Post on 16-Dec-2015
Kayvan Karamifar, M.DOccupational Medicine Specialist
The Most Important Disorders• Shoulder:
• Rotator cuff tendinitis• Bicipital tendinitis
• Elbow:– Lateral Epicondylitis– Medial Epicondylitis– Olecranon Bursitis– Cubital Tunnel Syndrome
• Forearm:– Pronator Teres Syndrome– Anterior interosseous syndrome– Posterior interosseous syndrome– Intersection syndrome
• Wrist:– Carpal tunnel syndrome– DeQuervain disease– Ganglion cyst– Trigger wrist
• Hand:– Guyon`s canal syndrome– Hypothenar hammer
syndrome– Trigger finger– Trigger thumb– Occupational hand cramp
Occupational Physical Stressors (Job Risk Factors)RepetitionForceAwkward postureContact stressVibration
High-risk JobsSome examples:
Auto assemblers Butchers VDT users Drivers Packinghouse workers Seamstresses Musicians Clerical workers Textile workers Miners Dentists
Diagnosis RequirementsDefinite clinical diagnosis
History Specific physical examination Motor, sensation, reflexes, ….
Ergonomic stressors Taking occupational history Job visit and ergonomic analysis Video recording
Off-the-job exposurePrevious trauma
Treatment MethodsConservative therapy
Specific splint useMedical therapy
Drug therapyCorticosteroid injection
Physical therapyHome exerciseOccupational therapySurgery
Work AccommodationsEngineering control
Ergonomic design modificationUse tools with proper ergonomic design
Administrative Reduce working hoursAppropriate work-rest period
Job rotationSafe work practiceTemporary job transfer to low-risk jobRe-training
Lateral Epicondylitis
Lateral Epicondylitis ( Tennis Elbow)Inflammation, or
enthesitis, at the muscular origin of the extensor carpi radialis brevis (ECRB).
the most common overuse injury of the elbow
up to 10 times more frequently than medial epicondylitis
most often occurs between the third and fifth decades of life.
Ergonomic StressorsFrequent liftingRepetitive contraction
of the wrist extensors (repetitive wrist dorsiflexion with force)
Sustained power gripping.
Repetitive forearm supination
Sudden elbow extension
Tool use, shaking hand, twisting movement
Common Jobs Involved
Clinical Presentationslateral elbow pain of
gradual onset. pain generally
increases with activityPicking up a cup of
coffee or a gallon of milkHeavy liftingGripping
Pain may be present at night.
Symptoms are typically unilateral.
Area of Pain
Physical Examination
localized tenderness to palpation just distal and anterior to the lateral epicondyle.
The combination of lateral epicondylar pain on palpation plus pain on resisted wrist extension is highly suggestive of the diagnosis of lateral epicondylitis. As this maneuver is performed, the
Presumptive Diagnosis Requires:Local tenderness directly over the lateral
epicondylePain aggravated by resisted wrist extension
and radial deviationPain aggravated by strong gripping Normal elbow range of motion
Paraclinical TestingNo specific test is required
Differential DiagnosisCervical radiculopathy ( C6-C7)Radial tunnel syndromeSynovitis of the radiohumeral jointPosterior interosseous nerve palsyNeuralgic amyotrophy Cervical myofacial pain
Splints for Tennis Elbow
Carpal Tunnel Syndrome (CTS)• Most common entrapment neuropathy• Cause: median nerve injury in carpal tunnel• RF: repetition, force, awkward postures (wrist flexion,
extension, ulnar deviation)• Jobs: seamstresses, packinghouse workers, electronic
assemblers, furniture assemblers, clerical workers, VDT users, typists, …
CTS (cont.)• Non-occupational risk factors: female sex, obesity, small
carpal tunnel• Non-occupational causes: diabetes, RA, Thyroid
dysfunction, amyloidosis, wrist OA, edema, acute trauma, …
CTS (cont.)Carpal tunnel:
Limits: wrist bones, transverse carpal ligament Traversing elements:
Digital flexor tendons Flexor policis longus Median nerve
a
MEDIANNERVE
CARPALLIGAMENT
TENDONSBONES
CTS (cont.)Signs and symptoms
Early: paresthesia, hypersthesia, hyposthesia (intermittent and in dominant hand)
Then: pain, numbness, clumsiness Late: progressive pain and numbness, weakness and
atrophy, loss of sweatingDD: TOS, C7 radiculaopathy, general neuropathy
CTS (cont.)Diagnostic methods:
Provocative tests Tinel Phalen
Electrophysiologic tests (gold standard) Screening for diabetes, Thyroid dysfunction, and RA
CTS (cont.)Therapy:
Non-surgical: Indications: intermittent or mild symptoms, no atrophy,
contraindication for surgery Methods: night splint, NSAIDs, work limitations Causes of inappropriate response: age>50, symptoms>10m.,
persistent paresthesia, positive phalen test in less than 30s.
CTS (cont.)Surgical therapy:
Indications: inappropriate response to non-surgical therapy, severe and prolonged symptoms, muscular weakness or atrophy, positive electrophysilogic tests
Post-surgery problems: persistent symptoms, recurrence, median nerve injury, neuroma formation, adhesions, …
Ergonomic ModificationsDepends on ergonomic stressor:
VDT User: adjust workstation, ergonomic mouse, wrist pad, modify contact stress, work-rest period, ergonomic keyboard, work exercises
Hand tool user: electrical hand tools, work-rest period, work exercises, ergonomic hand tools
Electrical Screwdriver
Wrist Awkward Posture
Ergonomic Mouse pad
Compression = soft tissue is compressed between the bone and a hard or sharp object
Before: Worker rests his wrists on the sharp tray edges. His wrist is extended into a non-neutral posture.
Ergonomic Improvement: Worker rests her wrists and forearms on a padded surface. Wrist and forearms are in a neutral position.