⫾4.4
Yes 190 48.4⫾3.6 0.5⫾0.5 3.12⫾0.20 368.02⫾20.80 54.21⫾3.62 30.49⫾5.00 12.6⫾2.4
Overall No 528 39.4⫾4.9 1.5⫾1.3 2.39⫾0.21 299.52⫾25.75 48.26⫾5.04 20.85⫾4.53 14.9⫾3.6
Yes 768 52.1⫾4.1 0.4⫾0.6 3.16⫾0.19 384.19⫾22.08 52.08⫾4.12 26.36⫾4.06 14.9⫾2.9
P⬍.05 NS P⬍.01 P⬍.01 NS NS NS

NOTE. Values mean ⫾ SE unless otherwise indicated.

*Subclasses of equal size were created according to the ranked propensity score; within subclasses, patients with and without splints have
similar propensity scores; overall estimates were produced using direct standardization methods with subclass total weights.

Arch Phys Med Rehabil Vol 86, June 2005

1086 SPLINTING AND EPICONDYLITIS OUTCOMES, Derebery

adverse impact on the patient, not only physiologically but also

*Subclasses of equal size were created according to the ranked propensity score; within subclasses, patients with and without splints have similar propensity scores; overall estimates
4.89⫾0.26 684.57⫾41.59
5.97⫾0.23 886.53⫾37.18
5.30⫾0.30 707.88⫾41.79
6.46⫾0.25 931.13⫾39.60
5.59⫾0.37 728.77⫾44.20
6.65⫾0.24 946.81⫾36.17
5.44⫾0.34 642.31⫾37.65
6.64⫾0.22 828.20⫾27.27
6.56⫾0.53 735.46⫾56.28
7.65⫾0.27 894.93⫾29.46
5.56⫾0.37 699.85⫾44.76
6.67⫾0.24 897.56⫾34.27
psychologically.36 Splint use sends a powerful message, not

Charges ($)
Avg PT

P⬍.01
only to the patient but also to family and colleagues, that the
patient has an injury and that the injured arm needs to be rested.
Because good physical conditioning is helpful to the healing
process of nontraumatic injuries as well as to job performance
under healthy circumstances, it is all the more important to
Avg PT

P⬍.01
Visits

consider carefully both the risks and the benefits of splinting.

Our study used patient data collected by a large occupational
medicine network to explore the effects of splinting versus not
splinting on outcomes for epicondylitis patients. Pretreatment
% Refd Out to

16.2⫾2.4
21.4⫾2.0
22.2⫾2.9
21.7⫾1.9
22.2⫾3.3
24.7⫾1.9
18.5⫾3.2
27.5⫾2.0
28.0⫾4.4
34.8⫾2.0
21.4⫾3.3
26.0⫾2.0
Specialist

differences in observed demographic and initial injury charac-

NS
teristics were identified and controlled for by using propensity
score methods. The obtained results suggest that the presumed
benefits of splinting— commonly including alleviation of dis-
Table 5: Estimated Outcome Differences Between Groups, Splint Versus No Splint for Cases With PT*

comfort, cushioning of the area, and support of weakened

Avg Treatment

muscles—may not translate to better outcomes. Rather, splint-

29.29⫾3.17
37.26⫾2.70
36.08⫾4.47
47.26⫾3.39
31.83⫾3.23
44.60⫾3.13
44.94⫾6.03
50.01⫾2.58
56.53⫾7.59
68.01⫾3.66
39.74⫾5.19
49.44⫾3.12
Duration

NS ing appears to be related to higher treatment utilization and

costs and higher rates of duty restrictions (which translate to
higher indemnity costs for workers’ compensation cases) than
not splinting— even after adjusting for important pretreatment
differences, such as severity, age, injury history, geographic
% Completed Care
(full duty release)

region, and other characteristics.

The results of our study are consistent with research on
60.0⫾3.2
55.6⫾2.4
61.4⫾3.4
61.9⫾2.3
63.0⫾3.8
62.2⫾2.2
62.3⫾4.0
62.8⫾2.1
57.9⫾4.8
64.7⫾2.0
60.9⫾3.9
61.4⫾2.2

activity restriction reported for other types of musculoskeletal

NS

injuries. Back pain studies have found that patients who remain
active despite back pain do better than those who rest.37,38
Similarly, it has been reported that, in chronic back pain
patients who experience increased pain during the first month
1045.22⫾52.86
1351.29⫾44.40
1171.23⫾57.11
1499.28⫾49.27
1221.17⫾65.18
1545.47⫾54.14
1128.03⫾55.22
1465.46⫾40.42
1279.69⫾86.21
1614.10⫾44.32
1169.16⫾64.49
1495.22⫾46.75

of a strenuous exercise program, if they are told to continue

Charges ($)
Avg Total

P⬍.01

performing the exercises anyway despite pain, they go on to

have better outcomes than patients whose treatments involve
less vigorous activity.39 In another study,40 patients with rheu-
matoid arthritis who were placed on an intensive, dynamic
exercise program had better joint mobility, muscle strength,
360.66⫾20.64
464.76⫾13.89
463.34⫾22.97
568.16⫾17.71
492.40⫾27.81
598.66⫾22.21
485.72⫾24.21
637.26⫾19.23
544.24⫾38.25
719.17⫾22.21
469.32⫾27.49
597.65⫾19.30

and physical conditioning than patients whose treatments were

Charges ($)
Avg MD

P⬍.01

less intensive.40 These studies represent a sample of a growing

were produced using direct standardization methods with subclass total weights.

trend in almost every medical discipline toward early activation

in injury management.
A limitation of this study is its retrospective design, which
restricts certainty about the causal relationship between splint-
Avg MD Visits

3.36⫾0.12
4.19⫾0.11
3.98⫾0.19
4.82⫾0.13
4.14⫾0.18
4.92⫾0.14
4.26⫾0.22
5.28⫾0.14
4.97⫾0.33
6.05⫾0.15
4.14⫾0.22
5.05⫾0.14

ing and outcomes. In a randomized controlled trial (RCT),

P⬍.01

pretreatment differences between patients are randomly allo-

cated among treatment and control groups, so balance on both
observed and unobserved characteristics is assured. Although
propensity score methodology was used here to successfully
balance splinted and nonsplinted patients on all available (ob-
% Lost Time

NOTE. Values mean ⫾ SE unless otherwise indicated.

1.3⫾0.8
1.4⫾0.6
2.4⫾1.0
1.3⫾0.5
1.2⫾0.9
1.2⫾0.5
0.7⫾0.7
1.4⫾0.5
2.8⫾1.6
2.7⫾0.7
1.7⫾1.0
1.6⫾0.6

served) pretreatment differences, unobserved differences, by

NS

definition, were not controlled for. To the extent that an im-

portant predictor of splinting and outcomes was not available
for consideration, and particularly if this omitted characteristic
does not correlate with the variables included, propensity
% Ltd Duty

65.4⫾3.2
77.5⫾2.0
76.3⫾3.0
87.5⫾1.6
81.5⫾3.0
84.9⫾1.6
80.1⫾3.3
87.4⫾1.5
82.2⫾3.7
87.3⫾1.4
77.1⫾3.2
84.9⫾1.6
P⬍.05

scores may not have adequately removed selection bias from

splint allocation (eg, the differences in patient or treatment
conditions that may have influenced both splinting decisions
and outcomes).
Patients

The sensitivity of the splint and no-splint results was eval-

No. of

228
435
207
457
162
502
146
516
107
558
850
2468

uated by looking at patients who received PT separately from

those who did not. The contribution of therapy can be inter-
preted in 2 ways. First, the sports medicine model of this
Splint

Yes

Yes

Yes

Yes

Yes

Yes
No

No

No

No

No

No

occupational network emphasizes early, aggressive therapeutic

intervention to achieve optimal outcomes. Therefore, as far as
differentially pairing treatments for patients with and without
Subclass

Overall

splints, it seems possible that patients without splints would

receive PT sooner. A statistically significant association be-
1

tween splinting and lag to therapy was observed in the study

Arch Phys Med Rehabil Vol 86, June 2005

 SPLINTING AND EPICONDYLITIS OUTCOMES, Derebery
population—91% of patients without splints started PT within
a week of beginning care versus 88% with splints. To the
extent that early therapy makes a difference in outcomes and
correlates with splinting decisions, the observed differences
could have been incorrectly labeled as splinting effects. Sec-
ond, the measure of severity used in the propensity score model
was dichotomous and, as such, might not achieve fine discrim-
inations between patients of differing injury severity. But pa-
tients with mild severity were less likely to be referred to a
physical therapist for supervised exercise sessions or applica-
tion of modalities and were more likely to be given instructions
on a home exercise regimen. The fact that differences between
splinted and nonsplinted patients persisted independent of re-
ceipt of therapy services offers some evidence that the differ-
ences have been appropriately labeled and that reduction of
selection bias because of severity has occurred.
Another limitation of this study is that differences between
types of splints were not assessed. The main hypothesis of this
study was that any type of splint involves restriction of move-
ment and would result in longer treatment durations, higher
costs, and more time away from work than no splint at all. By
extension, under this hypothesis, splints creating greater re-
striction of movement and worn for longer periods of time
might result in worse outcomes than splints with less restriction
of movement worn for shorter periods of time. These questions
were beyond the scope of our analysis but would make for
informative future follow-up investigations.
CONCLUSIONS
The challenge in occupational medicine, particularly with
respect to workers’ compensation, is for providers to maximize
the health and well-being of their patients while showing their
cost-effectiveness to employers and payers in the present en-
vironment of ever-escalating medical costs. Critical to the
success of such efforts is an evaluation of “what works” be-
cause cheaper procedures are not cost-effective if they inflate
total medical and indemnity costs by prolonging treatment
duration and increasing duty restrictions and time off work.
The findings of our study provide evidence that splinting
epicondylitis patients does not necessarily lead to better out-
comes and, in fact, may have adverse effects. Splinted patients
had higher rates of limited duty, more medical visits, higher
medical costs, and longer treatment durations than similar
patients without splints. Nonetheless, these results should not
replace high-quality RCTs of splinting; rather, they should
encourage their conduct, to determine under what conditions or
for which patients, if any, splinting produces better outcomes,
including long-term function and productivity. Additional stud-
ies might also address what treatment approaches tend to be
paired with splinting versus not splinting in practice, to verify
that the effect observed is correctly attributed to splinting.41
Finally, the effects of splinting decisions on actual versus
prescribed absences from work, objective measures of patient
function, recurrence of symptoms, and patient satisfaction with
treatment should be assessed.
References
1. US Bureau of Labor Statistics. Repetitive tasks loosen some
workers’ grip on safety and health. Washington (DC): BLS; Aug
1994. Available at: http://www.bls.gov/iif/oshwc/ossm0005.pdf.
Accessed November 29, 2004.
2. Gerr F, Letz R, Landrigan P. Upper-extremity musculoskeletal
disorders of occupational origin. Annu Rev Public Health 1991;
12:543-66.
3. US Bureau of Labor Statistics. Workplace injuries and illnesses in
2001. Washington (DC): BLS; Dec 2002. Available at: http://
1087
www.bls.gov/news.release/osh.nr0.htm. Accessed November 29,
2004.
4. Kurppa K, Viikari-Juntura E, Kuosma E, Huuskonen M, Kivi P.
Incidence of tenosynovitis or peritendinitis and epicondylitis in a
meat processing factory. Scand J Work Environ Health 1991;17:32-7.
5. Viikari-Juntura E, Kurppa K, Kuosma E, et al. Prevalence of
epicondylitis and elbow pain in the meat-processing industry.
Scand J Work Environ Health 1991;17:38-45.
6. Chiang HC, Ko YC, Chen SS, Yu HS, Wu TN, Chang PY.
Prevalence of shoulder upper-limb disorders among workers in the
fish-processing industry. Scand J Work Environ Health 1993;19:
126-31.
7. Byström S, Hall C, Welander T, Kilbom A. Clinical disorders and
pressure pain threshold of the forearm and hand among automo-
bile assembly line workers. J Hand Surg [Br] 1995;20:782-90.
8. Ritz BR. Humeral epicondylitis among gas and waterworks em-
ployees. Scand J Work Environ Health 1995;21:478-86.
9. Kurvers H, Verhaar J. The results of operative treatment of medial
epicondylitis. J Bone Joint Surg Am 1995;77:1374-9.
10. Moore J, Garg A. Upper extremity disorders in a pork processing
plant: relationships between job risk factors and morbidity. Am
Ind Hygiene Assoc J 1994;55:703-15.
11. Tichauer E. Biomechanics sustains occupational safety and health.
Ind Eng 1976;8:44-5.
12. Descatha A, Leclerc A, Chastang F, Roquelaure Y. Medical
epicondylitis in occupational settings: prevalence, incidence and
associated risk factors. J Occup Environ Med 2003;45:993-1001.
13. Dimberg L, Olafsson A, Stefansson E, et al. The correlation
between work environment and the occurrence of cervicobrachial
symptoms. J Occup Med 1989;31:447-53.
14. National Institute for Occupational Safety and Health. Bernard
BP, editor. Musculoskeletal disorders and workplace factors: a
critical review of epidemiologic evidence for work-related mus-
culoskeletal disorders of the neck, the upper-limb, and low back.
2nd printing. Cincinnati: NIOSH; 1997.
15. Jackson M. Evaluating and managing tennis elbow. Your Patient
Fitness 1997;11(2):104i-104l.
16. Chard M, Hazleman B. Tennis elbow: a reappraisal. Br J Rheu-
matol 1989;28:186-90.
17. Jobe F, Ciccotti M. Lateral and medical epicondylitis of the
elbow. J Am Acad Orthop Surg 1994;2(1):1-8.
18. Hay E, Paterson S, Lewis M, Hosie G, Croft P. Pragmatic ran-
domized controlled trial of local corticosteroid injection and
naproxen for treatment of lateral epicondylitis of the elbow in
primary care. BMJ 1999;319:964-8.
19. Hudak I, Cole D, Haines T. Understanding prognosis to improve
rehabilitation: the example of lateral elbow pain. Arch Phys Med
Rehabil 1996;77:586-93.
20. Smidt N, van der Windt D, Assendelft W. Corticosteroid injec-
tions, physiotherapy, or a wait-and-see policy for lateral epicon-
dylitis: a randomized controlled trial. Lancet 2002;359:657-62.
21. Kivi P. The etiology and conservative treatment of humeral epi-
condylitis. Scand J Rehabil Med 1988;15:37-41.
22. Verhaar J, Walenkamp G, van Mameren H, Kester AD, van der
Linden AJ. Local corticosteroid injection vs Cyriax-type physio-
therapy for tennis elbow. J Bone Joint Surg Br 1996;78:128-32.
23. Hadler N. The “ergonomics injury” as a social construction.
Workers Compensation Policy Rev 2001;1;5:20-5.
24. Wuori JL, Overend TJ, Kramer JF, MacDermid J. Strength and
pain measures associated with lateral epicondylitis bracing. Arch
Phys Med Rehabil 1998;79:832-7.
25. Knebel PT, Avery DW, Gebhardt TL, et al. Effects of the forearm
support band on wrist extensor muscle fatigue. J Orthop Sports
Phys Ther 1999;29:677-85.
Arch Phys Med Rehabil Vol 86, June 2005
1088 SPLINTING AND EPICONDYLITIS OUTCOMES, Derebery
26. Struijs PA, Kerkhoffs GM, Assendelft WJ, Van Dijk CN. Con-
servative treatment of lateral epicondylitis: brace versus physical
therapy or a combination of both—a randomized clinical trial.
Am J Sports Med 2004;32:462-9.
27. Rosenbaum PR, Rubin DB. The central role of the propensity
score in observational studies for causal effects. Biometrika 1983;
70:41-55.
28. Rosenbaum PR, Rubin DB. Reducing bias in observational studies
using subclassification on the propensity score. J Am Stat Assoc
1984;79:516-24.
29. Rubin DB. Estimation from nonrandomized treatment compari-
sons using subclassification on propensity scores. In: Proceedings
of the International Conference on Nonrandomized Comparative
Clinical Studies; 1997 April 10-11; Heidelberg (Germany).
30. D’Agostino RB. Tutorial in biostatistics: propensity score meth-
ods for bias reduction in the comparison of a treatment to a
non-randomized control group. Stat Med 1998;17:2265-81.
31. Braitman LE, Rosenbaum PR. Rare outcomes, common treat-
ments: analytic strategies using propensity scores. Ann Intern Med
2002;137:693-5.
32. Cochran WG. The effectiveness of adjustment by subclassification
in removing bias in observational studies. Biometrics 1968;24:
205-13.
33. Mosteller CF, Tukey JW. Data analysis and regression. Reading:
Addison-Wesley; 1977. p 221-57.
Arch Phys Med Rehabil Vol 86, June 2005
34. Ohnmeiss DD, Vanharanta H, Estlander AM, Jamsen A. The
relationship of disability (Oswestry) and pain drawings to func-
tional testing. Eur Spine J 2000;9:208-12.
35. McCracken LM, Gross RT, Eccleston C. Multimethod assessment
of treatment process in chronic low back pain: comparison of
reported pain-related anxiety with directly measured physical ca-
pacity. Behav Res Ther 2002;40:585-94.
36. Hall H, McIntosh G, Melles T, Holowachuk B, Wai E. Effect of
discharge recommendations on outcome. Spine 1994;19:2033-7.
37. Taimela S, Diederich C, Hubsch M, Heinricy M. The role of
physical exercise and inactivity in pain recurrence and absen-
teeism from work after active outpatient rehabilitation for
recurrent or chronic low back pain: a follow-up study. Spine
2000;25:1809-16.
38. Carragee E, Han M, Yang B, Kim DH, Kraemer H, Billys J.
Activity restrictions after lumbar discectomy: a prospective study
of outcomes in 152 cases with no postoperative restrictions. Spine
1999;24:2346-51.
39. Manniche C, Hesselsoe G, Bentzen L, Christensen I, Lundberg E.
Clinical trial of intensive muscle training for chronic back pain.
Lancet 1988;12:1473-6.
40. Intensive exercise for RA. Back Letter 1996;11(1):2.
41. Reichardt CS. A typology of strategies for ruling out threats to
validity. In: Brickman L, editor. Research design: Donald Camp-
bell’s legacy. Vol 2. Thousand Oaks: Sage; 2000. p 89-115.