Sickness absence after carpal tunnel release: a systematic review of the literature

Work Participation in Patients With Carpal Tunnel Syndrome Referred to Departments of Occupational Medicine-A Danish Register-Based Cohort Study

BACKGROUND

We describe long-term work participation of patients with carpal tunnel syndrome (CTS) referred to Danish departments of occupational medicine and compare to patients with contact dermatitis.

METHODS

One thousand seven hundred and sixty CTS-patients were included in this register-based nationwide longitudinal follow-up study and compared to 3158 contact dermatitis patients. We extracted register data on public benefits 5 years before and after assessment at a department of occupational medicine between 2000 and 2013. We defined a work participation score (WPS) as weeks where the patient was working divided by number of potential work weeks per year, dichotomized into low and high at the 75th percentile. We analyzed the risk of low WPS and of receiving permanent health-related public benefits during follow-up.

RESULTS

Before assessment, both CTS and contact dermatitis patients had high work participation. In the follow-up period work participation decreased permanently for both patient groups. Comparing women with CTS to women with contact dermatitis, odds ratios (OR) of low WPS were 2.56 (2.11-3.11) and 1.68 (1.38-2.05) one and 5 years after assessment. For men, OR of low WPS were 2.01 (95% CI, 1.67-2.44) and 1.27 (95% CI, 1.04-1.56). ORs of receiving permanent health-related public benefits during follow-up were 2.10 (95% CI, 1.56-2.83) for men and 1.97 (95% CI, 1.54-2.54) for women with CTS compared to those with contact dermatitis.

CONCLUSIONS

Patients referred to Danish departments of occupational medicine due to CTS have increased risk of reduced long-term work participation and of receiving permanent health-related public benefits compared to patients referred due to contact dermatitis.

Endoscopic Versus Open Carpal Tunnel Release: An Umbrella Review and a Meta-analysis

INTRODUCTION

Whether endoscopic carpal tunnel release (ECTR) versus open carpal tunnel release (OCTR) has superior outcomes remains a controversial topic. Therefore, we sought to perform an umbrella review and meta-analysis to compare ECTR and OCTR with regards to (1) postoperative functional ability, (2) operative outcomes, and (3) time to return to work.

METHODS

A PubMed, Scopus, and Cochrane database search was conducted for all meta-analyses comparing ECTR and OCTR performed between 2000 and 2022 in accordance to PRISMA and Joanna Briggs Institute guidance for umbrella reviews. The primary outcomes were as follows: (1) functional ability-symptoms severity, postoperative grip strength, postoperative pinch strength, 2-point discrimination, and pain; (2) operative outcomes-operation time, total complications, nerve injury, and scar-related complication; and (3) time to return to work. Quality was assessed using the Assessment of Multiple Systematic Reviews. Pooled analysis was performed to compare several clinical outcome measures between groups, depending on the availability of data using Review Manager Version 5.2.11.

RESULTS

A total of 9 meta-analyses were included, 5 were of high quality and 4 were moderate quality. For functional ability, ECTR was associated with better pinch strength after 3 months (0.70, 95% confidence interval [CI] = 0.00, 1.40, P = 0.05) and 6 months (0.77, 95% CI = 0.14, 1.40, P = 0.02, I2 = 84%). For return to work, OCTR was associated with longer return to work compared with ECTR (-10.89, 95% CI = -15.14, -6.64, P < 0.00001, I2= 83%). There were no significant differences between OCTR and ECTR in the hand function, symptom severity, grip strength, pain, operation time, and total complications.

CONCLUSIONS

In an umbrella review and meta-analysis of ECTR versus OCTR, ECTR was associated with a higher pinch strength, and a shorter time to return to work. Differences in major complications, such as nerve injury, were unclear due to statistical inconsistency and bias.

Algorithm Versus Expert: Machine Learning Versus Surgeon-Predicted Symptom Improvement After Carpal Tunnel Release

BACKGROUND AND OBJECTIVES

Surgeons rely on clinical experience when making predictions about treatment effects. Incorporating algorithm-based predictions of symptom improvement after carpal tunnel release (CTR) could support medical decision-making. However, these algorithm-based predictions need to outperform predictions made by surgeons to add value. We compared predictions of a validated prediction model for symptom improvement after CTR with predictions made by surgeons.

METHODS

This cohort study included 97 patients scheduled for CTR. Preoperatively, surgeons estimated each patient's probability of improvement 6 months after surgery, defined as reaching the minimally clinically important difference on the Boston Carpal Tunnel Syndrome Symptom Severity Score. We assessed model and surgeon performance using calibration (calibration belts), discrimination (area under the curve [AUC]), sensitivity, and specificity. In addition, we assessed the net benefit of decision-making based on the prediction model's estimates vs the surgeon's judgement.

RESULTS

The surgeon predictions had poor calibration and suboptimal discrimination (AUC 0.62, 95%-CI 0.49-0.74), while the prediction model showed good calibration and appropriate discrimination (AUC 0.77, 95%-CI 0.66-0.89, P = .05). The accuracy of surgeon predictions was 0.65 (95%-CI 0.37-0.78) vs 0.78 (95%-CI 0.67-0.89) for the prediction model ( P = .03). The sensitivity of surgeon predictions and the prediction model was 0.72 (95%-CI 0.15-0.96) and 0.85 (95%-CI 0.62-0.97), respectively ( P = .04). The specificity of the surgeon predictions was similar to the model's specificity ( P = .25). The net benefit analysis showed better decision-making based on the prediction model compared with the surgeons' decision-making (ie, more correctly predicted improvements and/or fewer incorrectly predicted improvements).

CONCLUSION

The prediction model outperformed surgeon predictions of improvement after CTR in terms of calibration, accuracy, and sensitivity. Furthermore, the net benefit analysis indicated that using the prediction model instead of relying solely on surgeon decision-making increases the number of patients who will improve after CTR, without increasing the number of unnecessary surgeries.

Occupational and non-occupational risk factors correlating with the severity of clinical manifestations of carpal tunnel syndrome and related work disability among workers who work with a computer

The contribution of certain occupational and personal factors to the development of carpal tunnel syndrome (CTS) is still uncertain. We investigated which specific occupational and non-occupational factors correlate with the level of clinical manifestations and work disability related to CTS. The study included 190 workers who work with a computer and have diagnosed CTS (100 men, 90 women, aged 20-65 years). Subjective experience of CTS-related impairments was assessed with the Symptom Severity Scale (SSS) and the Functional Status Scale (FSS) of the Boston Carpal Tunnel Syndrome Questionnaire (BCTQ). The objective, neural impairments were tested with electrodiagnostics (EDX), whereas CTS-related work disability data were collected from medical records. We found a high inter-correlation between BCTQ, EDX, and work disability data. These also showed high correlations with certain occupational factors (duration of computer-working in months and hours spent daily in computer-working, certain ergonomic, microclimatic, and other occupational conditions) and non-occupational factors (demographic and lifestyle factors: nutritional status, diet, smoking, alcohol consumption, and physical activity). Despite its limitations, our study has identified occupational and non-occupational risk factors that can aggravate CTS and work disability, but which can also be improved with workplace and lifestyle preventive and corrective measures. More research is needed, though, to establish the possible causal relationships and the independent influence of each of those risk factors.

Factors Associated with the Return to Work after Carpal Tunnel Release Surgery: A Cross-Sectional Study of the Worker Population

Background: There is controversy regarding the factors influencing the duration of sickness absence and return to work (RTW) after surgical treatment of carpal tunnel syndrome (CTS). This study aimed to determine factors related to RTW in these patients. Methods: This descriptive-analytical study was performed on all patients with CTS who underwent surgery in a main orthopaedic centre from December 2020 to April 2021. Patients were followed for 90 days after surgery for the RTW. The patients were classified into two groups based on the time of RTW, early (<21 days) and late (>21 days). These two groups were compared in terms of occupational, individual and disease-related factors and the type of surgery. Results: The mean time to RTW in patients was 23.2 ± 7.1 days, with a range of 7-60 days. There was a statistically significant relationship between early RTW and gender (female) (p = 0.005 OR = 6.5), non-manual work (p = 0.002 OR = 1.2), the total score of the Boston carpal tunnel questionnaire before surgery and job satisfaction (p = 0.04). The mean time to RTW in patients who underwent open surgery was less than in endoscopic surgery (22.89 ± 6.29 vs. 24.58 ± 4.7), but this difference was not statistically significant (p > 0.05). Conclusions: Based on the findings of our study, the type of surgery does not affect the RTW of patients with CTS. Considering the effect of job type and job satisfaction on RTW, it is recommended to pay attention to the type of occupation in addition to the type of surgery so that this workforce can RTW with good performance. Level of Evidence: Level IV (Therapeutic).

Effects of sex and age on work-related upper extremity musculoskeletal disorders in Ontario, Canada

BACKGROUND

Effective targeting of workplace upper extremity musculoskeletal disorder (MSD) prevention strategies requires the identification of demographic groups most at risk. Workers' compensation data provides an effective means of surveillance of MSDs at the population level.

OBJECTIVE

The primary purpose of this study was to identify the effects of age and sex on rates of tendon injuries of the wrist and hand, carpal tunnel syndrome (CTS), epicondylitis, and soft tissue shoulder injuries in Ontario, Canada between 2000-2019 using workers' compensation data from the Association of Workers Compensation Boards of Canada (AWCBC).

METHODS

Age and sex specific rates of lost-time injury claims from the four identified injury categories as well as "non-specific" upper extremity MSDs which did not fit into the four categories were calculated by standardizing injury claim totals with "at-risk" population estimates from the Canada Labour Force Survey. A multiple regression analysis was used to analyze the effects of age and sex on rates of specific injury claims.

RESULTS

Statistically significant age and sex effects were identified for rates of claims from tendon injuries of the wrist and hand, CTS, and shoulder injuries, while only age effects were significant for epicondylitis. Between 2000-2019, rates of claims from the four injury categories studied and the magnitude of the age and sex effects declined substantially over time.

CONCLUSION

Detailed surveillance of workplace ergonomic hazards in Ontario workplaces is needed to determine what is causing rates of upper extremity claims to decline.

Factors influencing return to work after surgery for ulnar nerve compression at the elbow

Ulnar nerve compression at the elbow (UNE) frequently affects people of working age. Surgically treated patients may not immediately return to work (RTW) postoperatively. In 2008, the Swedish Social Insurance Agency reformed the national insurance policy. We aimed to examine RTW postoperatively for UNE, variations among surgical methods, and potential risk factors for prolonged RTW (sick leave > 6 weeks). Surgically treated cases of UNE (n = 635) from two time periods (2004-2008 and 2009-2014) and two healthcare regions (Southern and South-eastern) were studied retrospectively regarding age, sex, comorbidities, occupation, type of surgery and time to RTW. A sub-analysis of the exact number of weeks before RTW (n = 201) revealed longer RTW for unemployed cases compared to employed cases. Prolonged RTW was seen among younger, manual workers and after transposition or revision surgery. Prolonged RTW was approximately four times more likely after transposition than after simple decompression. Comparisons before and after 2008 showed occupational differences and differences in RTW, where cases operated before 2008 more often had permanent sickness benefit, but the reform of the social insurance system did not seem to influence RTW. In conclusion, unemployment, younger age at surgery, manual labour, transposition, and revision surgery were related to prolonged RTW.

Work-relatedness of carpal tunnel syndrome: Systematic review including meta-analysis and GRADE

Background and Aims

Carpal tunnel syndrome (CTS) is the most common peripheral nerve entrapment syndrome with a high prevalence among workers. Insights on the physical work-related risk factors is necessary to develop appropriate preventative methods. The objective of this systematic review, including meta-analyses, is to assess which physical work-related risk factors are associated with carpal tunnel syndrome.

Methods

Systematic literature searches were carried out using PubMed and Embase until September 6, 2021. Studies were included if: (1) CTS was clinically assessed, (2) the studies were prospective cohort studies, and (3) the exposure was reported using terms of exposed/less or nonexposed. Risk of bias was assessed using the Quality in Prognosis Studies (QUIPS) tool. Quality of evidence was assessed using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE).

Results

In total, 9270 patients with CTS from a population of 1,051,707 workers were included from 17 studies. Meta-analyses revealed high-quality evidence for associations between CTS and high exposures to repetition (hazard ratio [HR] 1.87, 95% CI 1.42-2.46), force intensity (HR 1.84, 95%CI 1.22-2.79), exposures above hand activity level of ACGIH (HR 1.75, 95%CI 1.40-2.17), and the Strain Index >10 (HR 1.58, 95% CI 1.09-2.30). No significant associations were found for pinch gripping, hand-arm vibration or force duration. High computer-use exposure was significantly associated with a decreased rate of work-related CTS (HR 0.28, 95% CI 0.12-0.64).

Conclusion

This systematic review of prospective cohort studies found high certainty for an increased rate of CTS due to a high Strain Index, exposures exceeding the Activity Level of ACGIH, and high force intensity and high repetition. Workers performing tasks requiring both high force and high repetition even have a higher rate of developing CTS.

Driving, work, wound care and rehabilitation after carpal tunnel release: Consensus recommendations from a UK Delphi study

Introduction

There is variability in the information available for patients after carpal tunnel release (CTR). We aimed to establish (i) what advice should be provided regarding return to driving after CTR; (ii) how work activities should be categorised and defined in relation to CTR, and when patients should be recommended to return to these activities; (iii) what wound care and rehabilitation advice should be provided after CTR.

Methods

We developed consensus recommendations from an expert panel of hand surgeons, primary care surgeons and hand therapists using an electronic Delphi process. Participants were recruited from clinical organisations using pre-defined criteria. Delphi questionnaires included open text and tick-box responses. Consensus was defined as ≥75% agreement and summary feedback was provided after each round.

Results

There were 33 panellists (21 surgeons and 12 hand therapists), of which 27 (82%) completed all rounds. Expected return to driving was agreed as 5-14 days. Expected timescales were also agreed for return to seven selected occupational activities. Post-operative advice focused on using and moving the hand, rather than specific rehabilitation. While consensus was reached for most items, there were important areas of disagreement, including divergent views on driving with sutures in situ and the need to inform car insurers.

Conclusion

Recommendations from this study expand on existing advice by including functional descriptors for occupational activities and guidance timescales generated through a formal consensus process. Areas where consensus was not reached warrant further exploration to assess whether different practices impact clinical and functional outcomes for patients.

Return to Usual Work Following an Ulnar Shortening Osteotomy: A Sample of 111 Patients

PURPOSE

The primary aim of this study was to analyze the median time until patients performed their usual work following an ulnar shortening osteotomy (USO). The secondary aim was to identify factors influencing the median time until return to their usual work.

METHODS

We used a retrospective cohort of patients with ongoing data collection from our institution in the Netherlands. Patients with paid employment who underwent USO were invited to complete a return-to-work questionnaire at 6 weeks, 3 months, 6 months, and 12 months after surgery. The probability of and median time until return to usual work were assessed using an inverted Kaplan-Meier analysis. Factors influencing the return to usual work were evaluated using multivariable Cox proportional hazard regression.

RESULTS

In total, 111 patients who underwent USO were included, with a mean age of 46 years. The probability of returning to usual work in the first year was 92%, and the median time was 12 weeks. The type of work was independently associated with a return to work, with median times of 8, 12, and 14 weeks for light, moderate, and heavy physical work, respectively. We did not find differences in return to usual work based on age, sex, duration of complaints until surgery, treatment side, smoking status, the preoperative Patient-Rated Wrist Evaluation score, or whether the osteotomy was performed freehand or with an external cutting device.

CONCLUSIONS

Half of the patients that underwent USO fully performed their usual work by 12 weeks following surgery. We found that 92% of the patients performed their usual work within 1 year after surgery. We found a large variation in the time until a return to work based on the type of work. Surgeons can use this data to inform patients on the rehabilitation phase after USO.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic IV.

Sickness absence and disability pension after carpal tunnel syndrome diagnosis: A register-based study of patients and matched references in Sweden

Aims: The aim of this study was to examine sickness absence and disability pension (SA/DP) during working lifespan among individuals diagnosed with carpal tunnel syndrome (CTS) and their matched references, accounting for sociodemographic factors. Methods: We used a register cohort of 78,040 individuals aged 19-60 years when diagnosed with CTS in secondary health care (hospitals and outpatient specialist health care) and their 390,199 matched references from the general population in 2001-2010. Sociodemographic factors and SA/DP net days during a three-year follow-up were included. Negative binomial regression was used. Results: For those not on DP at inclusion, the average number of SA/DP days per person-year was 58 days (95% confidence interval (CI) 56-60 days) among individuals with CTS and 20 days (95% CI 19-21 days) among the matched references. Among both groups, these numbers increased with age and were higher among women than among men. The rate ratio (RR) of SA/DP days was threefold higher among people with CTS than among the matched references (adjusted RR=3.00, 95% CI 2.91-3.10) Moreover, compared to the matched references, the RR for SA/DP was higher among men with CTS (RR=3.86, 95% CI 3.61-4.13) than among women with CTS (RR=2.69, 95% CI 2.59-2.78). The association between CTS and the number of SA/DP days was smaller among older age groups. Sociodemographic factors were similarly associated with SA/DP among people with and without CTS. Conclusions: Numbers of SA/DP days were higher among people with CTS than their matched references in all age groups, particularly among individuals in their early work careers, highlighting public-health relevance of the findings.

The Influence of Illness Perception and Mental Health on Return to Work After Carpal Tunnel Release Surgery

PURPOSE

Although multiple factors influencing return to work after a carpal tunnel release (CTR) have been identified, little is known about the influence of psychological patient factors on return to work. Therefore, this study aimed to identify the psychological factors that play a role in the return to work after a CTR surgery.

METHODS

Patients who planned to undergo a CTR were asked to fill out the Brief Illness Perception Questionnaire and the Patient Health Questionnaire before surgery to measure their illness perceptions and mental health status, respectively. Return to work was defined as the time until returning to work for 50% of normal hours and was measured using a questionnaire at 6 weeks, 3 months, and 6 months. To identify associations between nonpsychological and psychological patient factors and the return to work after CTR surgery, a Cox proportional hazards model was constructed.

RESULTS

In total, 615 patients were included in our study. Six months after surgery, 91% of the patients returned to work. For the psychological patient factors, we found that increases of 1 point on the items of worrying about carpal tunnel syndrome and having faith preoperatively in a beneficial effect of the CTR surgery were associated with hazard ratios of 0.92 (95% confidence interval, 0.88-0.96) and 1.10 (95% confidence interval, 1.02-1.19), respectively, for returning to work in the first 6 months after surgery. An increase of 1 point on the depression subscale of the Patient Health Questionnaire was associated with a hazard ratio of 0.88 (95% confidence interval, 0.78-0.99) for returning to work in the first 6 months after surgery.

CONCLUSIONS

Our study showed that multiple psychological patient factors are associated with return to work after a CTR surgery. Addressing these psychological factors before surgery might be a low-cost intervention to improve return to work after the CTR surgery.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

Influence of Occupational Hand Force Requirements on Return to Work, Pain, and Disability After Trapeziometacarpal Total Joint Arthroplasty: A 12-Month Follow-Up Study

PURPOSE

We aimed to determine the prognosis after trapeziometacarpal total joint arthroplasty for basal thumb osteoarthritis with respect to sustainable return to work (RTW), pain, and disability. Our main hypothesis was that high occupational hand force requirements are related to slower RTW.

METHODS

We conducted a 12-month follow-up study of patients who were treated with a trapeziometacarpal total joint arthroplasty in 2003 to 2015 and were active in the labor market at the time of surgery. We used registry information about RTW. Before surgery and at the 12-month follow-up, we obtained data on pain and disability. To obtain estimates of occupational hand force requirements for individual patients, we linked the patients' self-reported job title to a job exposure matrix based on experts' ratings. We used Cox regression models to analyze the time until sustainable RTW and logistic regression models to analyze pain and disability.

RESULTS

A total of 133 patients were included. Most patients returned to work within 12 months after surgery (86%). For those who returned to work within 12 months (n = 114), mean time until sustainable RTW was 14 weeks (SD, 9 weeks). Higher hand force requirements were associated with slower RTW (for medium- and high-force requirements, adjusted hazard ratios were 0.48 [95% confidence interval, 0.30-0.78] and 0.41 [95% confidence interval, 0.25-0.69]). Occupational hand force requirements were not associated with pain and disability at follow-up.

CONCLUSIONS

High occupational hand force requirements were associated with slower RTW, but not with pain and disability 12 months after surgery.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic I.

Sickness absence after carpal tunnel release: a multicentre prospective cohort study

OBJECTIVES

To describe when patients return to different types of work after elective carpal tunnel release (CTR) surgery and identify the factors associated with the duration of sickness absence.

DESIGN

Multicentre prospective observational cohort study.

SETTING AND PARTICIPANTS

Participants were recruited preoperatively from 16 UK centres and clinical, occupational and demographic information were collected. Participants completed a weekly diary and questionnaires at four and 12 weeks postoperatively.

OUTCOMES

The main outcome was duration of work absence from date of surgery to date of first return to work.

RESULTS

254 participants were enrolled in the study and 201 provided the follow-up data. Median duration of sickness absence was 20 days (range 1-99). Earlier return to work was associated with having surgery in primary care and a self-reported work role involving more than 4 hours of daily computer use. Being female and entitlement to more than a month of paid sick leave were both associated with longer work absences. The duration of work absence was strongly associated with the expected duration of leave, as reported by participants before surgery. Earlier return to work was not associated with poorer clinical outcomes reported 12 weeks after CTR.

CONCLUSIONS

There was wide variation in the duration of work absence after CTR across all occupational categories. A combination of occupational, demographic and clinical factors was associated with the duration of work absence, illustrating the complexity of return to work decision making. However, preoperative expectations were strongly associated with the actual duration of leave. We found no evidence that earlier return to work was harmful. Clear, consistent advice from clinicians preoperatively setting expectations of a prompt return to work could reduce unnecessary sickness absence after CTR. To enable this, clinicians need evidence-informed guidance about appropriate timescales for the safe return to different types of work.

Occupation classification predicts return to work after carpal tunnel decompression

Background

The relationship between hand function, employment status and return to work (RTW) after carpal tunnel decompression (CTD) is unclear.

Aims

To investigate predictors of RTW following CTD.

Methods

We prospectively collected pre-operative and 1-year post-operative outcomes and RTW data for all patients undergoing CTD at one centre between 29 May 2014 and 29 May 2017. We used the Standard Occupation Classification 2010.

Results

Pre- and post-operative results were available for 469 (79%) of the 597 patients who had CTD surgery. Pre-operatively, 219 (47%) were employed, 216 (46%) were retired, 26 (6%) were not working due to long-term illness and eight (2%) were unemployed. Complete data sets were available for 178 (81%) of the 219 employed patients, of whom 161 (90%) were able to RTW. Of the rest, five (3%) had changed jobs and 12 (7%) were unable to work. Median RTW time was 4 weeks (interquartile range [IQR] 2–6 weeks). Significantly more patients undertaking manual labour were unable to RTW (15% versus 5%; P &lt; 0.05). There was no significant difference in mean number of weeks absent between manual (5.7; 95% confidence interval [CI] 4.9–6.5) and non-manual workers (6.2; 95% CI 4.8–7.6) (P &gt; 0.05). Median pre-operative (difference 15.9; 95% CI 4.5–25) and post-operative (difference 43.2; 95% CI 13.6–43.2) hand function scores were significantly worse in patients who did not RTW (P &lt; 0.05).

Conclusions

Most patients can RTW within 1 year of CTD. Failure to RTW is more likely in manual workers and patients with poorer pre-operative hand function.

Return to work after carpal tunnel release surgery: a qualitative interview study

Background

Carpal tunnel syndrome is a common nerve compression disorder which affects hand sensation and function. Carpal tunnel release surgery (CTR) is frequently performed to alleviate these symptoms. For many CTR patients, surgery occurs during their working lifetime, but there is currently no evidence-based guidance to inform clinicians or patients when it might be safe to return to different types of work afterwards. The aim of this qualitative study was to explore the return to work experiences of patients who had recently undergone CTR.

Methods

Semi-structured 1:1 interviews were conducted with a subgroup of participants recruited to a multi-centre prospective cohort study. Interviewees were purposely selected to represent a range of demographic, clinical and occupational characteristics. All had recently undergone CTR and had returned to work. Interviews were audio recorded, transcribed verbatim and analysed using the framework method. Participants were recruited until data saturation was achieved.

Results

Fourteen participants were interviewed: 11 women (median age 49 years, range 27–61) and 3 men (age range 51–68 years). Three key themes were identified. Theme 1 centred on the level of functional disability experienced immediately after surgery. There was an expectation that CTR would be a ‘minor’ procedure, but this did not match the participants’ experiences. Theme 2 explored the desire for validation for the time away from work, with participants recalling a need to justify their work absence to themselves as well as to their employers. Theme 3 focused on the participants’ reflections of handing their return to work and function, with many reporting uncertainties about what constituted appropriate activity loads and durations. There was a desire for specific information relating to individual work roles.

Conclusion

Individual return to work decision-making was largely influenced by the recommendations received. According to the views of participants, clinicians may be able to prepare patients better pre-operatively, especially with respect to function in the immediate post-operative period and by providing return to work guidance that can be tailored for individual work roles.

Electronic supplementary material

The online version of this article (10.1186/s12891-019-2638-5) contains supplementary material, which is available to authorized users.