Repetitive Strain Injuries Redefined
By Kimberley McMahon
Monotonous, tedious, repetitious, methodical, mind-numbing and dull. Many of my massage therapy patients, currently employed as assembly-line workers in the automotive manufacturing industry, use these words to describe their day-to-day responsibilities as they relate to their job.
Numb, dull, achy, clumsy and weak: These are the words used most commonly by those same clients to describe the pain and discomfort they are experiencing on a regular basis. Much of this discomfort occurs in the joints and is due to the repetitive strain of repeating the same awkward motions. Repetitive, rapid, forceful, awkward and unsupported are also words used to describe causes of repetitive strain injuries (RSIs).
During my pre-treatment interviews and assessments, it did not take me long to realize that many of these words were being used interchangeably by patients. I also quickly came to understand that, despite the differences with actual work-related duties,
these patients all had very similar chief complaints because they all did the same thing all day long. And many of them were presenting with very comparable symptomatology: localized pain, often accompanied with inflammation, numbness, muscle weakness and fatigue.
For many years, RSIs have typically been associated with sports-related injuries. Terms such as “tennis elbow” and “golfer’s elbow” have contributed to the ignorance of the correlation between RSIs and the workplace. Thankfully, we are now better at identifying causes and seeing new descriptive terms that better articulate the existence of RSIs. Consequently, more and more workers are seeking treatment for everyday aches and pains that were once often overlooked. As well, employers and employees alike are starting to recognize that these aches and pains are actually early warning signs that a serious injury may be on its way.
Today, disorders that develop due to repetitive movements, awkward postures and the influence of external forces are more commonly referred to as work-related upper limb disorder (WRULD), occupational overuse syndrome (OOS) and work-related complaints of the arm, neck or shoulder (CANS).1
CANS is the most common disorder I see in my practice. Many duties on the job require reaching above shoulder height for up to eight hours a day, looking upward, working with the body cramped or in an awkward position, or working with air-pressured tools. Repetitive movements, unsupported postures and external forces are all factors that encompass the majority of their day. This can cause a major strain on joints, especially the shoulder.
Tendon pathologies of the shoulder, elbow, and second
and third digits of the hands are the most common clinical impressions I make during the pre-treatment assessment with these patients. Assessment and treatment also uncover varying degrees of acute to chronic stages of tendinitis. Designing treatment programs that will help manage symptoms and workloads, as well as improve work styles and/or ergonomics, would help those suffering with CANS and many other workplace-related injuries. The theory is that this could facilitate decreased absenteeism, as well as improving productivity at work.2
A patient from the above-mentioned demographic has been seeing me regularly for a suspected biceps brachii tendinitis, determined by point tenderness over the proximal tendon of the long head of biceps, as well as a positive Speed’s and Yergason’s test. I have witnessed his digression from an acute to a chronic stage of tendinitis.
Treatment during the acute stage of biceps brachii tendinitis included Golgi tendon organ release on the distal insertion of the tendon to help counter hypertonicity within the muscle belly of biceps. Following treatments, my patient reported feeling less pain at the site, especially with passive movements that placed the tendon in a full stretch. I recommended that he look into some work restrictions to allow the tendon some time to rest and heal. I also suggested that he ice the area following his day at work or any other activity placing stress on the tendon. A slow stretch of the biceps brachii was demonstrated, with instructions to ensure that the stretch be performed pain-free. I also discussed the importance of posture, regular exercise consisting of stretch and strengthening, and ergonomics at work and in the home.
Despite the fact that my patient was consistently coming in for treatments as outlined in our treatment plan, and complied with his self-care regimen, he was not getting better. He continued to report feeling better for a short period of time following treatments, but eventually was experiencing more pain then when we started. Not only was he having difficulty performing work-related duties, but pain and a limited range of motion were now affecting his activities of daily life.
I was noticing differences in the tissue at the site, and in surrounding tissues as well. I was now palpating a significant amount of inflammation and adhesions near the proximal insertion of the long head of the biceps brachii. The treatment now included skin rolling, fascial spreading and muscle stripping as an attempt to break down the adhesions palpated at the musculotendinous junction. Cross-fibre frictions were also applied to the proximal insertion of the biceps brachii, followed with cold hydrotherapy in the form of an ice massage. This seemed to yield some better results for a short while.
After re-evaluating our treatment plan, we determined that the main reason for his slow progression was that he had never sought any work restrictions to allow the area some time to rest and heal. I strongly recommended that he speak with his doctor and ask that he be placed on modified duties at work, with limitations in shoulder flexion and abduction. I also recommended that he speak with his ergonomic rep at work and request an assessment of his workstation and processes. Given the short-term results we were seeing with treatment and his compliance to most of his self-care, I strongly believed that it was the continued repetition of his work that was creating the biggest obstacle to a full recovery.
Almost 11 months after first seeking massage therapy to help eliminate shoulder pain, my client has now been pain-free with full, unrestricted range of motion for almost nine weeks. Four weeks of work limitations, several more months of massage therapy and chiropractic care consisting of laser therapy and acupuncture, some ergonomic improvements to his workstation and processes, and a kettlebell exercise regimen have together produced the long-term results we were hoping for. His MRI revealed only micro tearing of the biceps brachii tendon.
While the evidence regarding the effectiveness of ergonomic interventions may be conflicting, a multi-faceted approach consisting of both biomechanical and psychosocial aspects was found to be effective in improving recovery from neck/shoulder symptoms, and reducing pain over the long term.2 Taking this approach to treatment with my client has contributed to his full recovery. His understanding of treatment modalities, coupled with workplace prevention programs designed to make “the job fit the person, rather than make the person fit the job”3 has given him a better appreciation for the physical strain placed on his body due to the repetitious nature of his work. He is certain to make better choices throughout his daily life with respect to his own personal well-being.
I would like to thank my client for granting me the permission to speak of his case. It was a long, discouraging journey for him, filled with many setbacks and a great deal of frustration.
Having worked in the automotive manufacturing industry for 10 years myself, I am well versed in the physical and mental demands of the job. For my client, that proved to be a key factor that helped him feel comfortable enough to put his trust in me as his therapist. Knowing that I knew first-hand what he was doing every day at work gave him comfort. He knew I really understood his pain and he appreciated that I was able to help him use the services his employer had in place to assist in his recovery.
Lesson learned: Always try to really put yourself in your client’s position. Really try to visualize what a day in their life looks like. You will be a better therapist for it.
Kimberly McMahon works at Beach Chiropractic and Wellness
Centre in Wasaga Beach, Ontario. She integrates her knowledge of the musculoskeletal system with her background in paramedical sciences and more than 10 years of employment in the manufacturing industry, to take a comprehensive, outcome-based approach to the relationship between workplace ergonomics, and soft tissue and joint dysfunction.
Reprinted from Massage Therapy Today, Fall 2015.
References available upon request.