SCIENTIFIC REVIEW

Repetitive Movement on Shoulder and

Rotator Cuff Syndrome

dr. Agustiany, MKK.

1806263760

LECTURER:
DR. dr. Astrid W. Sulistomo, MPH, Sp.Ok.
Dr. Suryo Wibowo, Sp.Ok.

FACULTY OF MEDICINE UNIVERSITY OF INDONESIA

OCCUPATIONAL MEDICINE SPECIALIST PROGRAM
JAKARTA, NOVEMBER 2018
APPROVAL OF THE LECTURER

Lecturer : Dr.dr. Astrid Sulistomo, MPH, Sp.Ok

Department : Occupational Medicine Studies Department of Community Medicine

Title of the article : Repetitive Movement on Shoulder and Rotator Cuff Syndrome

The paper has been completed and approved by the Lecturer

Jakarta, December 2018

Dr.dr. Astrid Sulistomo, MPH, SpOk

Lecturer

1
STATEMENT OF ORIGINALITY

I signed below by actually stated that the this paper was written without action of
plagiarism in accordance with the regulations at the University of Indonesia. If later on it
turns out I did the Act of plagiarism, I will be fully responsible for and ready to receive
adequate punishment determined by Universitas Indonesia.

Jakarta, December 2018

Dr. Agustiany, MKK

2
 CHAPTER 1
INTRODUCTION

1.1 Background
Work-related upper extremity musculoskeletal disorders (WRUEMSDs) which include carpal
tunnel syndrome, tendinitis and arthritis are associated with high costs to employers due to
absenteeism, lost productivity, increased health care costs, along with disability and workers’
compensation costs. Bureau of Labor Statistics (BLS) in 2012 reported nonfatal occupational
injuries totaled 1,153,980 cases with a median 9 days away from work which is equivalent to
41,543 years of work.1

Shoulder symptoms are common and costly. Friction of muscles and tendons against adjacent
structures has been reported as a cause, as have poor working postures, manual handling and
repetitive movements. A number of non-ergonomic risk factors including age, gender, high
levels of demand, poor control, poor support and finding work stressful, have also been
identified as important.2

A number of workplace physical exposures have been implicated in the causation or

exacerbation of shoulder disorders. Important occupational exposures include: manual
handling (heavy lifting, pushing, pulling, holding, carrying ; working above shoulder height;
repetitive work; vibration; and working in awkward postures. Interestingly, another review that
explored risk factors for specific shoulder disorders and shoulder pain, reported similar work
exposures as important: handling of loads frequently or with high force, highly repetitive work,
working in awkward postures and also high psychosocial job demand.3

Rotator cuff injuries occur most often in people who repeatedly perform overhead motions in
their jobs or sports. Examples include painters, carpenters, and people who play baseball or
tennis. The risk of rotator cuff injury also increases with age.4

Repetitive movement is one of the causes of shoulder pain. Many studies have reported the
strong relationship between shoulder pain and repetitive movements.5 Some studies mention
work that is at risk of being exposed to repetitive movements including assembly workers, bank
assistance, car mechanic, carpenter, construction workers, dentist, electrician, farmer, fish
industry worker, garbage collector, gardener, hairdresser, laundry worker, nurse, office worker,
truck driver.6

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1.2. Problem Statement
Repetitive movements on shoulders are suspected of increasing the risk of rotator cuff
syndrome. It is very important to review the association between repetitive movement on
shoulder and rotator cuff syndrome based on the available evidences in order to diagnosed
occupational disease.

1.3. Objective
The aims of this scientific review are to give a better understanding about rotator cuff syndrome
and to identify the association between the repetitive movement and rotator cuff syndrome.

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 CHAPTER 2
LITERATURE REVIEW

2.1. Anatomy of the Shoulder

Figure 1. Anatomy of the Shoulder

The shoulder is one of the largest and most complex joints in the body. The shoulder joint is
formed where the humerus (upper arm bone) fits into the scapula (shoulder blade), like a ball
and socket. Other important bones in the shoulder include:
 The acromion is a bony projection off the scapula.
 The clavicle (collarbone) meets the acromion in the acromioclavicular joint.
 The coracoid process is a hook-like bony projection from the scapula.
The shoulder has several other important structures:
 The rotator cuff is a collection of muscles and tendons that surround the shoulder,
giving it support and allowing a wide range of motion.
 The bursa is a small sac of fluid that cushions and protects the tendons of the rotator
cuff.
 A cuff of cartilage called the labrum forms a cup for the ball-like head of the humerus
to fit into.

5
The humerus fits relatively loosely into the shoulder joint. This gives the shoulder a wide range
of motion, but also makes it vulnerable to injury.7

2.2. Rotator Cuff Syndromes (including rotator cuff tendinosis, rotator cuff tendinitis,
supraspinatus tendinitis, rotator cuff partial tears, impingement syndrome, bursitis)

Figure 2. Rotator Cuff Injuries

The rotator cuff (RC) is an anatomic coalescence of the muscle bellies and tendons of the
supraspinatus (SS), infraspinatus (IS), teres minor (TM), and subscapularis (SubSc). Rotator
cuff syndrome (RCS) constitutes a spectrum of disease across a wide range of pathologies
associated with injury or degenerative conditions affecting the rotator cuff (RC). RCS includes
subacromial impingement syndrome (SIS) and bursitis, RC tendonitis, partial- versus full-
thickness RC tears (PTTs versus FTTs), and, chronically, can influence the development of
glenohumeral degenerative disease (DJD) and rotator cuff arthropathy (RCA). 21

Rotator cuff-related disorders as listed above are generally considered closely related if not the
same degenerative condition, and the various entities are not well distinguished. There has long
been evidence of insufficient blood supply in the typical area(s) of rupture and recent evidence

6
points to numerous atherosclerotic disease risk factors strongly suggesting a primarily
pathophysiological mechanism of atherosclerosis of the arterial supply to the tendons. The
other primary competing theory is biomechanical, particularly with impingement of the
acromion first described in the 1920s by Meyer and advanced by Neer that develops as a
consequence of the age-related degenerative processes. Both theories may play a role, although
the atherosclerotic vascular supply mechanism appears of primary importance. Patients with
tendon pathology often have shoulder pain that radiates to the upper arm and deltoid region,
and some even report more distal radiation without paresthesias. Bursitis tends to have non-
radiating shoulder joint pain, although it too may present with deltoid region pain. Partial-
thickness tears cannot reliably be distinguished from the other rotator cuff entities clinically or
with imaging. Many of the symptoms and examination maneuvers used to assign a diagnosis
of rotator cuff syndrome" are not specific to a cause. The supraspinatus tendon is the most
commonly affected tendon in the rotator cuff. Tendon pathology most commonly progresses
posteriorly to the infraspinatus. Tendonopathies are generally considered the most important
of the occupational shoulder disorders based on high prevalence.8

Clinicians evaluating patients with acute or chronic shoulder pain should obtain a
comprehensive history. Characteristics of rotator cuff syndrome (RCS) include
 Atraumatic, insidious onset of pain
 symptom exacerbation with overhead activity
 Pain at night

A thorough history includes current or history of sports participation (as well as specific
positions played in each sport), occupational history and current status of employment, hand
dominance, any history of injury/trauma to the shoulder(s) and/or neck, and any relevant
surgical history.21

2.3. Physical Examination of Rotator Cuff Syndrome8

The doctor have to do some physical examination to ensure the diagnosis of rotator cuff
syndrome, from the picture below can help for examining the patient.

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 Figure 3. Table physical examination of Rotator Cuff Tendinopathy

2.4. Diagnosis of Rotator Cuff Syndrome8

The mechanism of impingement/rotator cuff Tendinopathy; rotator cuff tendinosis, including
partial thickness tear is enerally gradual onset of shoulder pain. May have more acute
presentation. Pain becomes symptomatic or increases with overhead use. The symptoms are
nonunique, non-radiating pain in shoulder and/or deltoid area and night pain in shoulder joint.
Diagnostic Testing
 Shoulder x-rays for diagnosis in traumatic injuries and as an initial study, if diagnostic
imaging is needed, for non-traumatic shoulder problems is recommended (Insufficient
Evidence (I)).
 Magnetic resonance imaging (MRI) is recommended (Insufficient Evidence (I) and
some evidence for advanced imaging of soft tissues such as rotator cuff tears,
particularly in patients who are not recovering as expected or where additional
diagnostic information would change the treatment plan).

8
  MR arthrography is recommended (Insufficient Evidence (I) and some evidence to
diagnose labral tears in patients who are not recovering as expected or where additional
diagnostic information would change the treatment plan).
 Computerized Tomography (CT) is recommended (Insufficient Evidence (I)) for
advanced imaging of bone, if needed, particularly if fractures are suspected but not seen
on x-ray. CT or CT

2.5. Management of Shoulder Disorders8

Medications
 High quality evidence supports NSAIDs for treatment of shoulder disorders with
concomitant cytoprotective medications. High quality of evidence supports proton pump
inhibitors and misoprostol to treat patients at risk for gastrointestinal bleeding. Low to
moderate quality evidence supports treatment with sucralfate and H2 blockers for
cytoprotection.
 Moderate-quality evidence supports treating rotator cuff tendinopathies with subacromial
glucocorticoid injection usually combined with a local anesthetic. This may be indicated if
there is insufficient improvement after other non-invasive therapy (e.g., strengthening
exercises and NSAIDs) for 2 to 3 weeks.
 Judicious short term use of opioids to treat acute severe shoulder pain or severe post-
operative pain are recommended (Insufficient Evidence) when NSAIDS, acetaminophen or
aspirin are inadequate or inappropriate (e.g., potential bleeding complications).
Surgical Issues
 Moderate-quality evidence documents success of surgical rotator cuff repairs, whether
arthroscopic or open.
 Moderate-quality evidence supports the efficacy of surgical subacromial decompression to
treat impingement syndrome that has not improved sufficiently with NSAIDs and a quality
exercise program.
 High quality evidence supports surgery for treatment of select initial acute, traumatic
anterior shoulder dislocation.
Low quality evidence supports surgical repair of high grade acromioclavicular joint separation
and select patients with displaced proximal humeral or clavicular fractures.

2.6. Risk Factors of Rotator Cuff Injury9

Rotator cuff (RC) injuries have been classified as intrinsic when that tendon injury results from
direct tendon overload, intrinsic degeneration, or other insult. RC injury mechanisms are
9
extrinsic when: 1) the tendon is damaged through compression against surrounding structures
usually the coracoacromial arch, 2) Elevation of the arm may either tear or squeeze subacromial
tendon structures; and 3) Microcirculation in the tendon is impaired by high intramuscular
pressure resulting in inflammation (tendinitis) leading to degeneration. It is not always clear
which of these three injury mechanisms explains a patient’s RC injury and overuse likely
affects both intrinsic and extrinsic factors.
2.6.1. Occupational Factors
The overuse theme is common for workers in industrial occupations that perform repetitive
manual tasks resulting in an increased prevalence of shoulder disorders. For example,
prevalence rate of shoulder pain among cashier workers exposed to repetitive work was 28.9%
compared to 16% in an unexposed group. Both repetition and force requirements contribute to
increased risk of shoulder tendonitis with a 3.7% rate in a Danish population of 4162 workers.
Other studies reported worker shoulder tendinitis rates of 2.7% in textile workers, up to 10%
in slaughter house workers, 15% in fish processing workers, and 32% among rock blasters.
Cause-effect assignment becomes increasing difficult in older workers. Tendons weaken,
inflammation occurs, rotator cuffs tear with increasing age. Asymptomatic individuals older
than 70 have been demonstrated to have rotator cuff tears at a rate as high as 70%. The question
is when shoulder tendonitis is a result of work exposure and when is it due to natural causes
and therefore idiopathic. Morphological aging of the shoulder versus work-related exposure
has to be addressed as it is critical for worker compensation decisions. Exposure-response
patterns must be analyzed to better determine clinical attribution to workplace factors with age
taken into consideration.
2.6.2. Non Occupational Factors
Non-occupational risks for rotator cuff-related disorders: Rotator cuff disorders are not
characterized by frank inflammation; however, inflammatory mediators may be present in
rotator cuff tear, tendinitis and impingement patients. These include increased: interleukin-1,
tumor necrosis factor-alpha, basic fibroblast growth factor, transforming growth factor,
metalloproteinases, CD2-positive T-lymphocytes, tenascin-C, substance P and vascular
endothelial growth factor. It is unknown whether these factors precede or are a consequence of
the disease.
Some factors increase risk for shoulder pain, rotator cuff related disease, and atherosclerosis,
including obesity, smoking, hypercholesterolemia and diabetes mellitus. These factors may be
reduced with active exercise. Genetic factors are also reported risks.8

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2.7. Repetitive Movement 10
2.7.1. Definition of Repetition on Shoulder
According to NIOSH, Repetitiveness was defined in four different ways in the reviewed
studies: (1) the observed frequency of movements past pre-defined angles of shoulder flexion
or abduction, (2) the number of pieces handled per time unit, (3) short cycle time/repeated tasks
within cycle, and (4) a descriptive characterization of repetitive work or repetitive arm
movements.
1. Repetition Characterized as Frequency of Movements Past Pre-Defined Shoulder Angles
Bjelle et al. [1981] and Ohlsson et al. [1995] found a significant positive association between
the prevalence of neck-shoulder disorders and the frequency of upper arm movements past 60
degrees of flexion or abduction. English et al. [1995] found a significant association between
diagnosed cases of shoulder disorders and repeated shoulder rotation with an elevated arm
posture.
2. Repetition Characterized as the Number of Pieces Handled per Time Unit
A significant positive association was found between both nonspecific shoulder symptoms
[Ohlsson et al. 1989] and nonspecific shoulder disorders [Sakakibara et al. 1995] and the
number of pieces handled per hour or per day.
3. Repetition Characterized as Short Cycle Time
Chiang et al. [1993] found a significant association between a very short or repetitive cycle
(<30 seconds or >50% spent repeating same task) and shoulder girdle pain.
4. Repetition Characterized Descriptively
Three studies by Ohlsson et al. found a significantly higher proportion of shoulder MSDs in
exposed populations with work characterized as involving repetitive arm and hand movements
than in referent populations.

2.7.2. Repetitive Task Expossure 11

Execution of similar or identical movements during a large part of the working time with a
high rate of repetition (i.e. several times per minute). During the course of work the working
person has often little influence on the working pace, speed, task sequence and work and break
schedule. Commonly, the working person cannot abandon the workplace without being
replaced by another person.
Examples are:
 assembly line
 cash registration

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 loading of packing machines, etc

2.7.3. Prevention of Repetitive Movement 11

Advice to the employee:
 Avoid continuous loading of the same muscles for longer periods of time.
 Strive for changes in motion in order to avoid identical muscular activation patterns. For
strongly monotonous work, changes in the execution of movements may be limited.
 Change body posture frequently in order to reduce static loading.
 Use rest pauses.
Advice to the employer:
 Provide for organizational changes, such as job rotation, job diversification or job
enrichment, to reduce the extent of task repetition for individuals.
 Enable autonomous decisions about the timing of breaks.
 Mechanize unavoidable monotonous tasks with high load.

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 CHAPTER 3
JOURNAL REVIEW

3.1 Methods
We searched PubMed and scopus to find all published observational studies evaluating the
relationship between repetitive movement on shoulder and shoulder disorders using free the
free text and Medical Subject Headings (MeSH) terms “repetitive movement”, or “repetitive
movement on shoulder” and “shouder disorders”. Inclusion criteria of this searching is cross
sectional, case control, cohort, systematic review, and RCT. The searching period was from
21th of November till 10th of December 2018.

Tabel 1. Searching strategy by using database from PubMed and Scopus

Database Searching Strategy Found Selected
PubMed (("shoulder"[MeSH Terms] OR "shoulder"[All 44 3
Fields]) AND ("disease"[MeSH Terms] OR
"disease"[All Fields] OR "disorders"[All
Fields]) AND repetitive[All Fields] AND
("movement"[MeSH Terms] OR
"movement"[All Fields])) AND
("2008/12/11"[PDat] : "2018/12/08"[PDat])
Scopus ( TITLE-ABS-KEY rotator cuff 34 2
syndrome AND repetitive
AND movement ) ) AND ( shoulder AND tendinit
is AND repetitive AND movement )
Cochrane Shoulder disorders and repetitive movement 24 0

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 Repetitive movement Rotator Cuff Syndrome OR
OR Repetitive AND Shoulder disorder OR
movement on Shoulder Shoulder tendinitis

Inclusion criteria:
- cross sectional,
Pubmed: 44 Scopus: 34 Cochrane: 24 - case control,
- cohort,
- systematic review,
Repetitive movement
exposure and shoulder
disorders
3 2 0 - Study from year 2000-
2018

3 2 0
Exclusion criteriai:
- Study that cannot
be accessed

SCREENING FOR SAME JOURNAL

CHOSEN JOURNAL: 5

3.2 Critical Appraisal

From the selection anf filtration, five articles qualified for further assessment. These articles
were appraised and considered to have a good validity and relevance.

Table 2. Critical appraisal systematic review

Selection Bias

evaluation of

Homogenity
each study

evidence*
Exposure

Inclusion
Matched

Validity

Level of
Subject

criteria
Study

Rogier M van 17 study : 1 - No Yes Yes tidak 2a

Rijn, et all. 2010 cohort, 1 case
control dan 15
cross sectional.

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 Table 3. Critical Appraisal Observational Study

Enough Follow
Dose response
Intervension

evidence*
Matching

Blinding

gradient

Level of
Method

up time
Subject
Study

K Fredriksson, et Case Control 1587 No Yes No No - 3b

all. 2002
Julie Bodin, et all. Cross Sectional 3710 No No No No Yes 3b
2012
Poul Frost et all. Cross sectional 1961 No No No No Yes 3b
2002
A Leclerc, et all Cross sectional 598 No No No No No 2c

Level of evidence (therapy/etiology/harm) 9

1a : Systematic reviews (with homogeneity) of randomized controlled trials
1b : Individual randomized controlled trials (with narrow confidence interval)
1c : All or none randomized controlled trials
2a : Systematic reviews (with homogeneity) of cohort studies
2b : Individual cohort study or low quality randomized controlled trials (e.g. <80% follow-up)
2c : "Outcomes" Research; ecological studies
3a : Systematic review (with homogeneity) of case-control studies
3b : Individual case-control study
4 : Case-series (and poor quality cohort and case-control studies)
5 : Expert opinion without explicit critical appraisal, or based on physiology, bench research or "first principles"

3.3 Journal Review

3.3.1. Journal 1 12
Tittle : Associations between work-related factors and specific disorders of the shoulder – a
systematic review of the literature
Author : Van Rijn RM, Huisstede BMA, Koes BW, Burdorf A
Publish in : Environ Health Prev Med 2015 ; 20: 12-17
Objectives: to provide a quantitative assessment of the exposure–response relationships
between work-related physical and psychosocial factors and the occurrence of specific shoulder
disorders in occupational populations.
Methods: A systematic review of the literature was conducted on the associations between
type of work, physical load factors, and psychosocial aspects at work, on the one hand, and the
occurrence of tendinitis of the biceps tendon, rotator cuff tears, subacromial impingement
syndrome (SIS), and suprascapular nerve compression, on the other hand. Associations
between work factors and shoulder disorders were expressed in quantitative measures as odds
ratio (OR) or relative risk (RR).
Result: The occurrence of SIS was associated with force requirements >10% maximal
voluntary contraction (MVC), lifting >20 kg >10 times/day, and high-level of hand force >1

15
hour/day (OR 2.8–4.2). Repetitive movements of the shoulder, repetitive motion of the
hand/wrist >2 hours/day, hand–arm vibration, and working with hand above shoulder level
showed an association with SIS (OR 1.04–4.7) as did upper-arm flexion ≥45° ≥15% of time
(OR 2.43) and duty cycle of forceful exertions ≥9% time or duty cycle of forceful pinch >0%
of time (OR 2.66). High psychosocial job demand was also associated with SIS (OR 1.5–3.19).
Jobs in the fish processing industry had the highest risk for both tendinitis of the biceps tendon
as well as SIS (OR 2.28 and 3.38, respectively). Work in a slaughterhouse and as a betel pepper
leaf culler were associated with the occurrence of SIS only (OR 5.27 and 4.68, respectively).
None of the included articles described the association between job title/risk factors and the
occurrence of rotator cuff tears or suprascapular nerve compression.

3.3.2. Journal 2
Tittle: Work environment and neck and shoulder pain: the influence of exposure time. Results
from a population based case-control study 13
Author: K Fredriksson, L Alfredsson, G Ahlberg, M Josephson, Å Kilbom, E Wigaeus Hjelm,
C Wiktorin, E Vingård, the MUSIC/Norrtälje Study Group76
Publish In: Occup Environ Med 2002;59:182–188
Objective. To study associations between long term and short term exposure to different work
environmental conditions and the incidence of neck or shoulder pain. The results were obtained
as part of the MUSIC-Norrtälje study, which is a population based case-control study
conducted in Sweden in 1993–7.
Methods. The cases were people from the study base who sought medical care or treatment for
neck or shoulder pain. Information on physical and psychosocial conditions in the work
environment,currently and 5 years ago, and lifestyle factors, was obtained by self administered
questionnaires from 310 cases and 1277 randomly selected referents.
Results: Associations between both physical and psychosocial exposures in the work
environment and seeking care for neck or shoulder pain were found. The risk patterns differed
for the sexes, and risk ratios exceeding 1.5 were more often found among women than among
men. Generally, subjects who had experienced a recent increase of exposure were more likely
(relative risk (RR) 2.1–3.7) to seek care than those who had been exposed long term (RR 1.5–
1.8). Among women, an increased amount of visual display terminal (VDT) work, work above
shoulder level, and reduced opportunities to acquire new knowledge, and among men, an
increased amount of seated work were associated with neck or shoulder pain. This might
indicate short induction periods for neck or shoulder pain for these exposures. However, for

16
repetitive work with the hands and hindrance at work among women, and possibly also local
vibrations among men, the induction periods seem to be longer. Interactive effects between
factors, both at work and in the family, were found, but only among women.
Conclusions: Associations between some exposures in the work environment and seeking care
for neck or shoulder pain were found. The high RRs for short term exposure might indicate
that for many factors the induction period for neck or shoulder pain is short.

3.3.3. Journal 3 14
Tittle: Risk factors for incidence of rotator cuff syndrome in a large working population
Author: Bodin J, Ha C, Petit Le Manac’h A, Sérazin C, Descatha A, Leclerc A, Goldberg M,
Roquelaure Y.
Publish in: Scand J Work Environ Health. 2012;38(5):436–446.
Objective: The aim of this study was to assess the effects of personal and work-related factors
on the incidence of rotator cuff syndrome (RCS) in a large working population.
Methods A total of 3710 French workers were included in a cross-sectional study in 2002–
2005. All completed a self-administered questionnaire about personal factors and work
exposure. Using a standardized physical examination, occupational physicians established a
diagnosis of RCS. Between 2007–2010, 1611 workers were re-examined. Associations
between RCS and risk factors at baseline were analyzed by logistic regression.
Results A total of 839 men and 617 women without RCS at baseline were eligible for analysis.
RCS was diagnosed in 51 men (6.1%) and 45 women (7.3%). The risk of RCS increased with
age for both genders [odds ratio (OR) 4.7 (95% confidence interval [95% CI] 2.2–10.0) for
men aged 45–49 years and 5.4 (95% CI 2.3–13.2) for women aged 50–59 years; reference <40
years]. For men, the work-related risk factors were repeated posture with the arms above the
shoulder level combined with high perceived physical exertion [OR 3.3 (95% CI 1.3–8.4)] and
low coworker support [OR 2.0 (95% CI 1.1–3.9)]. For women, working with colleagues in
temporary employment [OR 2.2 (95% CI 1.2–4.2)] and repeated arm abduction (60–90°) [OR
2.6 (95% CI 1.4–5.0)] were associated with RCS.
Conclusions Age was the strongest predictor for incident cases of RCS, and arm abduction
was the major work-related risk factor for both genders. Lack of social support was a predictor
for RCS among men.

17
3.3.4 Journal 4
Tittle: Risk of Shoulder Tendinitis in Relation to Shoulder Loads in Monotonous
Repetitive Work15
Author: Poul Frost, MD, PhD, Jens Peter E. Bonde, MD, DrMedSc, Sigurd Mikkelsen, MD,
DrMedSc, Johan H. Andersen, MD, PhD, Nils Fallentin, MSc, PhD, Anette Kaergaard, MD,
PhD,and Jane F. Thomsen, MD, PhD
Publish in: American Journal Of Industrial Medicine 41:11±18 (2002)
Objective: This study evaluates the hypothesis that shoulder loads in repetitive work might
contribute to the occurrence of shoulder tendinitis.
Methods: This is a cross-sectional study of 1961 workers in repetitive work and 782 referents.
Shoulder loads were quantifed at task level and measures of exposures were assigned based on
task distribution. Symptoms in combination with clinical criteria defined shoulder tendinitis.
Results: The prevalence of shoulder tendinitis was higher among exposed workers (adjusted
OR 3.1, 95% CI 1.3±3). Neither frequency of movements (ranging 1±36/min) nor lack of
micro-pauses in shoulder fexion (ranging 0±100% of cyclus time) was related to disease
prevalence. Increasing force requirements (categorized as light.1, somewhat hard.2, hard.3 or
very hard.4) increased risk slightly (OR 1.6, 95% CI 1.0±2.6 per unit).
Conclusion: The results indicate that workers with repetitive tasks have increased risk of
shoulder tendinitis, which partially can be attributed to force requirements.

3.3.5. Journal 5 16
Tittle: Incidence of shoulder pain in repetitive work
Author: A Leclerc, J-F Chastang, I Niedhammer, M-F Landre, Y Roquelaure, Study Group on
Repetitive Work
Publish in: Occup Environ Med: first published as on 22 December 2003.
Objective: To determine the predictiveness of personal and occupational factors for the onset
of shoulder pain in occupations requiring repetitive work.
Methods: A sample of 598 workers in five activity sectors completed a self administered
questionnaire in 1993–94 and again three years later. Both questionnaires included questions
about shoulder pain. The associations between various factors at baseline and subsequent
shoulder pain were studied among subjects free from shoulder pain at baseline.
Result: The incidence of shoulder pain was associated with several independent risk factors:
depressive symptoms, low level of job control, and biomechanical constraints. After
adjustment for other risk factors, the presence of depressive symptoms predicted occurrence of

18
shoulder pain. A low level of job control was also associated with the onset of shoulder pain in
both sexes. For men, repetitive use of a tool was a strong predictor, while the two most
important biomechanical risk factors for women were use of vibrating tools and working with
arms above shoulder level.
Conclusion: This study used a longitudinal approach to examine different sets of risk factors
for shoulder pain simultaneously. The results confirm the role of several biomechanical
constraints. Psychological symptoms and a low level of job control also play a role.

19
 CHAPTER 4
IMPLEMENTATION SEVEN STEPS OF OCCUPATIONAL DIAGNOSIS

4.1. Establishing the Clinical Diagnosis

The clinical diagnosis of rotator cuff syndrome based on the history, physical examination, and
radiological examination. Patients with tendon pathology often have shoulder pain that radiates
to the upper arm and deltoid region, and some even report more distal radiation without
paresthesias. Bursitis tends to have non-radiating shoulder joint pain, although it too may
present with deltoid region pain. Partial-thickness tears cannot reliably be distinguished from
the other rotator cuff entities clinically or with imaging. Many of the symptoms and
examination maneuvers used to assign a diagnosis of rotator cuff syndrome" are not specific to
a cause. The supraspinatus tendon is the most commonly affected tendon in the rotator cuff.
Tendon pathology most commonly progresses posteriorly to the infraspinatus. Tendonopathies
are generally considered the most important of the occupational shoulder disorders based on
high prevalence.8
Rotator cuff syndrome can be diagnosed by physical examination. The clinician can perform
several test to support diagnosed of rotator cuff syndrome, the test include;
1. Neer’s test (Impingement)
The examiner should stabilize the patient's scapula with one hand, while passively
flexing the arm while it is internally rotated. If the patient reports pain in this position,
then the result of the test is considered to be positive.
2. Drop arm test (supraspinatus tendon)
Stand behind the seated patient and abduct patient's arm to 900, supporting the arm at
the elbow. Release the elbow support, and ask patient to slowly lower the arm to the
side. The test is negative if the patient is able to control the lowering of the arm slowly
and without pain. It is positive if there is pain while lowering the arm, sudden dropping
of the arm or weakness in maintaining arm position during lowering (with or without
pain), suggesting injury to the supraspinatus.17
3. Hawkin’s test (supraspinatus tendon)

20
 The examiner places the patient's arm shoulder in 90 degrees of shoulder flexion with
the elbow flexed to 90 degrees and then internally rotates the arm. The test is considered
to be positive if the patient experiences pain with internal rotation.18

Beside performing the physical examination the clinician can also confirm the diagnosed by
radiological examination such as;
• Shoulder x-rays for diagnosis in traumatic injuries and as an initial study, if diagnostic
imaging is needed, for non-traumatic shoulder problems is recommended
(Insufficient Evidence (I)).
• Magnetic resonance imaging (MRI) is recommended (Insufficient Evidence (I) and
some evidence for advanced imaging of soft tissues such as rotator cuff tears,
particularly in patients who are not recovering as expected or where additional
diagnostic information would change the treatment plan).
• MR arthrography is recommended (Insufficient Evidence (I) and some evidence to
diagnose labral tears in patients who are not recovering as expected or where
additional diagnostic information would change the treatment plan).
• Computerized Tomography (CT) is recommended (Insufficient Evidence (I)) for
advanced imaging of bone, if needed, particularly if fractures are suspected but not
seen on x-ray.
For definite diagnosis,a recent prospective study combining multiple examination maneuvers
demonstrated that a combination of 3 physical examination findings (supraspinatus weakness,
weakness in external rotation, and impingement) along with the patient’s age can often
diagnose or rule out a rotator cuff tear. This group of tests did not distinguish full versus partial
thickness tears. This approach is summarized in Figure 4.22

21
 Figure 4. diagnosing rotator cuff tear by physical and imaging study
Ultrasound (US) and MRI have high sensitivity for detecting full-thickness RCT. US
performed better in detecting partial-thickness tears, although the difference was not
significant.23

4.2. Listing of the Potential Hazards Found in the Workplace

It is important to know all of the potential hazard in the workplace to give information about
the diseases or the risk of occupational diseases that potentially happen to the workers. The
step to get the information of potential hazard by asking the workers job task; how long the
task is perform; listing the materials that is used; chronologically job descriptions; listing
physical, chemical, biological, ergonomic, and psychosocial hazard; and control of hazard. For
the ergonomic risk factors the detail information of the workers position could be asses by
using ergonomic tools:
 Rapid Entire Body Assessment (REBA)
 Rapid Upper Limb Assessment (RULA)
 Brief survey
From that assessment we can get detail information about how much ergonomic risk
experienced by workers. The risk factors are repetitive movement of the shoulder, position of
upper arm (abducted upper arm) and force requirements.
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4.3. Literature Searching to Find Evidence-Based Causal Relationship Between the
Suspected Workplace Potential Hazard and the Occurrence of the Clinical Diagnosis.
To identify any exposure-related diseases, reviewer should find the epidemiological studies
(evidence based) that showed whether there is a relationship or not between repetitive
movement on shoulder and rotator cuff syndrome. To review existing literature/ references by
applying the Sir Bradford Hill’s Criteria.
1. Strength:
Based on the five journals above, all studies showed there is an association between
repetitive movement on shoulder and rotator cuff syndrome, proven by statistical data
that shows significant results.
Journal 1 : OR 1.04–4.7 (systematic review; repetitive movement and shoulder
impingement), Journal 2 : RR 1,8 (frequent hand or finger movement), Journal 3 : OR
3.3 (95% CI 1.3–8.4) (repeated posture with the arms above the shoulder level
combined with high perceived physical exertion), journal 4: adjusted OR 3.1, 95% CI
1.3±3 (frequency of movements (ranging 1±36/min) nor lack of micro-pauses in
shoulder fexion), journal 5: OR 4.34 (1.58 to 11.9) (repetitive use of tool)
2. Consistency:
The same results (rotator cuff syndrome) that obtained at different times and places
have the same cause effect interpretation (all subjects, workers who exposed repetitive
movement on shoulder) have a symptom rotator cuff syndrome.
3. Specificity:
4. Repetitive movement on shoulder is one of the causes of rotator cuff syndrome. Rotator
cuff syndrome not specifically caused by repetitive movement of the shoulders, there
are still many occupational factors and individual factors that cause rotator cuff
syndrome.
5. Temporality:
Although temporality cannot be obtained from cross-sectional studies, one study in
jurnal 1 showed by systematic review of the occurrence of tendinitis of the biceps
tendon, rotator cuff tears, subacromial impingement syndrome (SIS), and suprascapular
nerve compression. Twelve from seventeen journal prove the asscociation between
rotator cuff syndrome and employees exposed to repetitive movement.
In the systematic study, there is one cohort study that show asscociation between job
title and shoulder disorders OR 2.54 (1.50–4.30).

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 5. Dose response:
Long Term exposure to frequent hand or finger work, and hindrance at work was
associated with seeking care for neck or shoulder pain among women (journal 1).
Repeated and sustained posture with the arms above shoulder level (≥2h/day) increase
the incident rotator cuff syndrome (RCS) in the male working population (journal 3).
6. Biological Plausibility
The exact mechanisms leading to the degeneration of the rotator cuff, however, are still
being debated. Rotator cuff pathology can result from extrinsic or intrinsic factors.
Extrinsic examples include a traumatic tear in tendons from a fall or accident. Overuse
injuries from repetitive lifting, pushing, pulling, or throwing are also extrinsic in nature.
Intrinsic factors include poor blood supply, normal attrition or degeneration with aging,
and calcific invasion of tendons.20
7. Coherence:
Different types of evidence from multiple sources support our cause-effect
interpretation.
8. Experiment:
None of five studies is doing experiment
9. Analogy:-

4.4. Determining Whether The Exposure Is Sufficient

There is no threshold value for repetitiveness on shoulder, but from several literature stated
that the increasing risk for rotator cuff syndrome influenced by:
1. repetitive hand–arm movements
2. frequency of shoulder movements/minutes (>14 more likely to have rcs)
3. work requiring repetitive motion hand/ wrist, ≥2 hours/day
4. repeated and sustained posture with the arms abduction (60–90°)
5. long term exposure to frequent hand or finger work.
1. High repetitiveness of tasks (≥4h/day)13,14,15,16

4.5. Determining Any Individual Factors That Play A Role

Individual factors that plays role for the incident of rotator cuff syndrome are:
 obesity,
 smoking,
 hypercholesterolemia

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  diabetes mellitus.
 age > 40
 genetics
 gender
 medical comorbidities 13,14,15,21

4.6. Determining Whether There Are Other Factors Outside Work

As alluded to earlier, overhead activities in sports such as throwing also predispose patients to
the development of rotator cuff syndrome.

4.7. Occupational Diagnosis

Review the information that has been gathered from previous steps. Based on the evidence and
up-to-date reference, make a decision whether the disease suffered is a result of work or not.
Rotator cuff syndrome is an occupational disease if step 1-4 are fulfilled. To prove work-related
disease in workers who exposed to repetitiveness, the following four steps must be fulfilled:
1. Already diagnosed rotator cuff syndrome.
2. The workers doing repetitive movement especially on shoulder.
3. There is evidence base revealed the relationship between repetitive movement on
shoulder and rotator cuff syndrome
There is no study that stated about treshhold limit value for repetitive movement.

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 CHAPTER 5
CONCLUSION

 Repetitive movement on shoulder is ergonomic potential hazard that can cause rotator cuff
syndrome.
 The symptoms of rotator cuff syndrome: atraumatic, insidious onset of pain symptom
exacerbation with overhead activity and pain at night. It is important to get information
about history includes current or history of sports participation (as well as specific
positions played in each sport), occupational history and current status of employment,
hand dominance, any history of injury/trauma to the shoulder(s) and/or neck, and any
relevant surgical history.
 Several physical examination should perform by the doctor to ensure the diagnosis.
 The increasing risk of rotator cuff syndrome influenced by:
1. repetitive hand–arm movements
2. frequency of shoulder movements/minutes (>14 more likely to have rcs)
3. work requiring repetitive motion hand/ wrist, ≥2 hours/day
4. repeated and sustained posture with the arms abduction (60–90°)
5. long term exposure to frequent hand or finger work.
6. high repetitiveness of tasks (≥4h/day)
 The occupational diagnosis can be confirmed if step 1-4 are fulfilled.

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