Understanding and Managing Repetitive Motion Injuries

Copyright 2016 Alliance Occupational Medicine

Alliance Occupational Medicine 315 S. Abbott Ave. Milpitas, CA. 95035

2737 Walsh Ave. Santa Clara. CA. 950511901 Monterey Rd. Ste. 10 San Jose, CA. 95112

Understanding &Managing Repetitive Motion Injuries

Presented by Jaishri Ramesh, MD. Medical Director

Board Certified Internal Medicine


RSI Statistics• According to US Dept. of Labor, OSHA repetitive stress injuries are the

nation’s most common and costly occupational health problem affecting hundreds of thousands of American workers and costing more than 20 billion $ per year in workers’ compensation costs. US spends another 100 billion $ on lost productivity, employee turnover, and other indirect expenses.

• Musculoskeletal disorders including CTS are among the most prevalent medical conditions in the US affecting 7% of the population. They account for 14% of physician visits and 19% of hospital stays.

• 62% of the persons with musculoskeletal disorders report some degree of limitation on activity compared with 14% of the population at large according to NIOSH.


RSI Statistics• CTS results in the highest number of days lost among all work related

injuries. Almost half of the CT cases result in 31 days or more of work loss. National Center for Health Statistics

• Each Work Comp claim for RSI can cost from $20,000-100,000. • 62% of the persons with musculoskeletal disorders report some degree

of limitation on activity compared with 14% of the population at large according to NIOSH.

• . According to the U.S. Bureau of Labor Statistics, nearly two-thirds of all occupational illnesses reported, were caused by exposure to repeated trauma to workers upper body ( the wrist, elbow or shoulder ).

• In California, median days away from work for repetitive motion cases is approximately five times higher than the average for all cases with days away from work.


Statistics - Typing• If you type 40 words/min you press 12,000

keys/hour or 96,000 keys per 8 hour day.• Approximately 8 ounces of force is necessary

to depress one key.• Almost 16 tons of force will be exercised by

your fingers.• Typing speed may affect risk for CTS For example the fingers of typists whose speed is 60 wpm exert up to 25 tons of pressure each day.


• RMI• RSI• CTD• CSI• too much of a “usually okay” thing• Definition: Pain or disability that arises gradually from either

repetitive use of continuous use of a muscle group or appendage (arm/leg)

WRMSDWork Related Musculo Skeletal

Disorder


• Represents a group of different conditions• Poorly understood mechanism• Affect different areas of the body • Every body area at potential risk• No single disease entity• Most commonly affect tendons and muscles• Attachment points to the bone, less frequently ligaments and

joints

Clarification Repetitive Motion Injuries


Awkward positionsExcessive force

Static muscular tensionCo-contraction

• These factors, alone or in combination, are the source of virtually all the pain and discomfort experienced by pianists

4 Major Causes


• A muscle attaches to the bone it moves by means of a tendon

• Tendon passes over a joint (or several joints)• Awkward or extreme positions of the wrist and hand stress

these tendons, making movement more difficult and weaker. • Awkward positions make movement stressful and can cause

injury.

Awkward positions


• more force is more stressful than less force. • doubling the force multiplies stress on the tendons not by

two but by five.• using more force than needed, and because of the

extremely high levels of repetition involved in piano playing, excessive force is potentially injurious.

Excessive force


• Typically muscle contracts and decreases in length as the part moves.

• This kind of activity is called dynamic. • But if the muscle exerts force without changing in length,

the activity is called static. • Static muscular activity is more stressful than dynamic

activity. • Dynamic activity permits circulation of the blood, whereas

static activity inhibits blood circulation, causing the muscle to become fatigued and making it prone to injury.

Static muscular activity


• Our arms and hands are moved by muscles. • Muscles exert force only when they contract, so• Each muscle can exert force in only one direction. To move

a body part in two directions requires at least two muscles • Flexors• Extensors• if the opposing muscle remains tense--then both muscles

are contracting simultaneously, which is called co-contraction.

Co-contraction


• Repetitive• Typically small movements• We are “self repairing”

-Recover naturally with rest overnightMicro trauma balance sheet• Recovery must meet or exceed micro trauma or

inflammation and damage accumulate

Micro trauma


• Neutral position• Excessive angulation during use

Compresses tendonsIncreases shearing forcesRequires greater muscle forces

• Excessive force• Increases amount of micro trauma per hour

Improper Use


Overuse• Excessive work hours• Insufficient recovery time• Lack of variety• Static positionsUnder use• Insufficient conditioning• Stretching (controlled micro trauma)• Flexibility• Strengthening: Self-repairing, balance sheet


Abuse• Tendons live in an environment…your body• Smoking• Alcohol & other drugs• Diabetes, Diet• Stretching, ExerciseEarly intervention• Discomfort of fatigue precede injury• Micro trauma exceeds recovery• Make changes during pre-injury phase• Relevance of age


• Other factors that contribute to the body's resistance to injury and its ability to recover.

• A person's general health is one factor, • Overall physical fitness is another. • Rest is also important; someone who gets adequate rest

will be more resistant. • Age: resistance to injury decreases as we get older.

Other Factors


• Aching, Soreness, Pain• Tenderness• Decreased Range of Motion – with or without pain• Tingling• Numbness• Weakness• Swelling

Symptoms


Tendinitis: inflammation of a tendon- any one of the thick fibrous cords that attaches muscle to bone

Tenosynovitis: Inflammation of a tendon & its sheathExamples: Flexor Tendinitis Extensor Tendinitis DeQuervan’s Tenosynovitis

Common RMI’sHand, Wrist & Arm


• Trigger Finger• Ganglion Cyst: non cancerous lumps that most commonly

develop along the tendons or joints on wrists or hands, ankles and feet

Typically are round or oval and are filled with jelly like fluid.

Common RMI’sHand


Lateral Humeral Epicondylitis = Tennis Elbow

Medial Humeral Epicondylitis = Golfer’s Elbow

Common RMI’sElbow


Shoulder Tendinitis Shoulder Bursitis Rotator Cuff Tendinitis Shoulder Impingement Rotator Cuff Tear

Common RMI’sShoulder


• Median Nerve Neuropathy = Carpal Tunnel Syndrome (CTS)

• Ulnar Nerve Neuropathy = Ulnar Nerve EntrapmentOther Common RMI’s• Upper Back Strain• Cervical Strain• Shoulder girdle strain

Common RMI’sNerve Injuries


• Medical• Sports / Recreational• Hobbies • Garden• Home / Projects• Personal / Family• Educational• Too Much Everything

Non-Industrial Causes


Where does it hurt? When? What makes it Better? Worse? Clear Causative Relationship? Better Away from Work? Worse at End of Day? Week? Prior treatment Recurrence Contributing/Causative Non-Industrial Illnesses

History


Prior acute trauma Home based activities Hobbies Sports Small children Home and garden Occupational History, Family History Review of Systems Clearly define symptoms at 1st visit to avoid injury/symptom

creep

History


• Visual Observation• Range of Motion• Palpation• Physical Tests

Objective / Exam


• Grip / Pinch Strength Testing• X-Ray Imaging• Blood Testing to Rule Out:

• Rheumatologic Disease• Thyroid Disease• Diabetes

• EMG/NCV

Additional Testing


• Curable• Our bodies have capacity to repair themselves. • Injuries will heal, provided that they have not been allowed

to progress to the point of permanent damage. • Even the tendons, despite their limited blood supply, will

recover in time. • Treatments provides conditions under which the body's

own healing powers can do their job.

Treatment


• Address underlying cause-Ergonomics-Technique-Operations/Procedures-Inadequate self-care Stretching, exercise, diet, etc.

Prevention & Self Treatment


Inadequate response to:• Workplace changes• Improved self careDecrease problem activity or substitute alternate activitySeek Medical Attention History, Exam, Diagnosis

SplintsAnti-inflammatory medications – Ibuprofen, Naprosyn

Physical TherapyAnti-inflammatory injections

Surgery

Medical Treatment


• What these “treatments” really do is to provide conditions in which the body’s own healing powers can do their job.

• The longer we delay intervention, the worse the inflammation & damage.

• Worsens odds of quick or full recovery.

Prevention & Treatment


Case # 1

• Ms. CD is a 26 yr. old female biller who presented with pain in Rt index finger during “closing” due to repetitive use of click mouse. Symptoms resolve after closing. Denied any other associated factors. She was right handed. She had been with the company for 4-1/2 years. She had ergonomic modifications, used a split ergonomic keyboard with standard click mouse. Exam revealed mild diffuse swelling of right index finger with normal ROMs.

• Rest of exam normal• Diagnosis: Right index finger tendon strain due to click mouse use• First Aid injury• She was given a vertical ergonomic mouse• Symptoms completely resolved in 6 weeks


Case # 2

• Mr. AB is a 38 yr old male software engineer who has worked for a software company for 13 years. His job involved computer use at desk for 8-10 hrs.day and 2-3 hrs @ home/day. He texts 1 hr/day (work & personal) used phone 40-60 min/day. No history of DM, HTN,CAD, etc. No other hobbies, music, sports. Doesn’t work out. Ergonomic evaluation done recently. Symptoms:insidious onset of pain and paresthesias of right hand/wrist for 6-8 mos., progressively worse, weaknss of hand, symptoms worse with computer work. Exam:

Ht 5’8” Wt 183# Slight swelling and tenderness over extensor tendons of right hand, volar wrist, Tinel’s +, Phalen’s +• Diagnosis :Right hand/wrist tendinitis, Right CTS Recordable• He was treated with rigid wrist brace at night, NSAIDs, neoprene wrist

wrap at work, PT 12 appts., 6 acupuncture • He fully recovered and was discharged as cured in 4 ½ months with

no PD & no future medical care.


Case # 3

• Ms. IJ is a 36 yr. old software engineer who did computer work for 6-8 hrs/day who presented with “burning right shoulder pain” for 2 weeks. She denied wrist FA or elbow pain or paresthesis. She thought that the computer work done on a daily basis at work caused her shoulder pain. She was taking OTC Advil with no relief of symptoms. She denied any other past medical history. She denied previous work comp claims. She denied any other non-industrial causes. She denied hobbies, sports, and other off work activities. On exam, her right wrist hand FA elbow exam was all “normal.” Right shoulder exam showed marked tenderness over anterior humerus. ROMs of the shoulder – abduction and internal rotation was very limited. Impingement tests were positive. X-ray of the right shoulder was obtained which showed chunks of calcific deposits adjacent to the humerus.

• Diagnosis: Calcific Tendinitis. Causation: Non-industrial, referred to PCP


Questions? Thank You

Jaishri Ramesh M.D.Phone: (408) 228-8400

[email protected] Occupational Medicine

2737 Walsh Ave. Santa Clara, CA. 95051315 S. Abbott Ave. Milpitas, CA. 95035

1901 Monterey Rd. Ste 10 San Jose, CA. 95112

Understanding and Managing Repetitive Motion Injuries

Healthcare

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