OCCUPATIONALAND ENVIRONMENTALMEDICINE 0095-4543/00 $15.00 + .

OO

WORK-RELATED
UPPER EXTREMITY
MUSCULOSKELETAL DISORDERS
Lisa Mani, MD, MPH, and Fredric Gerr, MD

Upper limb musculoskeletaldisorders, such as rotator cuff tendonitis,

epicondylitis, and carpal tunnel syndrome, are common ailments among
working people in the United States. The affected tissues include muscles,
tendons, nerves, and blood vessels. These disorders occur with increased
frequency among employees in a number of occupations, particularly
those requiring intensive use of the hands and arms as well as regular
exposure to vibration. This article provides the reader with an overview
of the clinical features, occupational and nonoccupational causes, primary
conservative treatment, and methods of preventing common work-related
upper extremity musculoskeletal disorders.

DESCRIPTIVE EPIDEMIOLOGY

The reported incidence of work-related upper limb disorders has in-

creased substantially in the United States over the past two decades.
Workplace illness and injury data collected by the Bureau of Labor Statis-
tics of the US Department of Labor (BLS) show that this category of illness
(called disorders associated with repeated trauma by the BLS) increased from
18%of all occupational illness in 1982 to 65% of all occupational illness
in 1998.*
Data from the BLS indicate that more than 500,000 workers were re-
ported in 1998 to have an illness or injury of the shoulder or upper ex-

From the Department of Environmental and Occupational Health, Rollins School of Public
Health, Emory University, Atlanta, Georgia

PRIMARY CARE

VOLUME 27 * NUMBER 4 DECEMBER 2000 845

846 MANI&GERR

tremity of sufficient severity to result in at least one lost work day.8 The
total number of cases, including those not involving lost work time, was
substantially greater. The event or exposure leading to the injury or illness
was reported as ”overexertion” or ”repetitive motion” in nearly 300,000
of the lost work day cases.
In 1998, industries with the highest incidence rates of occupational
disorders associated with repetitive motion included meat packing plants,
motor vehicles and car body manufacturing, poultry slaughtering and
processing, garment production, and shoe manufacturing. Extremely low
incidence rates were reported by real estate agents, security and com-
modity brokers, and elementary and secondary school teachers.8 Inci-
dence rates for the highest and lowest risk industries are presented in
Table 1.
Despite these incidence rates, reported work-related musculoskeletal
disorders likely underestimate the true disease burden. Underreporting
by employees to their employers and by employers to the Department of
Labor, variable methods of determining work-relatedness by health care
providers, and varying workers’ compensation systems by state contrib-
ute to the uncertainty of actual incidence rates. Actual rates are likely
considerably higher than those reported.

TERMINOLOGY ISSUES

Part of the difficulty characterizing work-related musculoskeletaldis-

orders has been widespread use of vague or misleading terminology. Non-

Table 1. INCIDENCE RATES AND NUMBERS OF “DISORDERS ASSOCIATED WITH

REPEATED TRAUMA FOR SELECTED INDUSTRIES, USA, 1998
Annual
Incidence Rate
Annual Average (per 100 Number of
Industry Employment (1000s) full-time workers) Cases (1000s)
Examples of high-risk
industries
Meat packing plants 149.4 9.9 15.9
Motor vehicles and 343.7 7.1 24.3
car bodies
Poultry slaughtering 248.3 4.9 12.7
and processing
Men’s and boy’s 59.1 4.1 2.2
trousers and slacks
Examples of low-risk
industries
Security and com- 6.7 0.06 0.4
modity brokers
Real estate agents 6.0 0.05 0.3
and managers

Data from US Department of Labor, Bureau of Labor Statistics

 WORK-RELATED UPPER EXTREMITY MUSCULOSKELETAL DISORDERS 847

specific terminology such as ”cumulative trauma disorder,” ”repetitive

strain injury,” ”occupational cervicobrachial disorder,” and ”overuse syn-
drome” provides little insight into anatomy affected, disease severity, ap-
propriate treatment, or expected prognosis. Furthermore, some terms im-
ply disease mechanisms (e.g., the accumulation of trauma or injury from
repeated strain) that are hypothetical, at best. The authors of this review
recommend a simple, descriptive nomenclature for these disorders. When
a well-defined disorder (e.g., DeQuervain’s disease) is diagnosed, it should
be called by its usual name. Should the disorder be determined by the
examining physician to be occupational in origin, then the term work-
related should be used to modify the condition’s name (e.g., work-related
DeQuervain’s disease). When the clinical picture is inconsistent with any
well-defined disorder, then descriptive nomenclature (e.g., diffuse fore-
arm pain) should be used, rather than more technical sounding but, in
fact, less accurate terms.

RISK FACTORS

Overview of Occupational Risk Factors

Occupational risk factors nearly universally mentioned as potentially

causative for upper extremity musculoskeletal disorders include forceful
hand and arm exertions, repetitive hand and arm use, movements that
require extremes of hand and arm posture, prolonged static postures, and
~ i b r a t i o n . ~ ,The
’ ~ , evidence
~ ~ , ~ ~ associating each risk factor with each spe-
cific disorder is variable, however, adding a level of complication to the
understanding of work-related musculoskeletal disorders. For disorders
of the distal upper extremity (tendonitis, carpal tunnel syndrome, hand-
arm vibration syndrome), force, repetition, and vibration are the most
well-established risk fact01-s.~ For disorders of the neck and shoulder (tra-
pezius myalgia, rotator cuff disorders) posture, repetition, and force are
the most well-established risk factors? Investigators from the National
Institute for Occupational Safety and Health have prepared an extensive
review of the epidemiologic literature, in which they report well-sup-
ported associations between specific hazardous exposures and specific
musculoskeletal disorder^.^ A brief summary of the results of their review
is provided in Table 2. Specific occupational risk factors and specific jobs
associated with upper limb disorders are discussed for each of the dis-
orders described in this article.
Unfortunately, in part because of marked synergy between risk fac-
tors and in part because of limitations in assessment of risk factors in the
literature, quantitative levels of exposure that result in ”acceptable”levels
of risk are not available. As a result, prevention of occupational muscu-
loskeletal disorders cannot be based upon the application of simple ex-
posure limits, as is done for many chemical exposures. Rather, for any
given workplace, an ”ergonomics program” that includes (1) inspection
of facilities for potentially hazardous exposures, (2) surveillance of work-
848 MAN1 & GERR

Table 2. SUMMARY OF FINDING OF NATIONAL INSTITUTE FOR OCCUPATIONAL

AND HEALTH REVIEW OF EVIDENCE FOR CAUSAL RELATIONSHIPS BETWEEN
PHYSICAL WORK FACTORS AND UPPER EXTREMITY MUSCULOSKELETAL
DISORDERS
Body Part Strong Insufficient Evidence of
Risk Factor Evidence Evidence Evidence No Effect
Neck and neck-shoulder
Repetition X
Force X
Posture X
Vibration X
Shoulder
Repetition X
Force X
Posture X
Vibration X
Elbow
Repetition X
Force X
Posture X
Combination X
Hand and wrist
Carpal tunnel syndrome
Repetition X
Force X
Posture X
Vibrat ion X
Combination X
Tendonitis X
Repetition X
Force X
Posture X
Combination X
Hand arm vibration syndrome
Vibration X

Data from Bernard B (ed): Musculoskeletal disorders and workplace factors. Cincinnati, OH, National
Institute for Occupational Health and Safety, US Department of Health and Human Services, 1997.

ers for unusual elevations of disease incidence, (3) control of exposure

when experience suggests they are likely to be hazardous or incidence
rates indicate a problem, (4) appropriate management of clinical illness
when it occurs, and (5) education of employees and managers is the best
method of preventing these disorders.'O

Nonoccupational Risk Factors

As is true for almost all illnesses associated with work, a number of

nonoccupational factors also increase risk. In general, rates of musculo-
skeletal disorders increase with increasing age and female gender. It is
possible, however, that these associations are because of increased dura-
tions of exposure and preferential placement of women workers into jobs
with intense hand use. Other risk factors include pre-existing rheumato-
 WORK-RELATED UPPER EXTREMITY MUSCULOSKELETAL DISORDERS 849

logic disease, history of musculoskeletal disorder, and, at least for carpal

tunnel syndrome, body mass index, pregnancy, diabetes, renal dialysis,
and, possibly, thyroid disease.28,35,40,45

CLINICAL EVALUATION

History of Current Illness

Musculoskeletal pain or discomfort on the job is the hallmark of a

work-related musculoskeletal disorder. Other symptoms might include
muscle fatigue, loss of strength, numbness, burning, or tingling. Charac-
teristics of the pain, including rapidity of onset, intensity, quality, location,
radiation, aggravating and alleviating factors, and daily patterns should
be elicited and can provide insight into its cause. Evaluation of pain early
in the course of the illness (i.e., early reporting by workers) is considered
important for control of symptoms and to provide an opportunity for
exposure reduction to minimize future risk to the patient.

Occupational History

The purpose of the occupational history is to obtain information

about the patient’s exposure to risk factors. Reviewing the patient’s tasks
at work is essential to determine an occupational basis for musculoskeletal
injury. Inquiry should be made about the following factors:
postures that require joint movement to the extremes of the motion range
(e.g., work with hands above shoulder height)
forceful exertions of the hands and arms (e.g., squeezing tool handles,
pulling or pushing raw materials)
performance of a particular repetitive activity for more than 1 to 2 hours
(e.g., use of a knife to split chickens in a processing plant)
exposure to vibration (e.g., chain saws, air-power tools)
pacing by machine (e.g., assembly line work)
Important information to obtain during the occupational history also in-
cludes changes in symptoms with changes in work tasks and documen-
tation of break frequency.
When taking an occupational history, it may be helpful to have the
patient act out his or her job tasks to give the examiner a better idea of
the postures and movements assumed on the job. Having the patient bring
a photograph of his or her workplace and activity may be helpful. De-
scriptions of the physical demands of many jobs are now kept by many
employers; having the patient bring the written description of the job may
be helpful for assessing ergonomic risks. Also helpful in assessing a pos-
sible occupational basis to symptoms is determining whether coworkers
are similarly affected. The history should also include recreational expo-
850 MAN1 & GERR

sures, such as hobbies and other tasks undertaken outside of work. Finally,
because evidence is mounting that the psychological and emotional con-
text of work may be important in the development of musculoskeletal
disorders, information should be collected about the patient’s control over
his or her own work, deadline pressures, workplace relationships, and job
security.l6

Physical Examination

Physical examination should include inspection; palpation; testing of

passive and active range of motion; evaluation of nervous system func-
tion, and assessment of pulses. A number of excellent guides to physical
examination of the upper extremities are a ~ a i l a b l e . 2 ~ , ~ * , ~

Laboratory Evaluation

The main use of laboratory tests is to rule out systemic illness as a

cause or contributor to musculoskeletal symptoms. Systemic disorders
include infection, arthritis, gout, calcium pyrophosphate deposition, dia-
betes; hypothyroidism, and collagen vascular disease.42Selection of fur-
ther studies such as nerve conduction testing, electromyography, and
radiologic imaging also depends on the differential diagnosis formulated
following examination. In most cases, however, laboratory work is not
required at the time of initial evaluation unless an underlying illness is
suspected.

Treatment

Treatment of most occupational musculoskeletaldisorders should be-

gin with conservative measures, including immobilization, anti-inflam-
matory medication, cold and heat applications, and occupational or physi-
cal therapy. Treatment of occupational musculoskeletal disorders requires
control of exposures that were contributory to the development of the
disorder. Treatment without control of work conditions that led to the disorder
is likely to fuil. Exposure control includes transfer of the worker to another
position, reduction of time the worker can be exposed to his usual work
activities (restricted duty), redesign of the workplace and work tasks,
change in work policies such as worker rotation and increased rest breaks,
and use of personal protective devices. Surgery for occupational muscu-
loskeletal disorders should rarely be considered until conservative ther-
apy has failed.
 WORK-RELATED UPPER EXTREMITY MUSCULOSKELETAL DISORDERS 851

SHOULDER DISORDERS

The shoulder has broad range of motion and is susceptible to injury

on the job.%Shoulder disorders are frequently difficult to categorize, es-
pecially when symptoms are chronic and s e ~ e r e . ' ~ , ~ ~

Trapezius Myalgia

Trapezius myalgia is localized discomfort of the trapezius muscles. It

is sometimes also referred to as tension neck syndrome. It is the most com-
mon of the occupational shoulder and neck disorders and affects large
proportions of some working populations. The pathophysiology is not
well understood but is believed to be minimal. In fact, some argue that it
is not a true disease entity.

Clinical Presentation
Patients present with pain, tenderness, stiffness, or burning of the
upper back, shoulder, and areas just lateral to the neck. On physical ex-
amination, muscle tightness or "trigger points" of increased muscle tone
and tenderness may be noted. Mild decreases in range of motion can be
observed. Often, the examination is completely normal. Differential di-
agnoses include cervical spine disorders and shoulder pathology. No lab-
oratory test or radiologic evaluation is useful in diagnosing trapezius my-
algia.

Risk Factors
A worker may describe unvarying job tasks requiring static position-
ing of the neck, shoulders, and back, such as data entry on a computer
terminal. Occupational risk factors include unvarying stationary position-
ing of the neck, shoulder, or back or prolonged static loading of shoulder
muscles. This disorder occurs among persons performing assembly line
manufacturing, dental work, some medical work, fine electrical or micro-
electronic work, artisantry or jewelry crafting, and office work such as
data entry or k e y b ~ a r d i n g . ' ~ , ~ ~ , ~ ~

Treatment
Ice and heat applications may relieve symptoms. For those with par-
ticularly disabling symptoms, low doses of tricyclic antidepressants may
be valuable for control of pain and improvement of sleep. Maintaining
active use of the arms and shoulders will, at least, cause no harm and
may serve to alleviate symptoms. Altering postures at work and taking
frequent rest breaks may also help alleviate this condition.
852 h4ANI&GERR

Rotator Cuff Tendonitis

Rotator cuff tendonitis, also known as supraspinatus tendonitis, is a

muscle-tendon disorder involving the tendons of the rotator cuff. The
rotator cuff is the name given to the functional unit composed of the su-
praspinatus, infraspinatus, teres minor, and subscapularis muscles. Ten-
donitis of the rotator cuff is caused by impingement of cuff structures on
overlying bone.

Clinical Presentation
The patient with rotator cuff tendonitis presents with weakness, pain,
and tenderness, and may have limited ranges of shoulder abduction and
external r ~ t a t i o n . ' ~Clinically,
,~~ pain localizes to the superior or lateral
shoulder, although it may radiate down the arm.= A positive arc-of-mo-
tion test may be Forward flexion of the shoulder to 90" with
internal rotation of the humerus, called Huwkins' impingement sign, repro-
duces Muscle of the affected arm may be normal or mildly di-
minished.I2Radiologic imaging may show calcific deposits of the rotator
cuff tendon^.^,^^ Differential diagnoses include other shoulder pathology
such as subdeltoid bursitis, biceps tendonitis, arthritis, and pain from cer-
vical radiculopathy.

Risk Factors
Forceful or repetitive work involving all movements of the shoulder,
but most notably abduction, flexion, and rotation, places the worker at
risk for rotator cuff tendonitis. Overhead work-for example, holding a
tool while working with the hand at or above shoulder height-and force-
ful work with repetitive pulling or lifting predispose to rotator cuff ten-
donitis.IBt38 Heavy lifting and static postures of the upper extremity may
also increase risk for shoulder t e n d o n i t i ~ . ~Examples
, ~ ~ , ~ ~ of
, ~occupations
~
at risk include automobile exhaust system repair, plumbing, mechanical
maintenance, construction work, factory and assembly line work, poultry
processors, riveters, welders, mail carriers, telephone operators, grocery
store checkers, garment workers, orchard workers, and dentist^.^,'^,^^ Ad-
justments to work tasks and to the workplace may help prevent rotator
cuff tendonitis. Varying work tasks, especially to avoid overhead work
and high shoulder loads have been shown to improve symptoms of ro-
tator cuff tendoniti~.'~,~~

Treatment
Conservative treatment requires that the shoulder be rested but not
immobilized to avoid complications of adhesive capsulitis or frozen
shoulder ~ y n d r o m e . 'This
~,~~ may require avoiding all overhead work for
1 to 3 weeks with limitation of raising the arms.34Anti-inflammatory
agents provide symptomatic relief. Steroidal injections reduce acute pain,
 WORK-RELATED UPPER EXTREMITY MUSCULOSKELETAL DISORDERS 853

but action of steroids can be slow and they should be used sparingly if at
Physical therapy should begin after the resolution of acute symp-
toms and should graduate from gentle range-of-motion to strengthening
exercises.MSurgery is considered when conservative measures do not lead
to

Subdeltoid Bursitis

Subdeltoid bursitis is an inflammatory disorder of the subdeltoid

bursa. The subdeltoid bursa is a palm-sized sac beneath the deltoid muscle
and above the rotator cuff.= The deltoid bursa extends beneath the bony
acromion, so subdeltoid bursitis is also called subacromial bursitis.

Clinical Presentation
Symptoms include pain that is mostly dull and aching, swelling, and
restricted shoulder movement. Symptoms may be indistinguishablefrom
those of rotator cuff tendonitis. The pain may be worse at night, with
symptoms of pressure of the shoulder when ~upine.3~ On physical assess-
ment, the deltoid region may be tender. Physical assessment of shoulder
abduction and forward flexion may be restricted by pain. Muscle strength
should be intact.12The affected shoulder should be compared with the
opposite shoulder. The neck and elbow, as sites referring pain to the shoul-
der, should be examined. Differential diagnoses include rotator cuff dis-
orders, referred pain from cervical disorders, bicipital tendonitis, and the
arthritide~.~~

Risk Factors
Risk factors for subdeltoid bursitis include repetitive use of the upper
extremity with shoulder movement, and in particular, overhead work.38~39
Prevention involves altering the work routine to try to reduce shoulder
activity. Reducing mechanical loads on the shoulder through changes in
workplace design and use of lighter materials and equipment may pre-
vent subdeltoid

Treatment
Treatment includes resting the shoulder. Anti-inflammatory agents
and ice and heat applications reduce symptoms. Physical therapy for gen-
tle reconditioningis recommended with decrease in acute symptoms.Cor-
ticosteroid injections to the bursa may provide relief in persistent or severe
cases.39

Bicipital Tendonitis

Biapital tendonitis is inflammation of the biceps tendon and tendon

sheath in the bicipital groove of the anterior proximal humerus.
854 MAN1 & GERR

Clinical Presentation
Symptoms of bicipital tendonitis are ache and pain of the anterior
~houlder.3~ Marked tenderness on palpation of the biceps tendon at the
anterior shoulder is invariably present. Pain is also reproduced during
resisted shoulder flexion with the elbow fully extended and the forearm
in supination (Speed's test).32Range of shoulder motion is unaffected with
the condition.39Differential diagnoses include bicipital tendon tear and
rotator cuff disorders.

Risk Factors
Patients with biceps tendon pain should be asked about aggravating
movements on the job, including direct trauma to the biceps tendon, and
recreational activities, including involvement in sports. Risk factors in-
clude highly repetitive work requiring movement of the shoulder and
sustained shoulder postures, especially in flexion and abduction. Occu-
pations associated with bicipital tendonitis include assembly of heavy
equipment, red-meat slaughterhouse work, farm work or harvesting,
manufacturing, assembly line work, and grocery store ~ h e c k i n g . ~ , ' ~ , ~ ~ , ~ ~

Reatment
Management is conservative, with anti-inflammatory agents and ice
and heat applications. The arm and biceps muscle should be rested. With
resolution of acute symptoms, physical therapy may help with gradual
restrengthening of the biceps. Local injections of steroids to the bicipital
tendon increase the risk of tendon rupture, although they allow for im-
provement in some cases.39

ELBOW DISORDERS

Lateral Epicondylitis

Lateral epicondylitis, or tennis elbow, is a syndrome of pain of the

wrist extensor muscles at or near their lateral epicondyle origin or pain
directly over the e p i ~ o n d y l e . ' ~ , ~ ~

Clinical Features
The patient usually presents with discomfort of the lateral elbow. On
physical examination, point tenderness at or slightly distal to the lateral
epicondyle or tenderness of the proximal extensor muscle mass is present.
The lateral epicondyle is the origin of the wrist extensor muscles and
elbow pain with resisted wrist extension is suggestive of the diagnosis.32
 WORK-RELATED UPPER EXTREMITY MUSCULOSKELETALDISORDERS 855

Risk Factors
Although the literature is less consistent for lateral epicondylitis than
for some other disorders, high hand force with repetitive use of the hands
and arms have been reported by some to be risk factors for lateral epi-
condylitis.3,’6Repetitive rotation of the forearm, as in use of a screwdriver,
for example, has been associated by some investigators with lateral epi-
~ondylitis.’~,~~ Forceful gripping with wrist extension is also associated
with this d i ~ o r d e r . ~ ,Among
* ~ , * ~ published studies, high-risk jobs for work-
related epicondylitis include work in construction, assembly, and manu-
facturing; food processing; and f ~ r e s t r y . ~ , ’ ~ , ~ ~

Treatment
The disorder may be slow to improve. Therapy includes rest, splint-
ing, ice and heat applications, and anti-inflammatory or pain medications.
With resolution of acute symptoms, stretching and strengthening exercises
are ~ecommended.~~ Prevention includes modifying work tasks and tools.
Work movements may be altered to execute work tasks with the palm up,
thereby decreasing reliance on the lateral extensor

Medial Epicondylitis

Medial epicondylitis or “golfer’s elbow” is a syndrome of pain of the

wrist flexor extensor muscles at or near their medial epicondyle origin or
pain directly over the epi~ondyle.’~,~~
Medial epicondylitis occurs with less
frequency than lateral epicondyliti~.~~

Clinical features
Physical examination reveals tenderness of the medial epicondyle.
Resisted flexion of the wrist elicits medial elbow pain.32The differential
diagnoses include arthritis and nerve compression disorder~.’~

Risk Factors
Medial epicondylitis is not well established as an occupational dis-
order. The literature includes some suggestions that the disorder is seen
with repetitive wrist flexion, as might occur with use of some hand tools
in assembly or installation tasks.

Treatment
Elbow pads are recommended to cushion the injured epicondyle
when resting the elbow on hard surfaces. Control of exposure may aid
recovery. Other treatment is similar to that for lateral epicondylitis, but
steroid injection is not re~ommended.~’
856 MAN1 & GERR

DISTAL UPPER EXTREMITY DISORDERS

DeQuervain’s Disease

DeQuervain’s disease is the name given to stenosing tenosynovitis of

the extensor tendons of the thumb, manifesting as pain over the radial
styloid process with impaired thumb fLln~tion.~~

Clinical features
Symptoms include pain, possible swelling, and warmth of the radial
wrist. The pain is worsened by abduction and extension of the thumb.
Physical examination may reveal tenderness, pain, and nodularity at the
radial wrist. A positive Finkelstein’s test is the classic diagnostic maneu-
~ e r . ~ ~
Differential diagnoses include osteoarthritis of the wrist or first car-
pometacarpal joint, Wartenberg’s syndrome (ulnar nerve compression at
the wrist), and intersection syndrome (tendonitis of the dorsal wrist ex-
tensor~).’~,~~

Risk Factors
DeQuervain’s disease has been associated with assembly line work,
small goods manufacturing, meat and poultry processing, textile produc-
tion, food packing, key punching, and computer U S ~ . Jobs B ~ requiring
~ ~ ~ ~
repetitive hand motion with frequent extension of the thumb and extreme
lateral wrist deviations are reported to increase the risk of DeQuervain’s
di~ease.~

Treatment
Treatment includes rest with the thumb in a spica-splint, anti-inflam-
matory medication, and physical or occupational therapy. Cortisone in-
jections are an option following a trial of conservative treatment. Changes
in work routine and workplace design may be necessary to allow recovery
and prevention of further i n j ~ r y . ~ ~ , ~ ~

Tendonitis of Forearm and Wrist Extensors

Tendonitis of forearm and wrist extensors is characterized by discom-

fort of the forearm extensor tendons. Diagnostic entities are numerous,
with the potential for all dorsal compartments of the wrist to be affected.
Examples include extensor indicis and extensor carpi ulnaris tendonitis.
 WORK-RELATED UPPER EXTREMITY MUSCULOSKELETAL DISORDERS 857

Clinical Features
Pain may be accompanied by tenderness, swelling, warmth, redness,
, ~ ~ be possible to localize all symptoms to extensor
or c r e p i t a n ~ e . 'It~should
compartments or discrete locations on the dorsum of the hand, the wrist,
or the forearm.31Physical examination maneuvers include eliciting pain
on resisted movements-for example, on resisted wrist or digital exten-
sion. The differential diagnoses include arthritis, acute strain, or direct
trauma.

Risk Factors
Repetitive and forceful use of the hands, use of the hands in extremes
of joint range of motion, and performance of unusual or unaccustomed
tasks increase the risk of extensor t e n d o n i t i ~ . ~ , ~ ~ , ~ ~

Treatment
Clinical treatment is initially conservative, with rest, splinting, and
nonsteroidal anti-inflammatory medications. Physical and occupational
therapy may have some efficacy. Steroid injections should be reserved for
refractory cases. Altering the work site and work routine to avoid aggra-
vating movements are key elements of treatment.

Tendonitis of Forearm and Wrist Flexors

Tendonitis of the forearm and wrist flexors is suspected when volar

forearm pain is elicited with resisted wrist or digital flexion. Diagnostic
entities include flexor carpi radialis tendonitis and flexor carpi ulnaris
tendonitis.

Clinical Features
Tenderness to palpation, crepitus, swelling, warmth, or (rarely) red-
ness may be found on physical e x a m i n a t i ~ nPain
. ~ ~ with resisted flexion
of the hand and fingers is a helpful diagnostic sign. Median or ulnar neu-
ropathies should be considered as alternate causes of pain. As with exten-
sor tendonitis, the differential diagnoses include arthritis, acute strain, or
direct trauma.

Risk Factors
As with extensor tendonitis, repetitive and forceful use of the hands,
use of the hands in extremes of joint range of motion, and performance
of unusual or unaccustomed tasks increase the risk of flexor tendoni-
tis.3.26,42
858 MANI&GERR

Treatment
The treatment of wrist flexor tendonitis is the same as for wrist ex-
tensor tendonitis.

Trigger Finger

Trigger finger is caused by swelling of the finger flexor tendon or

narrowing of the tendon pulley superficial to the metacarophalangeal
(MCP) joint, preventing smooth tendon m o ~ e m e n t . ' ~ , ~ ~

Clinical Features
Trigger finger manifests with pain or crepitance in the flexor tendon
sheath at the A1 pulley and impaired finger flexion with triggering or
locking. Decreased range of motion of the affected digit may be noted
because of locking in flexion or extension. Pain on palpation directly over
the MCP joint is a classic feature of the illness.42

Risk Factors
The association between occupation and trigger finger is not well
e s t a b l i ~ h e d .Occupational
~~,~~ history often includes pressure to the area
from hard objects, such as tool handles, and repeated r n o v e m e n t ~Trig-
.~~
ger finger is frequently seen in middle-aged women, and can be associated
with endocrinologic or rheumatoid disease.43

Treatment
Nonsteroidal anti-inflammatory medication, steroid injections, and
splinting are the treatments of choice? Surgical release of the fibrotic ten-
don has been reported to be

NERVE ENTRAPMENT DISORDERS

OF THE UPPER EXTREMITY

Carpal Tunnel Syndrome

Carpal tunnel syndrome (CTS) is a painful hand disorder caused by

compression of the median nerve as it passes through the carpal tunnel
of the Although frequently discussed in the lay media and promi-
nent in the minds of patients, it is much less common than are the tendon
disorders. It is, however, associated with considerable occupational dis-
ability.I9
 WORK-RELATED UPPER EXTREMITY MUSCULOSKELETAL DISORDERS 859

Clinical Features
Symptoms of pain, numbness, tingling, or burning are present in the
distribution of the median nerve. The patient may also report a clumsiness
of the hand and decreased grip strength. The only muscle in the hand
innervated by the distal portion of the median nerve is the abductor pol-
licis brevis, one of three muscles of the thenar eminence. In advanced
cases, weakness of abduction of the thumb out of the plane of the palm
may be present, as may hypothenar atrophy. Sensory examination of the
hand is usually normal, although diminished sensory function may be
observed in the median distribution in advanced cases. Phalen's test and
Tinel's sign have been repeatedly shown to be of little or no value in
distinguishing patients who have carpal tunnel syndrome from the larger
population of patients with hand ~ y m p t o m s . ~The
~ , ' ~diagnosis is con-
firmed with electrophysiologic measurement of nerve conduction velocity
and needle electromyography. The differential diagnosis includes periph-
eral neuropathy.

Risk Factors
Risk factors for CTS include forceful use of the hands, repetitive use
of the hands, and exposure to hand-arm vibration. The disorder has been
described in numerous occupations, including meatpackers, poultry pro-
cessors, assembly line workers, garment workers, mechanics, construction
workers, supermarket cashiers, and forestry workers. A number of non-
occupational contributors have also been described, including age, female
gender, pregnancy, diabetes, hypothroidism, and renal d i a l y s i ~ . ~ ~ , ~ ~ , ~ ~

Peatment
Initial treatment is conservative,including splinting and nonsteroidal
anti-inflammatory medication. Experienced practitioners have good suc-
cess using intracarpal canal steroid injection, at least for temporary relief
of symptoms. Surgical intervention should be considered in all but mild
cases, within 6 to 8 weeks of conservative treatment, if symptoms persist.21
Occupational risk factors must be controlled or treatment will fail.

VASCULAR DISORDERS OF THE UPPER EXTREMITY:

THE HAND-ARM VIBRATION SYNDROME

Hand-arm vibration syndrome (HAVS), also known as Raynauds

phenomenon of occupational origin, white finger, and vibration-induced
white finger, is caused by occupational exposure to vibrating t o o 1 ~ . ~ , ~ , ~ ~ , ~
860 MANI&GERR

Clinical Features
Manifestations of HAVS include sensorineural (neurologic)and vas-
cular impairment. Symptoms of sensorineural effects include numbness,
tingling, and loss of grip strength and dexterity. The vascular symptoms
are indistinguishable from Raynaud's p h e n o m e n ~ n . ~Symptoms
,~,~~ are
episodic, but usually increase in frequency and severity with increasing
intensity and duration of exposure.
The clinician should determine vibratory exposure, by job history,
and attempt to characterize vibration dose by hours of daily use and type
of tool. The frequency of symptomatic attacks should be recorded, noting
whether attacks occur outside of work or by season or time of day. Sen-
sorineural and vascular symptoms can occur independently of each other
and have separate staging systems (Table 3).7,13
Physical examination should include evaluation of sensory function
of the hand^.^^,^' A cold challenge test can be performed to identify vaso-
spasm consistent with HAVS. A simple test is immersion of the hand for
1 to 5 minutes in water maintained at a temperature of 10°C.4,29,41 Nerve
conduction studies and vibrometry testing may be very useful objective
tests for characterizing sensorineural impairment and for identifying con-
comitant CTS.30
Hand-arm vibration syndrome should be differentiated from pri-
mary Raynaud's phenomenon, nerve compression, occlusive vascular dis-
ease, peripheral neuropathy of other causes, and primary connective
tissue diseases such as rheumatoid arthritis and systemic lupus erythema-
tOSUS.3,*9,41

Risk Factors
Use of hand-held, vibrating tools such as chainsaws, rock drills,
grinders, riveters, pneumatic hammers, and jackhammers is associated
with development of HAVS. Forestry workers, stonecutters, construction
workers, shipbuilders, and mechanics are some occupational groups at
risk for HAVS.3,6Low temperature might enhance the effect of exposure.
Although assessments of the intensity and duration of vibratory exposure
are not standardized, rapidity of onset has been related to intensity of
e x p o s ~ r e . ~ , With
~ , ' ~ ,intense,
~~ full-time, daily exposure, time to onset of
HAVS can be as rapid as 3 months.29

Treatment
Abatement of exposure to vibration is the mainstay of treatment. Nei-
ther vascular nor neurologic impairment from HAVS shows consistent
reversal with cessation of exposure, but disease progression is a r r e ~ t e d . ~ , ~ ~
Smoking cessation should be encouraged aggressi~ely.~~ Calcium-channel
antagonists and antiplatelet agents have been used to control vascular
symptoms.
 WORK-RELATED UPPER EXTREMITY MUSCULOSKELETAL DISORDERS 861

Table 3. STOCKHOLM WORKSHOP SCALE FOR STAGING SENSORINEURAL

AND VASCULAR SEVERITY OF HAND-ARM VIBRATION SYNDROME
Stage Symptom
I. Sensorineural Staging
0 Exposed but no symptom
1 Intermittent numbness, with or without tingling
2 Intermittent or persistent numbness, reduced sensory perception
3 Intermittent or persistent numbness, reduced tactile discrimination and/or
manipulative dexterity
11. Vascular Staging
0 No attacks
1 Occasional attacks affecting only the tips of one or more finger
2 Occasional attacks affecting the distal and middle phalanges of one or
more finger
3 Frequent attacks affecting all phalanges of most fingers
4 As in stage 3, with trophic skin changes to the finger tips

From Pelmear PL, Taylor W Hand-arm vibration syndrome: Clinical evaluation and prevention. J
Occup Med 33:1145, 1991; Bilgi C, Pelmear PL: Hand-arm vibration syndrome: A guide to medical im-
pairment assessment. J Occup Med 35937,1993.

CHRONIC PAIN DISORDERS

A number of patients who have exposure to risk factors for muscu-

loskeletal disorders present with upper limb pain in the absence of physi-
cal findings. For some patients, the pattern and characteristicsof the pain
are consistent with known upper limb disorders and for others the pain
does not correspond to any known condition. Patients with pain in the
absence of physical findings can be categorized into three groups: (1)pa-
tients with subclinical illness, such as early CTS (2) patients without upper
limb disease who are, nevertheless, honestly reporting their experience of
pain, and (3) patients who are fraudulently reporting upper limb pain.
Clearly, treatment and prognosis vary greatly across the three groups.
The clinical picture of patients in group 1 usually evolves over time.
With conservative treatment, many respond and improve because their
illness at time of presentation was mild. Those whose disease progresses
despite conservative treatment eventually develop clinical signs observ-
able on examination or special testing that confirm the diagnosis.
The clinical picture of patients in group 2 may remain static over time
or change in nonphysiologic ways. The patient may complain of numb-
ness of all fingers of the hand with eventual involvement of the entire
arm, for example. Many of these patients meet criteria for one of the so-
matoform disorders (typically conversion disorder or pain disorder).'
Some may have a variant of fibromyalgia or regional myofascial pain
~yndrome.9,~~ In general, conservative treatment will not harm these pa-
tients, and regardless of whether current symptoms are a consequence of
occupational risk factors, such risk factors, when present, should be con-
862 MANI&GERR

trolled. Unlike group 1 patients, however, group 2 patients are best served
by continuation of full-time employment. Many group 2 patients benefit
from low-dose tricyclic antidepressant medication and some find relief
from increased levels of aerobic activities, such as brisk walking or run-
ning. Some group 2 patients may be experiencing conflicted relationships
with their work as a physical ailment. This can be a very difficult, if not
impossible, problem for the primary care provider to sort out.
In the authors’ experience, group 3 patients are much less common
than those in groups 1 and 2. Such patients are either seeking monetary
gain or controlled substances. The experienced clinician can often detect
such patients by their behavior during the examination, including mark-
edly inconsistent effort on motor examination, inconsistent responses on
sensory examination, and otherwise exaggerated behaviors intended to
convince the clinician of severe pathology.

CONCLUSIONS

The occurrence of upper extremity musculoskeletal disorders in in-

dustry in the United States has increased to record levels over the past 20
years. One unfortunate trend has been the lumping of numerous diverse
upper limb disorders into a single category, often called overuse injury or
repetifivestrain injury. The authors of this article recommend use of a more
descriptive and clinically accurate nomenclature. Despite ongoing contro-
versy about the occupational causes of these disorders, the medical liter-
ature has sufficient consistency to conclude that the adverse ergonomic
factors of force, repetition, vibration, and possibly work with joints at the
extremes of postural range (i.e./ “awkward posture”) are risk factors for
distal upper limb disorders (CTS and flexor and extensor tendonitis) and
that force and posture are risk factors for shoulder disorders (rotator cuff
tendonitis, bicipital tendonitis, and subdeltoid bursitis) and neck disor-
ders (trapezius myalgia). Of course, the presence of occupational risk fac-
tors does not eliminate contributions by nonoccupational risk factors. An
important task of the clinician is to elicit information on occupational
exposure to adverse ergonomic factors by taking an occupational history.
Treatment is usually straightforward but will likely fail unless adverse
ergonomic exposures are controlled. A large proportion of these disorders
are preventable by reduction of adverse exposure and considerable mor-
bidity can be reduced by encouraging companies to facilitate rapid as-
sessment of affected workers.

References

1. American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disor-

ders, ed 4. Washington, DC, American Psychiatric Association, 1994, pp 445-470
2. Ayoub MA, Wittels NE: Cumulative trauma disorders. International Review of Ergo-
nomics 2217-272,1989
 WORK-RELATED UPPER EXTREMITY MUSCULOSKELETAL DISORDERS 863

3. Bernard B (ed): Musculoskeletal disorders and workplace factors. Cincinnati, OH, Na-
tional Institute for Occupational Health and Safety, US Department of Health and Hu-
man Services, 1997
4. Bilgi C, Pelmear P L Hand-arm vibration syndrome: A guide to medical impairment
assessment. J Occup Med 35:936-942,1993
5. Biundo JJ, Mipro RC, Fahey P: Sports-related and other soft-tissue injuries, tendonitis,
bursitis, and occupation-related syndromes. Curr Opin Rheumalol9:151-154, 1997
6. Bovenzi M: Exposure-response relationship in the hand-arm vibration syndrome: An
overview of current epidemiology research. Int Arch Occup Environ Health 71:509-519,
1998
7. Brammer AJ, Taylor W, Lundborg G: Sensorineural stages of the hand-arm vibration
syndrome. Scand J Work Environ Health 13:279-283, 1987
8. Bureau of Labor Statistics: News, United States Department of Labor. Washington, DC,
Bureau of Labor Statistics. USDL 99-102, April, 1999
9. Campbell SM: Regional myofascial pain syndromes. Rheum Dis Clin North Am 15:31-
44,1989
10. Cohen AL, Gjessing CC, Fine LJ, et al: Elements of Ergonomics Programs. DHHS Pub-
lication No. 97-117 Washington, DC, US Department of Health and Human Services,
1997
11. DeKrom MCTFM, Knipschild PG, Kester ADM: Efficacy of provocative tests for diag-
nosis of carpal tunnel syndrome. Lancet 335:393-395, 1990
12. dewinter AF, Jans MP, Scholten RJPM, et al: Diagnostic classification of shoulder dis-
orders: Interobserver agreement and determinants of disagreement. Ann Rheum Dis
58:272-277, 1999
13. Gemme G, Pyykko I, Taylor W, et al: The Stockholm Workshop scale for the classification
of cold-induced Raynauds phenomenon in the hand-arm vibration syndrome (revision
of the Taylor-Pelmear scale). Scand J Work Environ Health 13:275-278,1987
14. Gerr F, Letz R: The sensitivity and specificity of tests for carpal tunnel syndrome vary
with the comparison subjects. J Hand Surg [Br123151-155,1998
15. Gerr F, Letz R, Landrigan PJ: Upper-extremity musculoskeletal disorders of occupational
origin. Ann Rev Public Health 12:543-566, 1991
16. Hales TR, Bernard BP: Epidemiology of work-related musculoskeletal disorders. Orthop
Clin North Am 27679-709,1996
17. Harrington JM, Carter JT, Birrell L, et a1 Surveillance case definitions for work-related
upper limb pain syndromes. Occup Environ Med 55:264-271,1998
18. Herbert R, Dropkin J, Levin S, et a1 Diagnosis and medical management of work-related
neck and upper extremity musculoskeletal disorders in dental care workers. In Murphy
DC (ed): Ergonomics and the Dental Care Worker. Washington, DC, The American Public
Public Health Association, 1998, pp 375-417
19. Herbert R, Gerr F, Dropkin J: Clinical evaluation and management of work-related carpal
tunnel syndrome. Am J Ind Med 37:62-74,2000
20. Hoppenfeld S: Physical Examination of the Spine and Extremities. East Norwalk, CT,
Appleton-Century-Crofts, 1976
21. Katz JN, Lew RA, Bessette L, et al: Prevalence and predictors of long-term work disability
due to carpal tunnel syndrome. Am J Ind Med 33:543-550, 1998
22. LeNoir JL: Subacromial-subdeltoid bursitis of the shoulder. Orthop Rev 730-732, 1986
23. Letz R, Cherniack M, Gerr F, et al: A cross-sectional epidemiological survey of shipyard
workers exposed to hand-arm vibration. Br J Ind Med 49:53-62, 1992
24. Luopajarvi T, Kuorinka I, Virolainen M, et al: Prevalence of tenosynovitis and other
injuries of the upper extremities in repetitive work. Scand J Work Environ Health 5:48-
55,1979
25. Moore JS: Carpal tunnel syndrome. Occup Med 7:741-763,1992
26. Moore JS: Function, structure, and responses of components of the muscle-tendon unit.
Occup Med 7713-740, 1992
27. Moore JS: De Quervain’s tenosynovitis: Stenosing tenosynovitis of the first dorsal com-
partment. J Occup Environ Med 39:990-1002,1997
28. Nordstrom DL, Vierkant RA, DeStefano F, et a1 Risk factors for carpal tunnel syndrome
in a general population. Occup Environ Med 54734-740,1997
864 MAN1 & GERR

29. Pelmear PL, Taylor W Hand-arm vibration syndrome: Clinical evaluation and preven-
tion. J Occup Med 33:1144-1149,1991
30. Pelmear PL, Taylor W Carpal tunnel syndrome and hand-arm vibration syndrome.
Arch Neurol51:416-420,1994
31. Piligian G, Herbert R, Hearns M, et a1 Evaluation and management of chronic work-
related musculoskeletal disorders of the distal upper extremity. Am J Ind Med 3775-93,
2000
32. Reider B: The Orthopaedic Physical Examination. Philadelphia, WB Saunders, 1999
33. Rempel D, Harrison RJ, Barnhart S: Work-related cumulative trauma disorders of the
upper extremity. JAMA 2675338-842
34. Rodgers JA, Crosby LA: Rotator cuff disorders. Am Fam Physician 127-134,1996
35. Roquer J, Can0 J F Carpal tunnel syndrome and hyperthyroidism, a prospective study.
Acta Neurol Scand 88:149-152,1993
36. Rot0 P, Kivi P: Prevalence of epicondylitis and tenosynovitis among meat cutters. Scand
J Work Environ Health 10:203-205,1984
37. Silverstein 8, Welp E, Nelson N, et al: Claims incidence of work-related disorders of the
upper extremities: Washington State, 1987 through 1995. Am J Public Health 88:1827-
1833,1998
38. Sommerich CM, McGlothlin JD, Marras WS: Occupational risk factors associated with
soft tissue disorders of the shoulder. Ergonomics 697-717,1993
39. Smith DL, Campbell SM: Painful shoulder syndromes: Diagnosis and management. J
Gen Intern Med 7:328-339,1992
40. Stevens JC, Beard CM, OFallon WM, et al: Conditions associated with carpal tunnel
syndrome. Mayo Clin Proc 67541-548,1992
41. Taylor W. The hand-arm vibration syndrome-diagnosis, assessment and objective
tests, a review. J R SOCMed 86:lOO-103, 1993
42. Thorson EP, Szabo RM Tendonitis of the wrist and elbow. Occup Med 4:419-431,1989
43. Trezies AJH, Lyons AR, Fielding et a1 Is occupation an aetiological factor in the devel-
opment of trigger finger? J Hand Surg [Br123:539-540, 1998
44. Tubania R, Thomine J-M, Mackin E: Examination of the Hand and Wrist. St Louis, MO,
Mosby, 1996
45. Voitk AJ, Mueller JC, Farlinger D, et al: Carpal tunnel syndrome in pregnancy. Can Med
ASSOC J 128~277-281,1983
46. Waris P: Occupational cervicobrachial disorders, a review. Scand J Work Environ Health
5:3-14, 1979
47. Wolfe F: Fibromyalgia: The clinical syndrome. Rheum Dis Clin North Am 15:1-18,1989

Address reprint requests to

Fredric Gerr, MD
Department of Environmental and Occupational Health
Rollins School of Public Health
1518 Clifton Road
Atlanta, GA 30322

e-mail fgerr@sph.emory.edu