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                                           UPPER LIMB DISORDERS

                                                   Dr Stefanus Snyman
                                              Occupational Medicine Practitioner

                                                      11 February 2009

Case study:                         Case study:
Symptoms - 45-year-old lady with…   Clinical signs

     •   Burning sensation          • Crepitus (crackling sound in subcutaneous
     •   Fatiguability
     •   Loss of grip strength      • Muscle spasm
     •   Loss of normal sensation   • Muscle weakness
     •   Muscle spasm               • Reduction of range movement
     •   Muscle weakness            • Swelling
     •   Pain
                                    • Tender trigger points in muscles
     •   Paraesthesia (tingling)
                                    • Tenderness
     •   Sensation of cold
     •   Swelling

 Case study:
 Typical management                 Stupid…
 • De Quervain’s syndrome
   and Carpal Tunnel                • R80,000 later (pyn en leiding &
   Syndromes were                     verlies aan inkomste, uitgesluit)
   diagnosed during the past
   2 years                          • Het niemand nog gevra “WAT DOEN
                                      JY BY DIE WERK?” nie…
 • She received steroid
   injections into the relevant          !!!@#$%^&*()!@#$%^&&?!!!
   tendon sheaths
                                    • Tipies dokter / spesialis …???!!!
 • Twice surgery
 • Only little improvement
 • And now it is “all in the

Work-related Upper Limb Disorder                    Risk Factors
                        WRULDs is a collective
                        term for a group of         WRULDs are caused, aggravated or precipitated by
                        occupational diseases        one or more of the following risk factors, singly
                        that consist of musculo-     or in combination:
                        skeletal disorders caused     – Highly repetitive movements
                        by exposure in the            – Movements requiring force
                        workplace affecting           – Movements at the extremes of reach
                        tissues (muscles,             – Static muscle loading
                        tendons, nerves, blood        – Awkward sustained postures
                        vessels, joints and           – Contact stress (e.g. uncomfortable gripping and
                        bursas) of the hand,            twisting, sharp edges to hand tools, desk edges,
                        wrist, arm and shoulder.        etc.)
                                                      – Vibration

Progression of disease I                            Progression of disease II

STAGE 1                                             STAGE 2

• Pain, aching & tiredness of limb during work      • Recurrent pain, aching and tiredness earlier in
• Improve overnight                                   day
                                                    • Persist at night and may disturb sleep
• Most often reversible with rest alone
                                                    • Physical signs (e.g. swelling) may be visible
• Sometimes guided exercise and treatment is

State progression of disease III                    Circular Instruction 180
                                                    Occupational Disease
                                                    vs. Occupational Injury
                                                    • Occupational Disease = WRULD caused by repetitive
• Persistent pain, aching, weakness and fatigue       movements and other risk factors (≠ injury )

  even if not been working for some time            • Occupational Injury = Complication of initial
                                                      occupational injury
• Sleep is often disturbed                             – Example: Fracture of the forearm
• This can be irreversible if it is not treated        – Tenosynovitis (because no work hardening)
  appropriately                                        – Here WRULD should be reported to Compensation
                                                         Commissioner on the Progress Medical Reports i.t.o.
                                                         occupational injury.

Circular Instruction 180                                   Historical Perspective I
Compensation & Prevention
                                                           • Not a new problem
                                                           • 1713: Ramazzini – serious
• Report to the Compensation Commissioner so                 disease caused violent and
  that payment of medical costs, sick leave and              irregular motions and
  compensation could be considered in terms of               unnatural postures of the
  the COID Act.                                              body".
• Prevention: Report to Provincial Executive               • Scrivener's Palsy –
  Manager of Labour / Regional Principal                     incessant driving of pen
  Inspector of Mines                                         over paper causes intense
                                                             fatigue of hand & arm
                                                             because of continuous
                                                             strain of the muscles &

Historical Perspective III                                  Cost of WRULDs I
• Telegraphist’s cramp
• Hop picker’s gout
• Fisherwoman’s finger
                                                              – CTD = 60% of all
• Upholsterer’s hand                                            work-related disorders
• Gamekeeper’s thumb
                                                                  $13-20 billion annually
• Cotton-twister’s hand
• Tennis elbow
                                                              – CTD claim = 2X average cost
• Pizza-cutter’s wrist
                                                                  $8070 vs. $4075
• Nintendonitis (Nintendo® play station – ‘computer game
  wrist’ in children)
• SMS thumb / “Mxitis”                                        – CTD cost more than LBP

                                                                                            Source: NIOSH (1997)

Cost of WRULDs II                                                   Cost of WRULDs III
European Union                                                      South Africa
• WRULDs cost
                                                           • Limited data – need research
  – Nordic Countries –0,5% GNP                             • WRULDs expected to be higher than industrially
                                                             developed countries – excessive physical
  – Netherlands – 2% GNP
                                                             demands made on workers
  – UK £1.25 billion per year
                                                           • SAMOSA (SA Musculoskeletal
  – Sources:                                                 Surveillance Action
  – HSE (1996)                                               Group)
  – EU Agency for Safety & Health
    at work (1990)

 Compensationism versus Preventionism            Classification
                                                 Types of WRULDS 1

                                                 TYPE 1
                                                 • Well-defined musculo-skeletal conditions &
                                                   nerve entrapment syndromes affecting the
                                                   upper limbs
                                                 • Carpal Tunnel Syndrome, De Quervain’s
                                                 • Relatively clear cut characteristics &
                                                   established treatment methods

Classification                                   Classification
Types of WRULDS 2                                According to affect on specific
• Regional Pain Syndrome                         • Tendon-related disorders
• Widespread dissemination of symptoms           • Nerve-related disorders
  between neck & hand                            • Bursa-related disorders
• Regional allodynia & hyperalgesia    neural    • Blood vessel disorders
  sensitisation & pain
                                                 • Other

Classification                                   Classification
Tendon-related disorders I                       Tendon-related disorders II

• Tendonitis                                     • Tendinosis - common
   – Confusion with terminology                     – Sports Medicine
   – Rare condition                                 – Intratendinous collagen degeneration due
   – Inflammation of tendon & tendon muscle              Aging
   – (e.g. Achilles tendon in conjunction with           Microtrauma (chronic overuse repetitive
     tendinosis)                                         movements)
   – Promote collagen production & reduce                Vascular compromise
     paratendon inflammation                        – Examples:
                                                          epicondylitis, rotator cuff syndrome

Classification                                          Rx tendinosis compared with tendonitis
Tendon-related disorders IV                                          Trait                  Overuse Tendinosis   Overuse Tendinitis

                                                          Prevalence                        Common               Rare
• Tenosynovitis                                           Time for recovery,        early
                                                                                            6-10 weeks
                                                                                                                 Several days to 2
                                                          presentation                                              weeks
   – Rapid repetitive movements especially of             Time for full recovery,
                                                                                            3-6 months           4-6 weeks
     hands and fingers                                    chronic presentation
                                                          Likelihood of full recovery to
        Inflammation of synovial lining of the tendon     do repetitive work from           ~80%                 99%
        sheath                                            chronic symptoms
                                                                                            Encouragement of
        swelling   pain                                                                        collagen-         Anti-inflammatory
                                                          Focus of conservative
                                                                                               synthesis            modalities and
        restricted movement of tendon in sheath           therapy
                                                                                               maturation and       drugs
   – Repeated exposure    scar tissue            pain                                       Excise abnormal
                                                          Role of surgery                                        Not known
        mobility   strength                                                                    tissue
                                                          Prognosis for surgery             70%-85%              95%
   – Examples:
                                                          Time to recover from surgery      4-6 months           3-4 weeks
        Trigger Finger, De Quervain’s
                                                                                                                   Source: Khan (2000)

Classification                                          Classification
Nerve-Related Disorders III                             Bursa-related disorders

• Carpal Tunnel Syndrome                                • Fluid-filled sacks that protect muscles,
                                                          tendons & skin from friction against bones
• Pronator Teres Syndrome                                 during joint movement
• Cubital Tunnel Syndrome                               • Overexertion     inflammation (bursitis)
• Guyon tunnel Syndrome                                   swelling & dull, aching pain

• Radial Tunnel Syndrome                                • Examples:
                                                           – Olecranon bursitis (beat elbow)
• Anterior Interosseous Nerve Syndrome
                                                           – Subacromial burisits
• Posterior Interosseous Nerve Entrapment, etc.            – Subdeltoid bursitis

Classification                                          Classification
Blood-vessel disorders                                  Other Disorders

• Usually due to vibration or hammering                 • Effect on muscles and joints
  vasospasm & circulation                                  – Problematic to prove objectively
• Excessive exposure      circulation +                    – Controversial
  neurological findings ( motor function of             • Static loading
  hand and arm)                                            – Occurs proximally when repetitive movement
• Examples:                                                  occurs distally
                                                           – Static loading  muscle imbalances & trigger points
   – Raynaud’s Phenomenon
   – Hand Arm Vibration Syndrome                           – Examples:
   – Hypothenar Hammer Syndrome                                  Tension neck syndrome, myalgia, strains, etc.

Shoulder                                        Shoulder
Rotator Cuff Syndrome I                         Job activities and tasks typically
                                                associated with rotator cuff syndrome
• Executing repetitive                                  •   Belt conveyor assembly
  overhead movements,                                   •   Carrying load on shoulders
  static loading and/or                                 •   Construction work
  sustained postures.
                                                        •   Electrical work
• Prone to develop                                      •   Lifting
  bursal side tears                                     •   Overhead assembly
  secondary to                                          •   Overhead painting
  impingement                                           •   Overhead welding
• Sign of rotator cuff                                  •   Packing
  lesions = pain                                        •   Punch press operation
  exacerbated by                                        •   Reaching
  abduction against                                     •   Work with the arms away from the body

Elbow                                           Elbow
Lateral Epicondylitis I                         Lateral Epicondylitis II
• “Tennis Elbow” -                              • Often starts as an acute               • Drillers
  Pain at epicondyle                              direct injury to the site of           • Carpenters
                                                  the muscle origin which                • Polishers
                                                  progresses to an epicondylitis         • Turning screws
                                                • Work action:                           • Small parts
                                                  – Unusual forces (power                  assembly
                                                    grasp),                              • Hammering
                                                  – Repetition                           • Repetitive wrist
                                                  – Forceful gripping                      extension
                                                  – Repeated supination and              • Repetitive wrist
                                                    pronation.                             grasp
                                                                                         • VDT work

Forearm, Wrist & Fingers                        Forearm, Wrist & Fingers
De Quervain’s Tenosynovitis II                  De Quervain’s Tenosynovitis III

                                                • De Quervain’s can               • Buffing
• Presents with pain &
                                                                                  • Grinding
  localised swelling                              results from overuse of
                                                                                  • Polishing
  over styloid                                    the thumb                       • Sanding
  process of radius                                – such as in the               • Endo filing (dentist)
• Common variant :               Syndrome            repetitive grasping of       • Pushing
                                                     a straight handled           • Pressing
  localised swelling at                                                           • Sawing
  base of the thumb                                  tool
                                                                                  • Use of pliers
  & thickening of                                  – (e.g. screwdriver,           • Use of small tools
  fibrous sheath                                     endo files of dentist).      • “Turning” controls as on
  (extensor                                                                       • Inserting screws in holes
  retinaculum).                                                                   • Forceful hand wringing

Forearm, Wrist & Fingers                               Forearm, Wrist & Fingers
Trigger Finger / Thumb I                               Trigger Finger / Thumb II

• Stenosing                                            • Hand tools that have sharp edges pressing into
  tenosynovitis and/or                                   the tissue
  tendinosis of flexor                                 • Hand tools whose handles are too far apart for
  tendons                                                user.
• Inability to move                                    • Repetitive movements with repeated or
  fingers or thumb                                       prolonged gripping or pinching can also cause
  smoothly                                               operating trigger finger.
• Locking of affected
                                                           • Investigate concomitant diseases
  digit, with or without                                     and/or other reasons for trigger
  pain.                                                      finger
                                                              – rheumatoid arthritis
                                                              – diabetes, etc.

Forearm, Wrist & Fingers                               Forearm, Wrist & Fingers
Carpal Tunnel Syndrome I                               Carpal Tunnel Syndrome II
• Condition which results                              • Specific occupations
                                                                                        •   Buffing
  from direct or indirect                                where wrists are in            •   Grinding
  pressure on nerves                                     abnormal positions for         •   Prehensile task especially
                                                                                            in extremes of flexion,
• Common ailment                                         prolonged periods with             extension and ulnar
  affecting the wrist and                                                                   deviation
                                                         highly repetitive              •   Assembly work
                                                         movements                      •   Typing
• Majority of cases not                                                                 •   Packing
  caused by work                                                                        •   Scrubbing
                                                       • Tenosynovitis of flexor        •   Hammering
• More prevalent in women than in men                    tendons                        •   Repetitive or forceful grip
• It is common during pregnancy                                                         •   VDT work
                                                                                        •   Polishing
• Occur twice as often in both hands suggesting that   • Pressure on the median
                                                                                        •   Sanding
  occupational factors are not very important            nerve in the carpal tunnel

Forearm, Wrist & Fingers                               Forearm, Wrist & Fingers
Carpal Tunnel Syndrome III                             Flexor/Extensor
SYMPTOMS                                               • Punch press operation     • Sanding

• Symptoms start with a gradual onset of               • Assembly work             • Punch press operation
                                                       • Wiring                    • Sawing
   – tingling and numbness in the fingers
                                                       • Packaging                 • Cutting
• Can progress to                                      • Use of pliers             • Use of pliers
  – pain                                               • Buffing                   • “Turning” controls such
  – Clumsiness                                         • Grinding                    as on motorcycle
  – muscle atrophy in the hand.                        • Polishing                 • Inserting screws in
                                                                                   • Forceful hand wringing

Diagnosis                                                                   Diagnosis
Principles of diagnosis I                                                   Principles of diagnosis II
                                                                            • Functional capacity evaluation
• Medical assessment                                                           – E.g. the employee is able to type, but develops
  – Medical history                                                              symptoms after continuous typing for 30 minutes.)
                                                                               – This might be simple and straightforward …
      The employee’s current medical history:
                                                                               – in complicated cases a formal occupational therapy
      site and distribution of the symptoms                                      and / or physiotherapy assessment
      quality (type, character)                                             • Job analysis / Ergonomic assessment
      severity (intensity, frequency, duration)                                – Assess the employee’s working environment(s) for
      progression of the symptoms.                                               human and environmental risk factors.
  – Physical examination
  – Special investigations

  JOB ANALYSIS                             Briefly describe the job task    Diagnosis
                                % of
                                                 where this risk factor
                                                occurs and quantify in
                                                                            PLEASE NOTE THAT…
                             working day         terms of repetitions /
                                             duration / strength required
                                              / range of movement, etc.
            Risk factor                                                     • Symptoms may not always be accompanied
Repetitive movements                                                          by objective signs
Movements requiring force                                                   • Any one symptom or sign is not indicative of
Movements at the extremes
                                                                              WRULDs and some may be common with
  of reach                                                                    normal function
Static muscle loading
                                                                            • Very few sufferers experience all the
Awkward sustained postures                                                    symptoms
Contact stress                                                              • The symptoms do not appear in any particular
Vibration                                                                     order

Diagnosis                                                                   Diagnosis
History of occupational exposure II                                         History of occupational exposure IV
• Psychosocial stress at work and fatigue                                   • Minimum duration of exposure: generally
                                                                              6 months
• Cold environment or handling chilled or
  frozen products                                                              – WRULDs take a period of time to develop
                                                                                 and generally a job which involves
• Vibration                                                                      repetitive movements should be performed
• Overhead working postures or jobs with                                         for more than 6 months before the
  minimal movement and non-optimal                                               condition develops.
  sustained postures.
• High-risk jobs - Combination of repetitive,
  forceful movements, awkward postures,
  static loading

 Treatment                                               Treatment
 Employee Education                                      Anti-inflammatory Strategies

 • OHP: explain pathology of tendinosis                  • Cryotherapy (ice)
 • Most vulnerable employees                             • Electrotherapeutic modalities
        Those with symptoms of short duration and
        still able to work
        Should they continue without Rx  exacerbate      • Non-steroid anti-inflammatory drugs
                                                           (e.g. Voltaren)
                                                         • Infiltration with corticosteroids
                                                            – Inhibits collagen repair           avoid

Treatment                                                Treatment
Biokinetic and ergonomic strategies I                    Biokinetic and ergonomic strategies II
                                                         • Biomechanical deloading
                                                            – Collagen degeneration & mechanical overload
 • Initial treatment may include rest                       – Mechanical overload due to
                                                                 Work environment
 • Compression and elevation                                     Work tasks (repetition, force, posture, vibration, etc.)
                                                                 Individual biomechanics (trigger points, muscle
 • Temporary job change
                                                            – Correct biomechanics
                                                                 Movement patterns
                                                                 muscle imbalances
                                                                 Equipment used / environment

 Treatment                                               Treatment
 Biokinetic and ergonomic strategies III                 Biokinetic and ergonomic strategies IV

 • Immobilise – Splintage (occupational therapy)         • Mobilise – manual therapy (physiotherapy)
 • Load-decreasing devices                               • Mobilise – exercise therapy to appropriately
                                                           strengthen the tendons and muscles.
    – mechanical load on collagen
                                                            – Graded loading of tendon     improved collagen
        Splints                                               alignment & cross linkage     improved strength
        Braces                                              – Eccentric training drills stimulate
        Supports                                              mechanoreceptors in tenocytes       collagen
    – Examples                                              – Collagen production key to tendinosis recovery
        Tenosynovitis of forearm, wrist, fingers, etc.
                                                         • Re-introduction to the workplace (Work
                                                           hardening and ergonomics adjustments)

Treatment                                         Evaluation of Impairment
Psychology & Surgery

• Pscychological evaluation                       •   Description of residual impairment by the
• Surgery                                             treating doctor (W. Cl. 302)
   – where indicated as last resort               •   Most employees will recover and return to
                                                  •   only a small percentage will suffer any
                                                      permanent residual impairment.

Permanent impairment will be assessed             Permanent impairment will be assessed
after (I):                                        after (II):
• Medical treatment
                                                      – Addressing problem areas identified in the
• Vocational rehabilitation, which includes             job analysis / ergonomic assessment by
   – Optimising the person’s functional ability         allowing alterations in the way in which work
     through rehabilitation that includes work          is performed through reasonable
     hardening, work conditioning, etc.                 accommodation:
                                                          workplace environment adaptation
                                                          tool and equipment adaptation
                                                          workstation redesign
                                                          job task modification
                                                          retraining and reassignment
                                                          work schedule modifications

Reporting to the Compensation                     Reporting to the Compensation
Commissioner                                      Commissioner

• W. Cl. 1                                        • All other reports that may be relevant
  – Employer’s Report of an Occupational          • W. Cl. 6
    Disease                                         – Resumption Report
• W. Cl. 14                                       • W. Cl. 302
  – Notice of an Occupational Disease and           – Progress/Final Medical Report in respect of
    Claim for Compensation                            a Work-Related Upper Limb Disorder
• W. Cl. 301                                          (WRULD)
  – First Medical Report in respect of a Work-      – Progress medical reports - monthly
    Related Upper Limb Disorder (WRULD)             – W. Cl. 302 must be used instead of the
  – W. Cl. 301 must be used instead of the            usual W. Cl. 26
    usual W. Cl. 22

Reporting to Labour / DME   Reporting to Labour / DME

Reporting to Labour / DME

                                          Dr Stefanus Snyman
                                 Occupational Health Medicine Practitioner