1. Work Related Musculoskeletal Disorders
Dr. Majid Golabadi
Occupational Medicine Specialist
Isfahan University of Medical Sciences

2. Job Risk Factors Repetition Force Awkward posture Contact stress
Vibration

3. Upper Extremity Disorders

4. The Most Important Disorders
Shoulder:
Rotator cuff tendinitis
Bicipital tendinitis
Elbow:
Lateral Epicondylitis
Medial Epicondylitis
Olecranon Bursitis
Cubital Tunnel 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

5. Lateral Epicondylitis
(Tennis Elbow)

6. Lateral Epicondylitis (Tennis Elbow)
Inflammation, 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.

8. Ergonomic Stressors Frequent lifting
Repetitive wrist dorsiflexion with force
Sustained power gripping.
Repetitive forearm supination
Sudden elbow extension
Tool use, shaking hand, twisting movement

9. Clinical Presentations
lateral elbow pain of gradual onset.
pain generally increases with activity
Picking up a cup of coffee or a gallon of milk
Heavy lifting
Gripping
Pain may be present at night.
Symptoms are typically unilateral.

10. Physical Examination
localized tenderness to palpation just distal and anterior to the lateral epicondyle.

12. Presumptive Diagnosis Requires:
Local tenderness directly over the lateral epicondyle
Pain aggravated by resisted wrist extension and radial deviation
Pain aggravated by strong gripping
Normal elbow range of motion

13. Paraclinical Testing
No specific test is required

16. Splints for Tennis Elbow

17. Carpal Tunnel Syndrome

18. Carpal tunnel syndrome is a traumatic or pressure neuropathy of the median nerve in the wrist
The most common entrapment neuropathy in the body
Compression of the median nerve as it passes through the carpal tunnel
Overall prevalence is 2.7%
Is more common in women and between ages 40 to 60 years

20. Etiology

21. Work Related Risk Factors
Occupations that require Repetitive Flexion and extension of the fingers and wrist

24. Symptoms
Paresthesias in the median nerve distribution, gradually and spontaneously
With progression: pain, numbness, tingling and burning
In more progressed cases: Reduced force, Skin sensory deficit and Thenar Atrophy

25. Diagnosis
History:
Night-time and morning symptoms, sometimes occurring with driving, and relief by shaking or movement (Flick sign)
Intermittent Nocturnal Brachalgia
Clumsiness
Rule out of systemic causes

26. Physical Exam:
Phalen’s Test and Tinnel’s sign
Two-Point Discrimination Test
thumb abduction
thumb opposition
pinch movements

27. Phalen Test

28. Tinnel sign

29. Electrodiagnostic studies: EMG/NCV
confirm diagnosis
Thenar weakness should warrant full EMG studies

30. Treatment
1- Treatment of associated conditions 2- Splinting the wrist in a neutral position at night and during the day . For 2 to 4 weeks Job task modification is often critical in this phase 3- Corticosteroid injection into the carpal tunnel 4- Surgery. After 3 month of conservative treatment

31. Surgery indications Progressive symptoms Persistent symptoms
Thenar Atrophy
EMG abnormalities

32. De Quervain’s Disease

33. De Quervain’s Disease
Inflammation of the tendon sheath of the extensor pollicis brevis and abductor pollicis longus
Combination of Tendonitis and Tenosynovitis.
In individuals between 30 and 50 years of age and is ten times more prevalent among women than men
May be caused by OVER USE of thumb, like repetitive work and forceful gripping

34. Symptoms pain at the base of the thumb. swelling
Differential diagnosis
Old nonunion of navicular bone
Osteoartritis of first carpometacarpal joint

35. Finkelstein test

36. Treatment Modifying hand activity Immubilization of thumb (3-6 weeks)
NSAIDs
Local Injection of Lidocain-triamcinolone into tendon sheat (Standard Treatment)
Surgical decompression

37. Trigger Finger

38. Stenosing tenosinovitis of the flexor tendon of the finger
Painful snap or jerking movements in PIP
Collapse the joint suddenly like a trigger
Usually associated with using tools that have handles with hard or sharp edges.

40. Trauma,
Rheumatoid arthritis,
CTS
Differential diagnosis
De Qurvein
Dupuytren Contractures
Trauma, liver diseases, Alcohol Abuse

41. Dupuytren Contractures

42. Treatment
Local Injection of Lidocain-triamcinolone into tendon sheet (Standard Treatment)
Surgical decompression

43. Osteoarthritis of the first carpometacarpal joint

44. In 25% of women older than 55 years
Unknown cause
Pain at the base of thumb when grasping
Squaring of the base of thumb
Diagnosis with radiographs

47. Tratment Avoid repetitive painful activities Immobilization NSAIDs
Arthroplasty or arthrodesis

48. Scaphoid Fractures

49. Occur in younger people
Pain at the base of the thumb or wrist pain
Tenderness of the tuberosity of scaphoid
PA, Lateral and Scaphoid view Ragiographs
MRI or Bone Scan

51. Treatment Nondisplaced 12 weaks immobilization Displased
Open reduction and Internal Fixation

52. Mallet Finger

53. Disruption of extensor tendon at the distal interphalangial (DIP) joint

55. Some Useful Tests

56. Apley Scratch Test

57. Kyphosis is excessive curvature of the spine in the sagittal (A-P) plane. The normal back has 20° to 45° of curvature in the upper back, and anything in excess of 45° is called kyphosis.
Scoliosis is abnormal curvature of the spine in the coronal (lateral) plane. Scoliosis of between 10° and 20° is called mild. Less than 10° is postural variation.
Lordosis or hyperlordosis is excessive curving of the lower spine and is often associated with scoliosis or kyphosis.

58. Straight Leg Raise SLR Sensitivity 91% Specificity 26 %
Examiner raises straight leg (30 to 60 degrees) eliciting radicular pain on same side (Lasegue Sign). Then lowers leg until pain goes away, the foot is then dorsiflexed causing return of pain
Sensitivity 91%
Specificity 26 %
Consider Trendelenberg for Hip abductor weakness (L5) Hip extension for S1; short squat/getting out of chair (L4)

59. Crossed Straight Leg Raise
(Crossed SLR)
Examiner raises straight leg (30 to 60 degrees) eliciting radicular pain on opposite side.
Sensitivity 25%
Specificity 90-97%
Consider Trendelenberg for Hip abductor weakness (L5) Hip extension for S1; short squat/getting out of chair (L4)

60. Reverse Straight Leg Raise
(Reverse SLR)
Patient is prone, examiner raises straight leg (30 to 60 degrees) –pain radiating to anterior thigh indicative of L3-L4 root irritation
Sensitivity ?
Specificity ?
Consider Trendelenberg for Hip abductor weakness (L5) Hip extension for S1; short squat/getting out of chair (L4)

61. Duck Walk Test

62. Knee Deformities