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Musculoskeletal problems arise from the responses
in the human body to physiological and
biomechanical demands of physical activity.
The nature of those demands (and the responses)
changes with the type of task performed, across the
spectrum of jobs from those which require very
static posture to be held for long periods (by
keyboard operators, for example) to the heavy
dynamic work of brewery draymen or forestry
Method of assessing
Muscle activity
work demands
Dynamic work Energy - Heart rate
demands - O2 consumption
- Borg RPE scale
Psychophysic - Maximum acceptable weight of load
s (MAWL)
- NIOSH Equation
Muscle - EMG
Biomechanica - Strength
l load - Modelling (Spine compression, joint
- Stature changed
Posture - Notation classification of joint
analysis - movement
Discomfort or - Body map
Static work pain - Pain scale
Types of Musculoskeletal Disorders
Tendon disorders Shoulder tendinitis, epicondylitis, de
Quervain’s tendinitis, Dupuytern’s
contracure, Achilles tendinitis
Nerve disorders Carpal tunnel syndrome, thoracic outlet
syndrome, radiculopathy, vibration
Muscle disorder neuropathy
Tension neck syndrome

Joint disorder Osteoarthosis

Vascular disorders Hypothenar hammer syndrome

Bursa disorders Knee bursitis

Unspecified Cumulative trauma disorder, repetitive

musculoskeletal strain injury, occupational overuse
syndrome, occupational cervicobrachial
symptoms or
tissue disorders
Determination of Factors
affecting WRMSD and
specific body parts
Two types of
Few Non
o Factors
Age: Inconsistent OfYounger
relationship. CTDsworkers are
often reporting a higher prevalence of disorders than
older workers.

o Gender: Relative risk is higher in female than male

(Makela et al.,1991,Linton, 1990).

o Acute Trauma
o Chronic Disease
o Use of birth control pills
o Circumstances of Pregnancy
Few Occupational
Factors Of CTDs
o Repetition:
o Force:
o Duration of exposure: increased duration
exposure causes high prevalence of CTD (Jonsson
et.al., 1988)
o Awkward Posture
o Static Posture
o Mechanical stress
o Contact Stress
o Temperature Extremes
o Vibration
o Psycho Social

A cycle time of less than 30 seconds or

as more than 50% of the cycle time
spent performing the same
fundamental motion (Silverstein,
Injury may result from repetition when
the tissues do not have adequate time
to recover
High repetitive job causes higher
prevalence of CTD (Huang et al., 1988)
Force is the amount of physical effort
required by a person to do a task or
maintain control of tools or
A pinch grip produces 3-5 times more
force on the tendons in the wrist
than a grip with the whole hand
With excessive force the muscles are
contracting much harder than
normal, this can lead to stress on the
muscles, tendons and joints

The body position that minimizes

stresses on the body is called neutral
Typically the neutral posture will be
near the mid-range of any joint’s range
of motion
Awkward postures refer to the positions
of the body (limbs, joints, back) that
deviate significantly from the neutral
position while job tasks are being
The working posture maintained
longer than 4 sec. is the static
This applies to slight or non-
existent variations around a fixed
force level delivered by muscles and
other body structures
The muscles will become fatigued
from a lack of blood flow during a
static posture
This fatigue can lead to discomfort

Contact stress is caused by any

sharp or hard object putting localized
pressure on a part of the body
Contact stress will irritate local
tissues and interfere with circulation
and nerve function

Environmental conditions such as

extreme heat or cold can place stress
on tissues
Extreme cold constricts blood vessels
and reduces sensitivity and
coordination of body parts
Excessive heat can result in increased
fatigue and heat stress

Exposure to vibration can occur

while using power tools or while
driving equipment.
Vibration from power tools can
place stress on the tissues of the
fingers, hand and arms.
Whole body vibration from driving
puts stress on the spinal tissues.

Stress, boredom, job dissatisfaction

and anxiety can contribute to the
possibility of developing a MSD.
Psycho-social issues can create
increased muscle tension and reduce
a person’s awareness of work
Few Cumulative Trauma
 Carpal Tunnel Syndrome
 De Quervain’s Syndrome
 Thoracic Outlet
 Neck and Back injuries
 Tendonitis
 Tennis Elbow
 Strains/Sprains
 Bursitis
 Trigger finger
How to Diagnose
Four criteria for
diagnosing epidemiology
of MSD
 Risk indicator
 Odds ratio
 Prevalent rate ratio
 Incidence ratio

 Participation rate
 Physical examination
 Investigator blinded
How to calculate Odds
An example of calculation for odd ratio for
retrospective Epidemiological Study

Phalan’s test

Responses Organized Unorganized m = a/b; n = c/d

m = 3.25
+ve 36.1(a) 11.1(b) n = 0.72
responses Odd ratio = m/n =4.51
-ve 63.9(c) 88.9(d)
95% CI = 0.765 – 2.255

Standard error of Odds Ratio (SE) = √ (1/a + 1/b + 1/c +

95 % confidence interval (CI) = ln (Odds Ratio) ± 1.96 X
90 % confidence interval (CI) = ln (Odds Ratio) ± 1.645
Physical Examination
 History
 Inspection
 Palpation
 Range of Motion
 Muscular and Neurological

 An accurate history is essential

 How Symptoms started (mechanism of
 Duration of complaint?
 Location, nature of pain, or symptoms?
 Exacerbating or relieving maneuvers?

 General Appearance
 Observation of patient’s
 Look for asymmetry between
 Swelling
 Deformities
 Atrophy
 Erythema

 Palpate for swelling

 Palpate for Warmth
 Palpate each area of the structure
in turn evaluating for pain and
abnormalities as compared to the
other side
Range of Motion

 Passive (Patients allow the examiner to

move the body part)

 Active(Patients move the body part by


 Resisted (Patients move their body part

while examiner holds the part steady)
Range of Motion

Symptoms to be observed

 Nature of the movement

 Presence of “Popping” or
 Range of movement
 Presence of pain
Range of Motion
 Positive Passive ROM: Stress
located within the joint
 Positive Active ROM: Problems
within both tendon and joints
 Positive Resisted ROM: Problems
within both tendon and muscle
Few selected
l Disorders
Carpal Tunnel Syndrome
It is a nerve compression problem.
Compression in median nerve at the wrist
causes this CTS.
Carpal tunnel syndrome is often the result of a
combination of factors that increase pressure
on the median nerve and tendons in the
carpal tunnel
The main contributing factors are
 Trauma or injury to the wrist
Palmar ap
 Over activity of the pituitary gland
 Hypothyroidism

Median  Rheumatoid arthritis

nerve  Mechanical problems in the wrist joint
 Work stress
 Repeated use of vibrating hand tools
 Fluid retention during pregnancy or
 Development of a cyst or tumor in the canal
How to
By physical examination of the hands, arms, shoulders, and neck
 The wrist can be examined for tenderness, swelling, warmth,
and discoloration.
 Each finger should be tested for sensation
 The muscles at the base of the hand should be examined for
strength and signs of atrophy.
 Specific tests (Phalan’s tests, Tinel’s tests)
 By nerve conduction study: Electrodes are placed on the hand
and wrist. Small electric shocks are
applied and the speed with which
nerves transmit impulses is measured.

•Phalan’s test (Phalen,1966):

The patient place both flexed wrist into
opposition and applies slight pressure for
30-45 seconds.
De Quervain’s
It is a type of tendinitis. Tendinitis is
inflammation of tendon. Inflammation of the
tendon of the abductor pollicis longus and the
extensor pollicis brevis caused de Quervain’s

Point of discomfort
Causes of de Quervain’s
 Swelling of the compartment lining of the tendon
 Repetitive motion of the thumb constantly being
required to move up and down,
gripping or squeezing
 Awkward use of thumb muscles/tendons.
 Muscle imbalance
How to
 By physical examination of the wrist
 The wrist can be examined for Tenderness, and occasional
swelling along the thumb extensor tendons
 Specific tests (A positive Finklestein's test)
 Ultrasonic diagnosis

• Finkelstain’s test
(Mcmurtry,1978): the patient
is instructed to grasp the thumb of
the affected hand with the other
fingers and actively pull the thumb
towards the small finger.
Tennis Elbow is actually tendinitis of the wrist
extensor muscles. A sprain of elbow tendons between
forearm and upper humerus causes Tennis elbow.
Micro tears in part of the tendon surrounding the
elbow and muscle coverings are the first stages in
Tennis Elbow development. It is the lateral elbow pain
and tenderness over the lateral epicondyle.
Causes of Tennis elbow

 Exactly what causes tennis elbow is unknown.

 Tennis Elbow can be caused by injury, repetitive
movement, strain or the overuse of muscles.
 Muscles that are strained or overused, they
become inflamed, and painful to the touch.
 Incorrect grips, poor hitting positions, using a
metal framed tennis racquet, improperly carrying
a briefcase or other heavy object, or spending too
much time using isolated muscle groups in the
elbow area are the main causes.
How to
 The individual observation and recall of
symptoms, a thorough medical history and
physical examination by a physician
 Magnetic resonance imaging (MRI) has been
shown to be helpful in diagnosing cases of
early tennis elbow
 EMG also are sometimes obtained
 X rays are usually always negative because
the condition is primarily soft tissue in
Thoracic Outlet Syndrome
(TOS) difference of cervical rib or a fibrous
band that cause impingement of lower part of
the brachial plexus, causing pain down the ulnar
side of the arm and forearm and some times in
the hand.
Compression occurs when the size and
shape of the thoracic outlet is
The outlet can be altered by
 Exercise
 Trauma
 Pregnancy
 A congenital anomaly
 An exostosis
 Postural weakness or changes.
Compression of the interscalene space
between the anterior and middle scalene
muscles-probably from nerve root irritation,
spondylosis or facet joint inflammation
leading to muscle spasm
Compression in the space between the
clavicle, the first rib and the muscular and
ligamentous structures in the area-probably
from postural deficiencies or carrying heavy
Compression beneath the tendon of the
pectoralis minor under the coracoid process-
may result from repetitive movements of the
arms above the head (shoulder elevation and
Causes of Thoracic outlet
Static postures
 Workers of assembly line workers
 cash register operators
 students
Work often result in a drooping shoulder and
forward head posture.
Carrying heavy loads
 Briefcases and shoulder bags
Repetitive over head arm movements
How to
Adson or Scalene Maneuver
The examiner locates the
radial pulse. The patient
rotates their head toward
the tested arm and lets the
head tilt backwards
(extends the neck) while the
examiner extends the arm.
A positive test is indicated
by a disappearance of the
pulse. Allen Test
The examiner flexes the
patient�s elbow to 90
degrees while the shoulder is
extended horizontally and
rotated laterally. The patient
is asked to turn their head
away from the tested arm.
The radial pulse is palpated
and if it disappears as the
patient�s head is rotated the
Rotator cuff Syndrome
It is a type of tendinitis. Impingement of supraspinatus
on coracoacromial arch causes pain, is the rotator cuff
The Rotator Cuff of the shoulder includes:
Subscapular, Supraspinatus, Infraspinatus, and Teres
Minor Muscles.

Repetitive throwing
Overhead racquet sports
Swimming This type of injury
results from repetitive stretching of
the rotator cuff during the follow-
through phase of the activity. The
tear that occurs is not caused by
impingement, but more by a joint
How to
 Pain, weakness and loss of motion are the
most common symptoms reported
 A careful history taken and reviewed by the
 An x-ray to visualize the anatomy of the
bones of the shoulder
 Physical examination
 Special impingement tests
 An MRI (magnetic resonance imaging) scan
frequently gives the final proof of the status
of the rotator cuff tendon.